Joan Forsyth - Clinical Application of Mechanical Ventilation-White Press Academic (2018)

Clinical Application of
Mechanical Ventilation
Joan Forsyth
Joan Forsyth
Clinical Application of Mechanical Ventilation
by Joan Forsyth
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Contents
Preface ix
1. Introduction 1
Uses ...........................................................................................................................................................................................1
Associated Risk .....................................................................................................................................................................2
Complications .......................................................................................................................................................................2
Application and Duration .................................................................................................................................................2
Negative Pressure Machines ..........................................................................................................................................2
Positive Pressure ..................................................................................................................................................................3
Intermittent Abdominal Pressure Ventilator ........................................................................................................... 4
Types of Ventilators .............................................................................................................................................................4
Mechanical Ventilators ......................................................................................................................................................4
Breath Delivery .....................................................................................................................................................................4
Trigger .......................................................................................................................................................................................4
Cycle .........................................................................................................................................................................................4
Limit ...........................................................................................................................................................................................5
Breath Exhalation .................................................................................................................................................................5
Dead Space ............................................................................................................................................................................5
Modes of Ventilation ..........................................................................................................................................................5
Modification of Settings ....................................................................................................................................................5
Weaning from Mechanical Ventilation ...................................................................................................................... 6
Respiratory Monitoring .....................................................................................................................................................6
Artificial Airways as a Connection to the Ventilator ............................................................................................6
Ventilation formulas ...........................................................................................................................................................7
History .......................................................................................................................................................................................7
Nomenclature of Mechanical Ventilation ................................................................................................................ 7
2. Modes 13
Intermittent Mandatory Ventilation ......................................................................................................................... 13
Synchronized Intermittent Mechanical Ventilation (SIMV) ...........................................................................13
Mandatory Minute Ventilation (MMV) ..................................................................................................................... 13
Proportional Assist Ventilation (PAV) ....................................................................................................................... 14
Adaptive Support Ventilation (ASV) ......................................................................................................................... 14
Continuous Mandatory Ventilation ........................................................................................................................... 14
Expected Outcomes and Considerations .............................................................................................................. 14
Volume-controlled CMV ................................................................................................................................................ 14
Pressure-controlled CMV .............................................................................................................................................. 15
Dual-control Modes ......................................................................................................................................................... 15
Out-dated Terminology .................................................................................................................................................. 15
Continuous Spontaneous Ventilation ...................................................................................................................... 15
Dependent Modes ........................................................................................................................................................... 16
Non-invasive Ventilation ............................................................................................................................................... 16
Continuous Positive Airway Pressure ...................................................................................................................... 17
Airway Pressure Release Ventilation ....................................................................................................................... 19
Positive Airway Pressure ............................................................................................................................................... 22
Medical Uses ....................................................................................................................................................................... 22
Disadvantages .................................................................................................................................................................... 23
vi
Mechanism of Action ...................................................................................................................................................... 24
Components ....................................................................................................................................................................... 25
Optional Features ............................................................................................................................................................. 25
Care and Maintenance ................................................................................................................................................... 26
Portability ............................................................................................................................................................................. 26
Availability ........................................................................................................................................................................... 27
Mandatory Minute Ventilation .................................................................................................................................... 27
Application .......................................................................................................................................................................... 27
High-frequency Ventilation ......................................................................................................................................... 28
Physiology ........................................................................................................................................................................... 28
Procedure ............................................................................................................................................................................ 28
High Frequency Jet Ventilation (Passive) .............................................................................................................. 28
Transtracheal Jet Ventilation ....................................................................................................................................... 32
Adverse Effects .................................................................................................................................................................. 33
3. Mechanical Ventilation during Cardiopulmonary Resuscitation 51

History .................................................................................................................................................................................... 51
First Attempts at Resuscitation in the 18th Century ......................................................................................... 52
Modern Resuscitation ..................................................................................................................................................... 52
Defibrillation ....................................................................................................................................................................... 56
The development of Emergency Medical Services .......................................................................................... 63
Recent Developments in CPR .................................................................................................................................... 65
Medical Uses ....................................................................................................................................................................... 66
Effectiveness ...................................................................................................................................................................... 66
Complications .................................................................................................................................................................... 67
Methods ................................................................................................................................................................................ 67
Compressions with Rescue Breaths ......................................................................................................................... 67
Compression Only ........................................................................................................................................................... 68
Prone CPR ............................................................................................................................................................................ 68
Pregnancy ............................................................................................................................................................................ 68
Family Presence ................................................................................................................................................................ 68
Other ...................................................................................................................................................................................... 68
Pathophysiology ............................................................................................................................................................... 69
Additional Devices ........................................................................................................................................................... 69
Timing Devices .................................................................................................................................................................. 69
Manual Assist Devices .................................................................................................................................................... 69
Automatic Devices .......................................................................................................................................................... 69
Mobile Apps ........................................................................................................................................................................ 70
Prevalence ........................................................................................................................................................................... 70
Chance of Receiving CPR ............................................................................................................................................. 70
Chance of Receiving CPR in Time ............................................................................................................................. 70
Society and Culture ......................................................................................................................................................... 71
Portrayed Effectiveness ................................................................................................................................................. 71
Stage CPR ............................................................................................................................................................................. 71
Self-CPR Hoax .................................................................................................................................................................... 71
Learning from Film .......................................................................................................................................................... 71
Hands-only CPR Portrayal ............................................................................................................................................. 72
Other Animals .................................................................................................................................................................... 72
Research ............................................................................................................................................................................... 72
4. Artificial Airways and Management 73

Advanced Airway Management ................................................................................................................................ 73
Removal of Foreign Objects ........................................................................................................................................ 73
Supraglottic Techniques ................................................................................................................................................ 73
Infraglottic Techniques ................................................................................................................................................... 75
Surgical Methods .............................................................................................................................................................. 75
History .................................................................................................................................................................................... 75
Needle Cricothyrotomy ................................................................................................................................................ 75
Tracheotomy ....................................................................................................................................................................... 76
Pediatric Considerations ............................................................................................................................................... 79
Airway Management in Specific Situations .......................................................................................................... 79
vii
Cardiopulmonary Resuscitation ................................................................................................................................. 79
Trauma ...................................................................................................................................................................................79
Conclusion ........................................................................................................................................................................... 80
Basic Airway Management ........................................................................................................................................... 81
5. Life Support System and Equipments 85

Life Support System ........................................................................................................................................................ 85
Acute Care of at-risk Newborns ................................................................................................................................. 85
Advanced Cardiac Life Support .................................................................................................................................. 85
Advanced Trauma Life Support .................................................................................................................................. 88
Basic Life Support ............................................................................................................................................................. 91
Care of the Critically Ill Surgical Patient ................................................................................................................. 95
First Aid .................................................................................................................................................................................97
Neonatal Resuscitation Programme ..................................................................................................................... 102
Pediatric Advanced Life Support ............................................................................................................................ 103
Equipment ........................................................................................................................................................................ 103
Electrocardiography ..................................................................................................................................................... 103
Intraosseous Infusion ................................................................................................................................................... 118
Intravenous Therapy ..................................................................................................................................................... 120
Tracheal Intubation ....................................................................................................................................................... 135
Laryngeal Tube ................................................................................................................................................................ 154
Combitube ....................................................................................................................................................................... 155
Nasopharyngeal Airway .............................................................................................................................................. 157
Pocket Mask ..................................................................................................................................................................... 157
Bag Valve Mask ............................................................................................................................................................... 158
Chest Tube ........................................................................................................................................................................ 165
Automated External Defibrillator ........................................................................................................................... 168
Implantable Cardioverter-defibrillator ................................................................................................................. 173
6. Managing Initial Mechanical Ventilation in the Emergency Department 177

Medical Emergency ...................................................................................................................................................... 177
Response ........................................................................................................................................................................... 177
Clinical Response .......................................................................................................................................................... 178
Non-trauma Emergencies ......................................................................................................................................... 179
Emergency Department ............................................................................................................................................ 179
History ................................................................................................................................................................................. 179
Nomenclature in English ............................................................................................................................................ 180
Signage .............................................................................................................................................................................. 180
United States ................................................................................................................................................................... 181
United Kingdom ............................................................................................................................................................. 182
Critical Conditions Handled ...................................................................................................................................... 182
Special Facilities, Training, and Equipment ......................................................................................................... 184
Non-emergency Use ................................................................................................................................................... 184
Overcrowding ................................................................................................................................................................. 185
Emergency Departments in the Military ............................................................................................................. 185
Violence against Health Care Workers ................................................................................................................. 186
Medication Errors ........................................................................................................................................................... 186
Emergency Medical Services ................................................................................................................................... 186
History ................................................................................................................................................................................. 187
Service Providers ........................................................................................................................................................... 189
Purpose .............................................................................................................................................................................. 190
Levels of Care ................................................................................................................................................................. 190
Prehospital Delivery of Care ..................................................................................................................................... 195
Emergency Nursing ...................................................................................................................................................... 198
ED Nurse Role ................................................................................................................................................................. 198
Board Certification in Emergency Nursing ........................................................................................................ 198
Emergency Nurse Practitioner (ENP) ................................................................................................................... 199
Challenges of Emergency Nursing ........................................................................................................................ 199
Emergency Nurses in Africa ..................................................................................................................................... 200
The History of Emergency Nursing ........................................................................................................................ 200
Additional Emergency Nursing Education/Certification .............................................................................. 200
viii
Emergency Psychiatry ................................................................................................................................................. 201
Definition .......................................................................................................................................................................... 201
Delivery of Services ...................................................................................................................................................... 201
History ................................................................................................................................................................................. 201
Scope .................................................................................................................................................................................. 202
Treatment .......................................................................................................................................................................... 205
Observation and Collateral Information .............................................................................................................. 206
Disposition ........................................................................................................................................................................ 206
Golden Hour (Medicine) ............................................................................................................................................. 207
General Concept ............................................................................................................................................................ 207
Origins of the Term ....................................................................................................................................................... 207
Controversy ...................................................................................................................................................................... 207
International Emergency Medicine ....................................................................................................................... 207
Background ...................................................................................................................................................................... 208
Role in Overall Health System ................................................................................................................................. 211
Initiatives to Expand Emergency Medicine ........................................................................................................ 212
Challenges ........................................................................................................................................................................ 213
Pediatric Emergency Medicine ............................................................................................................................... 214
Training ............................................................................................................................................................................... 214
Pre-hospital Emergency Medicine ........................................................................................................................ 215
Major Trauma ................................................................................................................................................................... 215
Classification .................................................................................................................................................................... 215
Causes ................................................................................................................................................................................ 216
Pathophysiology ............................................................................................................................................................ 216
Diagnosis ........................................................................................................................................................................... 216
Prevention ........................................................................................................................................................................ 217
Management ................................................................................................................................................................... 218
Prognosis ........................................................................................................................................................................... 219
Epidemiology .................................................................................................................................................................. 220
History ................................................................................................................................................................................. 220
Society and Culture ...................................................................................................................................................... 220
Special Populations ...................................................................................................................................................... 221
Research ............................................................................................................................................................................ 221
Trauma Center ................................................................................................................................................................ 221
History ................................................................................................................................................................................. 222
Definitions in the United States of America...................................................................................................... 223
Triage ................................................................................................................................................................................... 225
Outcomes ......................................................................................................................................................................... 227
Specific Systems ............................................................................................................................................................ 228
Conventional Classifications .................................................................................................................................... 229
Limitations of Current Practices ............................................................................................................................. 234
Ethical Implications ....................................................................................................................................................... 235
Bibliography 237
Index 241
Preface
Mechanical ventilation is the medical term for artificial ventilation where mechanical means is used to assist
or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be
assisted by an anesthesiologist, certified registered nurse anesthetist, physician, physician assistant, respiratory
therapist, paramedic, EMT, or other suitable person compressing a bag or set of bellows. Mechanical ventilation
is termed "invasive" if it involves any instrument penetrating the trachea through the mouth, such as an endotracheal
tube or the skin, such as a tracheostomy tube. There are two main types: positive pressure ventilation, where air
is pushed into the trachea, and negative pressure ventilation, where air is, in essence, sucked into the lungs.
There are many modes of mechanical ventilation, and their nomenclature has been revised over the decades as
the technology has continually developed.Mechanical ventilation is indicated when the patient's spontaneous
ventilation is inadequate to maintain life. It is also indicated as prophylaxis for imminent collapse of other physiologic
functions, or ineffective gas exchange in the lungs. Because mechanical ventilation serves only to provide assistance
for breathing and does not cure a disease, the patient's underlying condition should be correctable and should
resolve over time. In addition, other factors must be taken into consideration because mechanical ventilation is
not without its complications. In general, mechanical ventilation is instituted to correct blood gases and reduce
the work of breathing.
– Sean Lawrence
Chapter 1
Introduction
Mechanical ventilation is the medical term for artificial ventilation where mechanical means is used to assist
or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be
assisted by an anesthesiologist, certified registered nurse anesthetist, physician, physician assistant, respiratory
therapist, paramedic, EMT, or other suitable person compressing a bag or set of bellows. Mechanical ventilation
is termed “invasive” if it involves any instrument penetrating the trachea through the mouth, such as an
endotracheal tube or the skin, such as a tracheostomy tube. There are two main types: positive pressure ventilation,
where air (or another gas mix) is pushed into the trachea, and negative pressure ventilation, where air is, in
essence, sucked into the lungs. There are many modes of mechanical ventilation, and their nomenclature has
been revised over the decades as the technology has continually developed.

Mechanical ventilation is indicated when the patient’s spontaneous ventilation is inadequate to maintain
life. It is also indicated as prophylaxis for imminent collapse of other physiologic functions, or ineffective gas
exchange in the lungs. Because mechanical ventilation serves only to provide assistance for breathing and does
not cure a disease, the patient’s underlying condition should be correctable and should resolve over time. In
addition, other factors must be taken into consideration because mechanical ventilation is not without its
complications In general, mechanical ventilation is instituted to correct blood gases and reduce the work of
breathing.
Common medical indications for use include:
• Acute lung injury (including ARDS, trauma)
• Apnea with respiratory arrest, including cases from intoxication
• Acute severe asthma, requiring intubation
• Acute on chronic respiratory acidosis most commonly with Chronic obstructive pulmonary disease
(COPD) and obesity hypoventilation syndrome
• Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 50 mmHg and pH <
7.25, which may be due to paralysis of the diaphragm due to Guillain–Barré syndrome, myasthenia
gravis, motor neuron disease, spinal cord injury, or the effect of anaesthetic and muscle relaxant
drugs
• Increased work of breathing as evidenced by significant tachypnea, retractions, and other physical
signs of respiratory distress
• Hypoxemia with arterial partial pressure of oxygen and (PaO2) < 55 mm Hg with supplemental
fraction of inspired oxygen (FiO2) = 1.0
• Hypotension including sepsis, shock, congestive heart failure
• Neurological diseases such as muscular dystrophy and amyotrophic lateral sclerosis.
2 Principles and Practice of Mechanical Ventilation

• Barotrauma — Pulmonary barotrauma is a well-known complication of positive-pressure mechanical
ventilation. This includes pneumothorax, subcutaneous emphysema, pneumomediastinum, and
pneumoperitoneum.
• Ventilator-associated lung injury — Ventilator-associated lung injury (VALI) refers to acute lung
injury that occurs during mechanical ventilation. It is clinically indistinguishable from acute lung
injury or acute respiratory distress syndrome (ALI/ARDS).
• Diaphragm — Controlled mechanical ventilation may lead to a rapid type of disuse atrophy involving
the diaphragmatic muscle fibres, which can develop within the first day of mechanical ventilation.
This cause of atrophy in the diaphragm is also a cause of atrophy in all respiratory related muscles
during controlled mechanical ventilation.
• Motility of mucocilia in the airways — Positive pressure ventilation appears to impair mucociliary
motility in the airways. Bronchial mucus transport was frequently impaired and associated with
retention of secretions and pneumonia.
COMPLICATIONS
Mechanical ventilation is often a life-saving intervention, but carries potential complications including
pneumothorax, airway injury, alveolar damage, and ventilator-associated pneumonia. Other complications include
diaphragm atrophy, decreased cardiac output, and oxygen toxicity. One of the primary complications that presents
in patients mechanically ventilated is acute lung injury (ALI)/acute respiratory distress syndrome (ARDS).
ALI/ARDS are recognized as significant contributors to patient morbidity and mortality. In many health care
systems, prolonged ventilation as part of intensive care is a limited resource (in that there are only so many
patients that can receive care at any given moment). It is used to support a single failing organ system (the
lungs) and cannot reverse any underlying disease process (such as terminal cancer). For this reason, there can
be (occasionally difficult) decisions to be made about whether it is suitable to commence someone on mechanical
ventilation. Equally many ethical issues surround the decision to discontinue mechanical ventilation.

It can be used as a short-term measure, for example during an operation or critical illness (often in the
setting of an intensive-care unit). It may be used at home or in a nursing or rehabilitation institution if
patients have chronic illnesses that require long-term ventilatory assistance. Due to the anatomy of the human
pharynx, larynx, and esophagus and the circumstances for which ventilation is needed, additional measures
are often required to secure the airway during positive-pressure ventilation in order to allow unimpeded
passage of air into the trachea and avoid air passing into the esophagus and stomach. The common method is
by insertion of a tube into the trachea: intubation, which provides a clear route for the air. This can be either
an endotracheal tube, inserted through the natural openings of mouth or nose, or a tracheostomy inserted
through an artificial opening in the neck. In other circumstances simple airway maneuvres, an oropharyngeal
airway or laryngeal mask airway may be employed. If the patient is able to protect his/her own airway and
non-invasive ventilation or negative-pressure ventilation is used then an airway adjunct may not be needed.
NEGATIVE PRESSURE MACHINES

The iron lung, also known as the Drinker and Shaw tank, was developed in 1929 and was one of the first
negative-pressure machines used for long-term ventilation. It was refined and used in the 20th century largely
Introduction 3
as a result of the polio epidemic that struck the world in the 1940s. The machine is, in effect, a large elongated
tank, which encases the patient up to the neck. The neck is sealed with a rubber gasket so that the patient’s
face (and airway) are exposed to the room air. While the exchange of oxygen and carbon dioxide between the
bloodstream and the pulmonary airspace works by diffusion and requires no external work, air must be
moved into and out of the lungs to make it available to the gas exchange process. In spontaneous breathing,
a negative pressure is created in the pleural cavity by the muscles of respiration, and the resulting gradient
between the atmospheric pressure and the pressure inside the thorax generates a flow of air. In the iron lung
by means of a pump, the air is withdrawn mechanically to produce a vacuum inside the tank, thus creating
negative pressure.
This negative pressure leads to expansion of the chest, which causes a decrease in intrapulmonary pressure,
and increases flow of ambient air into the lungs. As the vacuum is released, the pressure inside the tank
equalizes to that of the ambient pressure, and the elastic coil of the chest and lungs leads to passive exhalation.
However, when the vacuum is created, the abdomen also expands along with the lung, cutting off venous
flow back to the heart, leading to pooling of venous blood in the lower extremities. There are large portholes
for nurse or home assistant access. The patients can talk and eat normally, and can see the world through a
well-placed series of mirrors. Some could remain in these iron lungs for years at a time quite successfully.
Today, negative pressure mechanical ventilators are still in use, notably with the polio wing hospitals in
England such as St Thomas’ Hospital in London and the John Radcliffe in Oxford. The prominent device
used is a smaller device known as the cuirass. The cuirass is a shell-like unit, creating negative pressure only
to the chest using a combination of a fitting shell and a soft bladder. Its main use is in patients with
neuromuscular disorders that have some residual muscular function. However, it was prone to falling off and
caused severe chafing and skin damage and was not used as a long-term device. In recent years this device
has re-surfaced as a modern polycarbonate shell with multiple seals and a high-pressure oscillation pump in
order to carry out biphasic cuirass ventilation.
POSITIVE PRESSURE
The design of the modern positive-pressure ventilators were based mainly on technical developments by
the military during World War II to supply oxygen to fighter pilots in high altitude. Such ventilators replaced
the iron lungs as safe endotracheal tubes with high-volume/low-pressure cuffs were developed. The popularity
of positive-pressure ventilators rose during the polio epidemic in the 1950s in Scandinavia and the United
States and was the beginning of modern ventilation therapy. Positive pressure through manual supply of 50%
oxygen through a tracheostomy tube led to a reduced mortality rate among patients with polio and respiratory
paralysis. However, because of the sheer amount of man-power required for such manual intervention,
mechanical positive-pressure ventilators became increasingly popular. Positive-pressure ventilators work by
increasing the patient’s airway pressure through an endotracheal or tracheostomy tube. The positive pressure
allows air to flow into the airway until the ventilator breath is terminated. Then, the airway pressure drops to
zero, and the elastic recoil of the chest wall and lungs push the tidal volume — the breath-out through
passive exhalation.
Transairway Pressure
PTA = PAO – PALV
• PTA = Transairway pressure
• PAO = Pressure at airway opening
• PALV = Pressure in alveoli
INTERMITTENT ABDOMINAL PRESSURE VENTILATOR

Another type is the intermittent abdominal pressure ventilator that applies pressure externally via an inflated
bladder, forcing exhalation, sometimes termed exsufflation. The first such apparatus was the Bragg-Paul Pulsator.
The name of one such device, the Pneumobelt made by Puritan Bennett has to a degree become a generic name
for the type.

Ventilators come in many different styles and method of giving a breath to sustain life. There are manual
ventilators such as bag valve masks and anesthesia bags that require the users to hold the ventilator to the face
or to an artificial airway and maintain breaths with their hands.
Mechanical ventilators are ventilators not requiring operator effort and are typically computer-controlled or
pneumatic-controlled.
MECHANICAL VENTILATORS
Mechanical ventilators typically require power by a battery or a wall outlet (DC or AC) though some ventilators
work on a pneumatic system not requiring power.
• Transport ventilators — These ventilators are small and more rugged, and can be powered
pneumatically or via AC or DC power sources.
• Intensive-care ventilators — These ventilators are larger and usually run on AC power (though virtually
all contain a battery to facilitate intra-facility transport and as a back-up in the event of a power
failure). This style of ventilator often provides greater control of a wide variety of ventilation
parameters (such as inspiratory rise time). Many ICU ventilators also incorporate graphics to provide
visual feedback of each breath.
• Neonatal ventilators — Designed with the preterm neonate in mind, these are a specialized subset of
ICU ventilators that are designed to deliver the smaller, more precise volumes and pressures required
to ventilate these patients.
• Positive airway pressure ventilators (PAP) — These ventilators are specifically designed for non-
invasive ventilation. This includes ventilators for use at home for treatment of chronic conditions
such as sleep apnea or COPD.

TRIGGER
The trigger is what causes a breath to be delivered by a mechanical ventilator. Breaths may be triggered by
a patient taking their own breath, a ventilator operator pressing a manual breath button, or by the ventilator
based on the set breath rate and mode of ventilation.
CYCLE
The cycle is what causes the breath to transition from the inspiratory phase to the exhalation phase. Breaths
may be cycled by a mechanical ventilator when a set time has been reached, or when a preset flow or percentage
of the maximum flow delivered during a breath is reached depending on the breath type and the settings.
Breaths can also be cycled when an alarm condition such as a high pressure limit has been reached, which is a
primary strategy in pressure regulated volume control.
Introduction 5
LIMIT
Limit is how the breath is controlled. Breaths may be limited to a set maximum circuit pressure or a set
maximum flow.

Exhalation in mechanical ventilation is almost always completely passive. The ventilator’s expiratory valve
is opened, and expiratory flow is allowed until the baseline pressure (PEEP) is reached. Expiratory flow is
determined by patient factors such as compliance and resistance.

Mechanical dead space is defined as the volume of gas breathed again as the result of use in a mechanical
device.
Example of calculation for mechanical dead space:
PaCO2 (VT − VD − VDmech )
VDmech = VT − VDphys −
PACO2
Simplified version:
VD PaCO2 − PECO2
=
VT PaCO2

Mechanical ventilation utilizes several separate systems for ventilation referred to as the mode. Modes come
in many different delivery concepts but all modes fall into one of three categories; volume-cycled, pressure-
cycled, spontaneously cycled. In general, the selection of which mode of mechanical ventilation to use for a
given patient is based on the familiarity of clinicians with modes and the equipment availability at a particular
institution.

In adults when 100% Oxygen (O2) (1.00 FiO2) is used initially, it is easy to calculate the next FiO
2 to be used and easy to estimate the shunt fraction. The estimated shunt fraction refers to the amount of oxygen
not being absorbed into the circulation. In normal physiology, gas exchange (oxygen/carbon dioxide) occurs at
the level of the alveoli in the lungs. The existence of a shunt refers to any process that hinders this gas exchange,
leading to wasted oxygen inspired and the flow of un-oxygenated blood back to the left heart (which ultimately
supplies the rest of the body with unoxygenated blood). When using 100% O2 (FiO2 1.00), the degree of
shunting is estimated by subtracting the measured PaO2 (from an arterial blood gas) from 700 mmHg. For each
difference of 100 mmHg, the shunt is 5%. A shunt of more than 25% should prompt a search for the cause of this
hypoxemia, such as mainstem intubation or pneumothorax, and should be treated accordingly. If such
complications are not present, other causes must be sought after, and positive end-expiratory pressure (PEEP)
should be used to treat this intrapulmonary shunt.
Other such causes of a shunt include:
• Alveolar collapse from major atelectasis.
• Alveolar collection of material other than gas, such as pus from pneumonia, water and protein from
acute respiratory distress syndrome, water from congestive heart failure, or blood from haemorrhage.
WEANING FROM MECHANICAL VENTILATION

Timing of withdrawal from mechanical ventilation—also known as weaning—should be carefully considered.
Patients should have their ventilation considered for withdrawal if they are able to support their own ventilation
and oxygenation, and this should be assessed continuously. There are several objective parameters to look for
when considering withdrawal, but there are no specific criteria that generalizes to all patients. The Rapid
Shallow Breathing Index (RSBI, the ratio of respiratory frequency to tidal volume (f/VT), previously referred
to as the “Tobin Index” after Dr. Martin Tobin of Loyola University Medical Center) is one of the best studied
and most commonly used weaning predictors, with no other predictor having been shown to be superior. It was
described in a prospective cohort study of mechanically ventilated patients which found that a RSBI > 105
breaths/min/L was associated with weaning failure, while a RSBI < 105 breaths/min/L predicted weaning success
with a sensitivity, specificity, positive predictive value and negative predictive value of 97%, 64%, 78%, 95%
respectively.

One of the main reasons why a patient is admitted to an ICU is for delivery of mechanical ventilation.
Monitoring a patient in mechanical ventilation has many clinical applications: Enhance understanding of
pathophysiology, aid with diagnosis, guide patient management, avoid complications and assessment of
trends. In ventilated patients, pulse oximetry it is commonly used when titrating FIO2. A reliable target of
Spo2 is greater than 95%. Different strategies exist to find the level of PEEP in these patients with ARDS
guided by esophageal pressure, Stress Index, static airway pressure-volume curve. In such patients, some
experts recommend limiting PEEP to low levels (~10cmH2O). In patients who have diffused loss of aeration
PEEP can be used provided it does not cause the plateau pressure to rise above the upper inflection point.
Most modern ventilators have basic monitoring tools. There are also monitors that work independently of
the ventilator which allow for measuring patients after the ventilator has been removed, such as a T tube
test.

There are various procedures and mechanical devices that provide protection against airway collapse, air
leakage, and aspiration:
• Face mask — In resuscitation and for minor procedures under anaesthesia, a face mask is often
sufficient to achieve a seal against air leakage. Airway patency of the unconscious patient is maintained
either by manipulation of the jaw or by the use of nasopharyngeal or oropharyngeal airway. These
are designed to provide a passage of air to the pharynx through the nose or mouth, respectively.
Poorly fitted masks often cause nasal bridge ulcers, a problem for some patients. Face masks are
also used for non-invasive ventilation in conscious patients. A full face mask does not, however,
provide protection against aspiration.
• Tracheal intubation is often performed for mechanical ventilation of hours to weeks duration. A
tube is inserted through the nose (nasotracheal intubation) or mouth (orotracheal intubation) and
advanced into the trachea. In most cases, tubes with inflatable cuffs are used for protection against
leakage and aspiration. Intubation with a cuffed tube is thought to provide the best protection against
aspiration. Tracheal tubes inevitably cause pain and coughing. Therefore, unless a patient is
unconscious or anaesthetized for other reasons, sedative drugs are usually given to provide tolerance
of the tube. Other disadvantages of tracheal intubation include damage to the mucosal lining of the
nasopharynx or oropharynx and subglottic stenosis.
Introduction 7
• Supraglottic airway — a supraglottic airway (SGA) is any airway device that is seated above and
outside the trachea, as an alternative to endotracheal intubation. Most devices work via masks or
cuffs that inflate to isolate the trachea for oxygen delivery. Newer devices feature esophageal ports
for suctioning or ports for tube exchange to allow intubation. Supraglottic airways differ primarily
from tracheal intubation in that they do not prevent aspiration. After the introduction of the laryngeal
mask airway (LMA) in 1998, supraglottic airway devices have become mainstream in both elective
and emergency anesthesia. There are many types of SGAs available including the Esophageal-tracheal
Combitube (ETC), Laryngeal tube (LT), and the obsolete Esophageal obturator airway (EOA).
• Cricothyrotomy — Patients requiring emergency airway management, in whom tracheal intubation
has been unsuccessful, may require an airway inserted through a surgical opening in the cricothyroid
membrane. This is similar to a tracheostomy but a cricothyrotomy is reserved for emergency access.
• Tracheostomy — When patients require mechanical ventilation for several weeks, a tracheostomy
may provide the most suitable access to the trachea. A tracheostomy is a surgically created passage
into the trachea. Tracheostomy tubes are well-tolerated and often do not necessitate any use of sedative
drugs. Tracheostomy tubes may be inserted early during treatment in patients with pre-existing severe
respiratory disease, or in any patient expected to be difficult to wean from mechanical ventilation,
i.e., patients with little muscular reserve.
• Mouthpiece — Less common interface, does not provide protection against aspiration. There are
lipseal mouthpieces with flanges to help hold them in place if patient is unable.

The following formulas are used to calculate certain aspects of ventilation
• Alveolar Ventilation −V = V − V
A ( T ×f
DSphys )
0.863 × VCO2
• Arterial PaCO2 − PaCO2 =
VA
• Alveolar volume VA = VT – Vf
QSP CcO2 − CaO2
Estimated physiologic shunt equation Q = 5 + CcO − CaO
•
T ( 2 2)

The Greek physician Galen may have been the first to describe mechanical ventilation: “If you take a dead
animal and blow air through its larynx [through a reed], you will fill its bronchi and watch its lungs attain the
greatest distention.” Vesalius too describes ventilation by inserting a reed or cane into the trachea of animals. In
1908 George Poe demonstrated his mechanical respirator by asphyxiating dogs and seemingly bringing them
back to life.

Many terms are used in mechanical ventilation, some are specific to brand, model, trademark and mode of
mechanical ventilation. There is a standardized nomenclature of mechanical ventilation that is specific about
nomenclature related to modes, but not settings and variables. Terms are now split into acronyms of CONTROL
VARIABLE + BREATH SEQUENCE + TARGETING SCHEME. As in PC-CMV, Pressure Controlled
Continuous Mandatory Ventilation. The term trigger (commonly flow or pressure) denotes the criteria that
starts inspiration and cycle denotes the criteria that stops it. The target variable should not be confused with the
cycle variable or the control variable. The target variable only sets an upper limit for pressure, volume or flow.
Control Variable
The physical parameter that controls the breath in accordance with the equation of motion
8<(;0656-6;065
Pressure = Elastance*Volume + Resistance*Flow
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Volume controlled ventilation is ventilation where both volume and flow are controlled by the ventilator.
Normally, flow is set to a fixed amount, meaning volume increases linearly over time. Any mode that relies on
flow to control inspiration falls under the VC- category.
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Pressure controlled ventilation is where pressure as a function of time is controlled by the ventilator. Normally,
pressure is set to a specific amount for a specific breath duration, letting volume and flow vary according to
patient demands. Any mode that relies on pressure to deliver a breath falls under the PC- category.
04,
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È
Rarely breaths can be purely time controlled. An example is intrapulmonary percussive ventilation.
Here only time is set by the operator and pressure and flow change obeying the equation of motion.
Breath Sequence
65;05<6<:(5+(;69@,5;03(;065Ç
È
Commonly known as “Assist/Control”; CMV is a breath sequence for which spontaneous breaths are not
possible between mandatory breaths because every patient trigger signal in the trigger window produces a
machine cycled inspiration (i.e., a mandatory breath). Machine triggered mandatory breaths may be delivered
at a preset rate. Therefore, in contrast to IMV, the mandatory breath frequency may be higher than the set
frequency but never below it. In some pressure controlled modes on ventilators with an active exhalation valve,
spontaneous breaths may occur during mandatory breaths, but the defining characteristic of CMV is that
spontaneous breaths are not permitted between mandatory breaths.
,94:,73(*,+)@
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• Assist/Control
• A/C
• ACV
• CMV
• Volume Assist/Control
• Volume Control
• Volume Limited Ventilation
• Volume Controlled Ventilation
• Controlled Ventilation
• Volume Targeted Ventilation.
Introduction 9
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• Assist/Control
• A/C
• ACV
• CMV
• Pressure Assist/Control
• Pressure Control
• Pressure Limited Ventilation
• Pressure Controlled Ventilation
• Pressure Targeted Ventilation.
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IMV is a form of ventilation where the ventilator delivers mandatory breaths, but spontaneous breaths are
possible between mandatory breaths. Mandatory breaths can be delivered at a set frequency (with spontaneous
breaths occurring in between), or can be delivered whenever breath volume per minute falls below a set
point.
Terms replaced by VC-IMV:
• Synchronized Intermittent Mandatory Ventilation.
• SIMV.
Terms replaced by PC-IMV:
• Synchronized Intermittent Mandatory Ventilation.
• SIMV.
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Continuous Spontaneous Ventilation — CSV is a breath sequence for which all breaths are spontaneous.
Terms no longer in use:
• Spont
• Spontaneous.
Targeting Schemes
• Set point - e.g. - PC-CSVs is the tag for Pressure support.
• Adaptive - e.g. - PC-IMVa,a is the tag for VC+.
• Optimal - e.g. - PC-IMVoi,oi is the tag for Adaptive Support Ventilation (ASV), technically due
only to minor safety algorhythms, if not it would only be “optimal” but not “intelligent”.
• Dual - e.g. - VC-CMVd is the tag for CMV + pressure limited ventilation.
• Biovariable - PC-CSVb is the tag for Variable Pressure Support.
• Servo - e.g. - PC-CSVr is the tag for NAVA.
• Intelligent - e.g. - PC-IMVoi,oi is the tag for Adaptive Support Ventilation (ASV) and for
INTELLiVent-ASV.
Mandatory Breath
Mandatory Breath is a breath type during mechanical ventilation for which inspiration is machine triggered
and/or machine cycled.

• Machine breath
• Mechanical breath
Spontaneous Breath
Spontaneous Breaths are a breath type for which inspiration is both patient triggered and patient cycled.
Applies to assisted or unassisted breathing.
Assisted Ventilation or Breath

Assisted ventilation or assisted breath references ventilation (or breath) for which a machine provides some
or all of the work of breathing.
• Patient triggered ventilation
• Patient triggered breath.
Patient Triggered Breath

Patient triggered breath — A breath that is initiated by the patient, independent of ventilator settings for
frequency.
Terms no longer in use
• Patient assisted breath
• Assisted breath.
Autotriggering
Autotriggering — Autotriggering is the unintended initiation of breath delivery by the ventilator, e.g., by an
external disturbance such as movement of the breathing tube or an inappropriate trigger sensitivity setting.
Terms no longer in use
• Autocycling.
Non-standardized Terminology
The following are terms that are included in modes of mechanical ventilation but are not yet included in the
standardized nomenclature.
Volume related:
• Vt — Tidal volume.
• Ve — Minute ventilation.
• Amplitude — High-frequency ventilation (Active).
Pressure related:
• Pip — Peak inspiratory pressure.
• Pplat — Plateau pressure (airway).
• Mpaw — Mean airway pressure.
• EPAP — Pressure applied to exhalation.
• IPAP — Pressure applied to inhalation.
• Phigh — Highest pressure attained, similar to Pip; this is a constant pressure.
• Plow — Pressure that Phigh drops to during expiratory time (Tlow).
Introduction 11
• PEEP — Positive end-expiratory pressure, pressure created by a backpressure valve.

• CPAP — Continuous positive airway pressure.
• Δp — Delta-P, the change in pressure from the highest pressure to the lowest pressure.
Time related:
• I:E — Inspiratory:Expiratory ratio.
• Thigh — Time set for inhalation.
• Tlow — Time set for exhalation.
Modes 13
Chapter 2
Modes

Intermittent Mandatory Ventilation (IMV) refers to any mode of mechanical ventilation where a regular series
of breaths are scheduled but the ventilator senses patient effort and reschedules mandatory breaths based on the
calculated need of the patient. Similar to continuous mandatory ventilation in parameters set for the patients
pressures and volumes but distinct in its ability to support a patient by either supporting their own effort or
providing support when patient effort is not sensed. IMV is frequently paired with additional strategies to improve
weaning from ventilator support or to improve cardiovascular stability in patients who may need full life support.
SYNCHRONIZED INTERMITTENT MECHANICAL VENTILATION (SIMV)

Synchronized Intermittent Mechanical Ventilation is a variation of IMV, in which the ventilator breaths are
synchronized with patient inspiratory effort. SIMV, with and without pressure support has not been shown to
have any advantages over continuous mandatory ventilation (CMV) in terms of mortality or weaning success,
and has been shown to result in longer weaning times when compared to t-piece trials or gradual reductions in
pressure support. Some studies have shown an increase in patient work of breathing when switched from CMV
to SIMV, and others have demonstrated potential detrimental effects of SIMV on respiratory muscles and
respiratory drive.
MANDATORY MINUTE VENTILATION (MMV)

Mandatory minute ventilation is a mode which requires the operator to determine what the appropriate
minute ventilation for the patient should be, and the ventilator then monitors the patient’s ability to generate
this volume every 7.5 seconds. If the calculation suggests the volume target will not be met, SIMV breaths are
delivered at the targeted volume to achieve the desired minute ventilation. Allows spontaneous breathing with
automatic adjustments of mandatory ventilation to the meet the patient’s preset minimum minute volume
requirement. If the patient maintains the minute volume settings for VT x f, no mandatory breaths are delivered.
If the patient’s minute volume is insufficient, mandatory delivery of the preset tidal volume will occur until the
minute volume is achieved. The method for monitoring whether or not the patient is meeting the required
minute ventilation (VE) is different per ventilator brand and model, but generally there is a window of time
being monitored and a smaller window being checked against that larger window (i.e., in the Dräger Evita®
line of mechanical ventilators there is a moving 20-second window and every 7 seconds the current tidal volume
and rate are measured against to make a decision for if a mechanical breath is needed to maintain the minute
ventilation). MMV is the most optimal mode for weaning in neonatal and pediatric populations and has been
shown to reduce long term complications related to mechanical ventilation.
PROPORTIONAL ASSIST VENTILATION (PAV)

Proportional assist ventilation is a mode in which the ventilator guarantees the percentage of work regardless
of changes in pulmonary compliance and resistance. The ventilator varies the tidal volume and pressure based
on the patients work of breathing, the amount it delivers is proportional to the percentage of assistance it is set
to give.
ADAPTIVE SUPPORT VENTILATION (ASV)

Adaptive Support Ventilation is a positive pressure mode of mechanical ventilation that is closed-
loop controlled. In this mode, the frequency and tidal volume of breaths of a patient on the ventilator
are automatically adjusted based on the patient’s requirements. The lung mechanics data are used to
adjust the depth and rate of breaths to minimize the work rate of breathing. In the ASV mode, every
breath is synchronized with patient effort if such an effort exists, and otherwise, full mechanical
ventilation is provided to the patient. ASV is a patented technology originally described as one of the
embodiments of US Patent No. 4986268. In this invention, the control algorithm computes the optimal
rate of respiration to minimize the work rate of breathing. The rationale is to make the patient’s breathing
pattern comfortable and natural within safe limits, and thereby stimulate spontaneous breathing and
reduce the weaning time.

Continuous mandatory ventilation (CMV) is a mode of mechanical ventilation in which breaths are
delivered based on set variables. Still used in the operating room, in previous nomenclature CMV referred
to “controlled mechanical ventilation” (“control mode ventilation”), a mode of ventilation characterized
by a ventilator that makes no effort to sense patient breathing effort. In continuous mandatory ventilation,
the ventilator can be triggered either by the patient or mechanically by the ventilator. The ventilator is set
to deliver a breath according to parameters selected by the operator. “Controlled mechanical ventilation”
is an outdated expansion for “CMV”; “continuous mandatory ventilation” is now accepted standard
nomenclature of mechanical ventilation. CMV today can assist or control dynamically, depending on
transient presence or absence of spontaneous breathing effort. Thus, today’s CMV would have been called
ACV (assist-control ventilation) in older nomenclature, and the original form of CMV is a thing of the
past. But despite continual technological improvement over the past half century, CMV sometimes may
still be uncomfortable for the patient.
EXPECTED OUTCOMES AND CONSIDERATIONS

Continuous mandatory ventilation is associated with profound diaphragm muscle dysfunction and atrophy.
CMV is no longer the preferred mode of mechanical ventilation.
VOLUME-CONTROLLED CMV
Limit
Limits in VC-CMV may be set and pressure based. The ventilator will attempt to deliver the set tidal volume
utilizing whatever pressure is required to reach its setting. A pressure limit may be added to limit damage to the
lungs (barotrauma).
Modes 15
Cycle
Expiration cycling can be set by time or the pressure limit. Once the Ti (inspiratory time) is reached, or a
pressure limit is reached the ventilator will cycle into expiratory mode and allow passive exhalation until
another breath is triggered.
PRESSURE-CONTROLLED CMV
Pressure control (PC) is a pressure-controlled mode of ventilation. The ventilator delivers a flow to maintain
the preset pressure at a preset respiratory rate over a preset inspiratory time. The pressure is constant during the
inspiratory time and the flow is decelerating. If for any reason pressure decreases during inspiration, the flow
from the ventilator will immediately increase to maintain the set inspiratory pressure.
DUAL-CONTROL MODES
Dual-control modes are pressure controlled modes with an exhaled tidal volume target. They work
on a breath-by-breath basis and provide pressure-limited time-cycled breaths, increasing or decreasing
the pressure of the next breath as necessary to achieve a user-selected desired tidal volume. They are
known by various vendor-specific terms such as pressure-regulated volume control (Siemens), autoflow
(Dräger), adaptive-pressure ventilation (Hamilton Medical), volume-control plus (Covidien), among
others.
OUT-DATED TERMINOLOGY
Many terms have been developed to describe the same modes of mechanical ventilation. Nomenclature of
mechanical ventilation has become more standardized and these terms are no longer preferred but still may be
seen in older research there are many different names that historically were used to reference CMV but now
reference Assist Control. Names such as: volume control ventilation, and volume cycled ventilation in modern
usage refer to the Assist Control mode.
• Assist/control
• A/C
• CMV
• Volume assist/control
• Volume control
• Volume limited ventilation
• Volume controlled ventilation
• Controlled ventilation
• Volume targeted ventilation.

Continuous spontaneous ventilation is any mode of mechanical ventilation where every breath is
spontaneous (i.e., patient triggered and patient cycled). Spontaneous breathing is defined as the movement of
gas in and out of the lungs that is produced in response to an individual’s respiratory muscles. In a nutshell,
spontaneous breathing is natural breathing. while at rest, a typical adult will take an average of 18 breaths per
minute. Most people are unaware of their breathing patterns unless something interferes with the efficiency
of this process. In extreme cases, mechanical ventilation is used when spontaneous breathing is inadequate
or ceases entirely.
DEPENDENT MODES
Some modes of mechanical ventilation require spontaneous ventilation, some of these include:
• Bilevel positive airway pressure (BPAP, BiPAP®)
• Continuous positive airway pressure (CPAP)
• Airway pressure release ventilation (APRV, (BiVent®).
NON-INVASIVE VENTILATION
Non-invasive ventilation (NIV) is the use of airway support administered through a face (nasal) mask instead
of an endotracheal tube. Inhaled gases are given with positive end-expiratory pressure often with pressure
support or with assist control ventilation at a set tidal volume and rate. Numerous studies have shown this
technique to be as effective as, and better tolerated than, intubation and mechanical ventilation in patients with
exacerbations of COPD. It is termed “non-invasive” because it is delivered with a mask that is tightly fitted to
the face, but without a need for tracheal intubation. While there are similarities with regards to the interface,
NIV is not the same as continuous positive airway pressure (CPAP), which applies a single level of positive
airway pressure throughout the whole respiratory cycle; CPAP does not deliver ventilation but is occasionally
used in conditions also treated with NIV.
Medical uses
NIV can be used acutely and long-term. In some people who have presented with acute respiratory failure,
there is an ongoing need for long-term use of NIV at home.
*<;,
NIV for acute respiratory failure is used particularly for severe exacerbations of chronic obstructive
pulmonary disease (COPD) but also for acute decompensated heart failure and other acute conditions. In
acute cardiogenic pulmonary oedema caused by decompensated heart failure, the quality of evidence is poor
but studies have shown a reduced risk of death and a decreased need for tracheal intubation for both NIV and
CPAP.
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Chronic use of NIV (“home NIV”) may be indicated for severe COPD. Home NIV may also be indicated
in people with neuromuscular disease and chest wall deformity. People with obesity hypoventilation
syndrome often require NIV initially in their care, but many can be switched to CPAP. People with motor
neuron disease (MND) may require home NIV in the course of their illness. Guidelines in the United
Kingdom stipulate that assessment of respiratory function is part of the multidisciplinary management of
MND.
Terminology
A number of terms have been used in the medical literature to describe NIV. The more formal name
non-invasive positive pressure ventilation (NPPV or NIPPV) has been used to distinguish it from the use
of the now very rare negative pressure ventilator (“iron lung”). The brand name BiPAP/BIPAP has also
enjoyed a degree of popularity, after an early NIV machine produced by Respironics, but its use is now
discouraged.
Modes 17
History
Non-invasive ventilation has been used since the 1940s for various indications, but its present-day use for
chronic breathing problems arose in the 1980s for people with chronic respiratory muscle weakness, and in
the 1990s on intensive care units and other acute care settings for acute respiratory failure. Since 2000 acute
NIV has been used widely in the treatment of acute respiratory failure, particularly in people with COPD,
including on general wards rather than the intensive care unit setting. In the United Kingdom, a 2017 report
by NCEPOD found that there were widespread problems in the delivery of high-quality care to patients.
CONTINUOUS POSITIVE AIRWAY PRESSURE
Fig. CPAP therapy: flow generator, hose, full face mask.

Continuous positive airway pressure (CPAP) is a form of positive airway pressure ventilator, which applies
mild air pressure on a continuous basis to keep the airways continuously open in people who are able to breathe
spontaneously on their own. It is an alternative to positive end-expiratory pressure (PEEP). Both modalities
stent the lungs’ alveoli open and thus recruit more of the lung’s surface area for ventilation. But while PEEP
refers to devices that impose positive pressure only at the end of the exhalation, CPAP devices apply continuous
positive airway pressure throughout the breathing cycle. Thus, the ventilator itself does not cycle during CPAP,
no additional pressure above the level of CPAP is provided, and patients must initiate all of their breaths. CPAP
typically is used for people who have breathing problems, such as sleep apnea. CPAP also may be used to treat
preterm infants whose lungs have not yet fully developed. For example, physicians may use CPAP in infants
with respiratory distress syndrome. It is associated with a decrease in the incidence of bronchopulmonary
dysplasia. In some preterm infants whose lungs haven’t fully developed, CPAP improves survival and decreases
the need for steroid treatment for their lungs. In resource-limited settings where CPAP improves respiratory
rate and survival in children with primary pulmonary disease, researchers have found that nurses can initiate
and manage care with once or twice daily physician rounds. CPAP therapy utilizes machines specifically designed
to deliver a constant flow of pressure. Some CPAP machines have other features as well, such as heated
humidifiers. CPAP is the most effective treatment for obstructive sleep apnea, in which the mild pressure from
the CPAP prevents the airway from collapsing or becoming blocked. Although delivery of CPAP through a
nasal mask is the most common modality of treatment, other systems exist for interfacing with adults and
children. Nasal CPAP is frequently used in infants, though its use is controversial. Studies have shown nasal
CPAP reduces ventilator time but an increased occurrence of pneumothorax was also prevalent. Oral masks and
naso-oral masks are often used when nasal congestion or obstruction is an issue. Devices that combine nasal
pressure with maxillary advancement devices (MAD) also exist.
High Flow Therapy

Humidified high flow nasal airway respiratory support is a method of delivering a high per-minute volume
of respiratory gas via nasal cannula. The respiratory gas is heated to near body temperature and humidified,
usually to saturation vapor pressure. This form of respiratory support is generally referred to as high flow
therapy (HFT). HFT is also referred to as transnasal insufflation (TNI), especially when used for treatment of
sleep apnea. Nasal cannulae usually used for oxygen delivery typically deliver 1–6 liters of oxygen per minute.
The FiO2 — the percentage of oxygen inhaled by the patient—usually ranges roughly from 24% to 35%, as
100% O2 delivered from the cannula is diluted with air at about 21% oxygen. Flow rates for delivery of oxygen
using typical nasal cannulae are limited because medical oxygen is anhydrous, and when delivered from a
pressurized source the gas cools as it expands with the drop to atmospheric pressure. Delivery of cold, dry gas
is irritating to the respiratory mucosa, can cause drying and bleeding of the nasal mucosa, can trigger
bronchospasm in asthmatics, and can increase metabolic demand by cooling the body. Thus oxygen delivery by
nasal cannula is limited to less than 6 liters per minute. Even with quiet breathing, the inspiratory flow rate at
the nares of an adult usually exceeds 12 liters per minute, and can exceed 30 liters a minute for someone with
mild respiratory distress. The typical upper limit for oxygen delivery via nasal cannula of six liters a minute
does not meet the inspiratory flow rates of the average adult, and therefore the oxygen is diluted with room air
during inspiration. Prior to the advent of HFT, when high FiO2 was required for respiratory support, special
face masks or intubation were required. With HFT, respiratory gas flow volume is delivered which meets or
exceeds the patient’s inspiratory flow rate, and is heated and humidified, allowing for comfortable delivery of
respiratory support. For HFT, a source of oxygen is usually blended with compressed air. Hospitals usually
have 350 kPa (50 psi) compressed O2 and air available for therapeutic use. This allows the delivery of air,
blends of air and O2 from 22% to 99%, or delivery of 100% oxygen with the use of an oxygen blender. The gas
is then heated, generally to about 37 °C (98.6 °F), and humidified to near 100% relative humidity using a
humidifier. The gas is transported to the patient through a heated delivery tube to prevent cooling and condensation
of the water vapor which has been added to the respiratory gas(es). HFT requires the use of a special nasal
cannula and tubing large enough to deliver flow rates of respiratory gas of up to 50 liters per minute in adults.
At the same time, the nasal cannula must be small enough that it does not seal inside the nares, as this allows
flow during exhalation and excess gas flow during inhalation to escape. If the cannula did seal, the high flow
volume could produce excessive pressure in the airway and might provoke barotrauma.
,5,-0;:
Since the delivered flow rate of HFT can meet the inspiration flow rate, the delivered gases are not diluted
by room air. The FiO2 is controlled by the clinician, and can be set from 21% to 100% oxygen. Nasal high flow
therapy reduces respiratory dead space, and generates some positive airway pressure resulting from the expiratory
Modes 19
resistance generated by continuous high-flow gas delivery. Flow rates exceeding inspiratory demand may also
provide positive pressure during inspiration. Heated humidification of the respiratory gas facilitates secretion
clearance and decreases the development of bronchial hyper-response symptoms. Some patients requiring
respiratory support for bronchospasm benefit from using air delivered by HFT without additional oxygen. HFT
is useful in the treatment of sleep apnea.
,65(;,:
Nasal HFT has shown to be useful in neonatal intensive care settings for premature infants with infant
respiratory distress syndrome (RDS), as it prevents many infants from being intubated, and allows safe respiratory
management at lower FiO2 levels, thus reducing the risk of retinopathy of prematurity or other forms of oxygen
toxicity.
Complications
• Swallowing of air into the stomach may occur.
Settings and Measurements

• CPAP: This is the pressure applied without pause or end to the airway. Generally utilizing flow to
generate the pressure.
• PEEP: Positive end-expiratory pressure (PEEP) is the pressure in the lungs (alveolar pressure) above
atmospheric pressure (the pressure outside of the body) that exists at the end of expiration.
• Ramp: This feature is present on many devices and allows the user to reduce the pressure to lowest
setting and gradually increase to the set pressure. This allows the user to fall asleep with the pressure
at a more comfortable setting.
• FIO2: Fractional O2 percentage — that is, the fraction of inspired oxygen that is added to the delivered
air.
AIRWAY PRESSURE RELEASE VENTILATION

Airway pressure release ventilation (APRV) is a pressure control mode of mechanical ventilation that
utilizes an inverse ratio ventilation strategy. APRV is an applied continuous positive airway pressure (CPAP)
that at a set timed interval releases the applied pressure. Depending on the ventilator manufacturer, it may be
referred to as BiVent. This is just as appropriate to use, since the only difference is that the term APRV is
copyrighted.
Fig. A pressure-time graphic.

Fig. Static pressure-volume curve during volume-controlled mechanical ventilation. High pressure (‘P high’)
is set below the high inflection point (HIP) and low pressure is set above the low inflection point (LIP).
Fig. Corresponding pressure and flow curves during one cycle of inflation deflation. Notice the flow curve goes
back to zero at the end of inflation, indicating full lung inflation; and also goes back to zero during the release
period before inflation starts, indicating complete gas exhalation with no intrinsic PEEP.
Fig. Pressure-time curve for APRV. ‘P high’ is the high CPAP, ‘P low’ is the low CPAP, ‘T high’ is the duration of ‘P
high,’ and ‘T low’ is the release period or the duration of ‘P low.’ Spontaneous breathing appears on the top of ‘P high.’
Modes 21
History
Airway pressure release ventilation was described initially by Stock and Downs in 1987 as a continuous
positive airway pressure (CPAP) with an intermittent release phase. APRV begins at a pressure higher than the
baseline pressure and follows with a deflation to accomplish tidal ventilation. Fundamentally APRV is a time-
cycled alternant between two levels of positive airway pressure, with the main time on the high level and a brief
expiratory release to facilitate ventilation.
Indications
Based on clinical and experimental data, airway pressure release ventilation is indicated in patients with
acute lung injury, acute respiratory distress syndrome and atelectasis after major surgery.
Inverse Ratio Ventilation

This is a type of inverse ratio ventilation. The exhalation time (Tlow) is shortened to usually less than one
second to maintain alveoli inflation. Fundamentally this is a continuous pressure with a brief release. APRV is
currently the most efficient, conventional mode for lung protective ventilation.
Settings and Measurements

Settings are sometimes brand specific and the term for the individual settings may differ, however
generally the settings listed here are a fundamental explanation of the purpose of the settings within the
APRV mode.
• Phigh — This is the inspiratory pressure (just like in pressure control).
• Thigh — This value is the number of seconds during the inhalation phase.
• Tpeep — Also known as the Tlow, this is the time allotted for expiration.
• FiO2 — The fractional O2 percentage that is being added to the delivered air.
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Mean airway pressure on APRV is calculated by this formula:
(Phigh )
* Thigh + ( Plow * Tlow )
Thigh + Tlow
Perceptions and Receptions

Different perceptions of this mode may exist around the globe. While ‘APRV’ is common to users in
North America, a very similar mode, biphasic positive airway pressure (BIPAP), was introduced in Europe.
The term APRV has also been used in American journals where, from the ventilation characteristics, BIPAP
would have been the appropriate terminology. To further confusion, BiPAP© is a registered trade-mark for
a non-invasive ventilation mode in a specific ventilator (Respironics Inc.). Other names (BILEVEL,
DUOPAP, BIVENT) have been created for legal reasons. Although similar in modality, these terms describe
how a mode is intended to inflate the lung, rather than defining the characteristics of synchronization or
the way spontaneous breathing efforts are supported. Concern has been raised about the amount of
mechanical power applied to the lung during APRV and the risk of ergotrauma, especially in pulmonary
ARDS.
Other Terms
APRV is used by many brands and models of mechanical ventilators under different names. Most names are
copyrighted as trademarks and do not represent nomenclature of mechanical ventilation but may be referred to
clinically by the brand name.
Some of these names include:
• BiVent - (Servo-i ventilator by Maquet)
• BiLevel - (Puritan Bennett 840 ventilator by Covidien)
• DuoPAP - ( C-1 ventilator by Hamilton).

Positive airway pressure (PAP) is a mode of respiratory ventilation used in the treatment of sleep apnea. PAP
ventilation is also commonly used for those who are critically ill in hospital with respiratory failure, in newborn
infants (neonates), and for the prevention and treatment of atelectasis in patients with difficulty taking deep
breaths. In these patients, PAP ventilation can prevent the need for tracheal intubation, or allow earlier extubation.
Sometimes patients with neuromuscular diseases use this variety of ventilation as well. CPAP is an acronym for
“continuous positive airway pressure”, which was developed by Dr. George Gregory and colleagues in the
neonatal intensive care unit at the University of California, San Francisco. A variation of the PAP system was
developed by Professor Colin Sullivan at Royal Prince Alfred Hospital in Sydney, Australia, in 1981. The main
difference between BiPAP and CPAP machines is that BiPAP machines have two pressure settings: the prescribed
pressure for inhalation (ipap), and a lower pressure for exhalation (epap). The dual settings allow the patient to
get more air in and out of their lungs.
MEDICAL USES
The main indications for positive airway pressure are congestive heart failure and chronic obstructive
pulmonary disease. There is some evidence of benefit for those with hypoxia and community acquired pneumonia.
PAP ventilation is often used for patients who have acute type 1 or 2 respiratory failure. Usually PAP ventilation
will be reserved for the subset of patients for whom oxygen delivered via a face mask is deemed insufficient or
deleterious to health. Usually, patients on PAP ventilation will be closely monitored in an intensive care unit,
high dependency unit, coronary care unit or specialist respiratory unit. The most common conditions for which
PAP ventilation is used in hospital are congestive cardiac failure and acute exacerbation of obstructive airway
disease, most notably exacerbations of COPD and asthma. It is not used in cases where the airway may be
compromised, or consciousness is impaired. CPAP is also used to assist premature babies with breathing in the
NICU setting.
The mask required to deliver CPAP must have an effective seal, and be held on very securely. The “nasal
pillow” mask maintains its seal by being inserted slightly into the nostrils and being held in place by various
straps around the head. Some full-face masks “float” on the face like a hover-craft, with thin, soft, flexible
“curtains” ensuring less skin abrasion, and the possibility of coughing and yawning. Some people may find
wearing a CPAP mask uncomfortable or constricting: eyeglass wearers and bearded men may prefer the
nasal-pillow type of mask. Breathing out against the positive pressure resistance (the expiratory positive
airway pressure component, or EPAP) may also feel unpleasant to some patients. These factors lead to inability
to continue treatment due to patient intolerance in about 20% of cases where it is initiated. Some machines
have pressure relief technologies that makes sleep therapy more comfortable by reducing pressure at the
beginning of exhalation and returning to therapeutic pressure just before inhalation. The level of pressure
relief is varied based on the patient’s expiratory flow, making breathing out against the pressure less difficult.
Modes 23
Those who suffer an anxiety disorder or claustrophobia are less likely to tolerate PAP treatment. Sometimes
medication will be given to assist with the anxiety caused by PAP ventilation. Unlike PAP used at home to
splint the tongue and pharynx, PAP is used in hospital to improve the ability of the lungs to exchange oxygen
and carbon dioxide, and to decrease the work of breathing (the energy expended moving air into and out of
the alveoli).
This is because:
• During inspiration, the inspiratory positive airway pressure, or IPAP, forces air into the lungs—thus
less work is required from the respiratory muscles.
• The bronchioles and alveoli are prevented from collapsing at the end of expiration. If these small
airways and alveoli are allowed to collapse, significant pressures are required to re-expand them.
This can be explained using the Young–Laplace equation (which also explains why the hardest part
of blowing up a balloon is the first breath).
• Entire regions of the lung that would otherwise be collapsed are forced and held open. This process
is called recruitment. Usually these collapsed regions of lung will have some blood flow (although
reduced). Because these areas of lung are not being ventilated, the blood passing through these areas
is not able to efficiently exchange oxygen and carbon dioxide. This is called ventilation–perfusion
(or V/Q) mismatch. The recruitment reduces ventilation–perfusion mismatch.
• The amount of air remaining in the lungs at the end of a breath is greater (this is called the functional
residual capacity). The chest and lungs are therefore more expanded. From this more expanded
resting position, less work is required to inspire. This is due to the non-linear compliance–volume
curve of the lung.
DISADVANTAGES
A major issue with CPAP is non-compliance. Studies showed that some users either abandon the use of
CPAP, and/or use CPAP for only a fraction of the nights. Prospective PAP candidates are often reluctant to use
this therapy, since the nose mask and hose to the machine look uncomfortable and clumsy. Airflow required for
some patients can be vigorous. Some patients will develop nasal congestion while others may experience rhinitis
or a runny nose. Some patients adjust to the treatment within a few weeks, others struggle for longer periods,
and some discontinue treatment entirely. However, studies show that cognitive behavioural therapy at the
beginning of therapy dramatically increases compliance—up to 148%. While common PAP side effects are
merely nuisances, serious side effects such as eustachian tube infection, or pressure build-up behind the cochlea
are very uncommon. Furthermore, research has shown that PAP side effects are rarely the reason patients stop
using PAP. There are reports of dizziness, sinus infections, bronchitis, dry eyes, dry mucosal tissue irritation,
ear pain, and nasal congestion secondary to CPAP use.
PAP manufacturers frequently offer different models at different price ranges, and PAP masks have many
different sizes and shapes, so that some users need to try several masks before finding a good fit. These different
machines may not be comfortable for all users, so proper selection of PAP models may be very important in
furthering adherence to therapy. Beards, mustaches, or facial irregularities may prevent an air-tight seal. Where
the mask contacts the skin must be free from dirt and excess chemicals such as skin oils. Shaving before mask-
fitting may be necessary in some cases. However, facial irregularities of this nature frequently do not hinder the
operation of the device or its positive airflow effects for sleep apnea patients. For many people, the only
problem from an incomplete seal is a higher noise level near the face from escaping air. The CPAP mask can act
as an orthodontic headgear and move the teeth and the upper and/or lower jaw backward. This effect can
increase over time and may or may not cause TMJ disorders in some patients. These facial changes have been
dubbed “Smashed Face Syndrome”.
MECHANISM OF ACTION
Continuous Pressure Devices
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A continuous positive airway pressure (CPAP) machine was initially used mainly by patients for the treatment
of sleep apnea at home, but now is in widespread use across intensive care units as a form of ventilation.
Obstructive sleep apnea occurs when the upper airway becomes narrow as the muscles relax naturally during
sleep. This reduces oxygen in the blood and causes arousal from sleep. The CPAP machine stops this phenomenon
by delivering a stream of compressed air via a hose to a nasal pillow, nose mask, full-face mask, or hybrid,
splinting the airway (keeping it open under air pressure) so that unobstructed breathing becomes possible,
therefore reducing and/or preventing apneas and hypopneas. It is important to understand, however, that it is
the air pressure, and not the movement of the air, that prevents the apneas. When the machine is turned on, but
prior to the mask being placed on the head, a flow of air comes through the mask. After the mask is placed on
the head, it is sealed to the face and the air stops flowing. At this point, it is only the air pressure that accomplishes
the desired result. This has the additional benefit of reducing or eliminating the extremely loud snoring that
sometimes accompanies sleep apnea. The CPAP machine blows air at a prescribed pressure (also called the
titrated pressure). The necessary pressure is usually determined by a sleep physician after review of a study
supervised by a sleep technician during an overnight study (polysomnography) in a sleep laboratory. The titrated
pressure is the pressure of air at which most (if not all) apneas and hypopneas have been prevented, and it is
usually measured in centimetres of water (cmH2O). The pressure required by most patients with sleep apnea
ranges between 6 and 14 cmH2O. A typical CPAP machine can deliver pressures between 4 and 20 cmH2O.
More specialised units can deliver pressures up to 25 or 30 cmH2O. CPAP treatment can be highly effective in
treatment of obstructive sleep apnea. For some patients, the improvement in the quality of sleep and quality of
life due to CPAP treatment will be noticed after a single night’s use. Often, the patient’s sleep partner also
benefits from markedly improved sleep quality, due to the amelioration of the patient’s loud snoring. Given that
sleep apnea is a chronic health issue which commonly doesn’t go away, ongoing care is usually needed to
maintain CPAP therapy. Based on the study of cognitive behavioural therapy (referenced above), ongoing
chronic care management is the best way to help patients continue therapy by educating them on the health risks
of sleep apnea and providing motivation and support.
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An automatic positive airway pressure device (APAP, AutoPAP, AutoCPAP) automatically titrates, or tunes,
the amount of pressure delivered to the patient to the minimum required to maintain an unobstructed airway on
a breath-by-breath basis by measuring the resistance in the patient’s breathing, thereby giving the patient the
precise pressure required at a given moment and avoiding the compromise of fixed pressure.
Bi-level Pressure Devices

“VPAP” or “BPAP” (variable/bilevel positive airway pressure) provides two levels of pressure: inspiratory
positive airway pressure (IPAP) and a lower expiratory positive airway pressure (EPAP) for easier exhalation.
(Some people use the term BPAP to parallel the terms APAP and CPAP.) Often BPAP is incorrectly referred to
as “BiPAP”. However, BiPAP is the name of a portable ventilator manufactured by Respironics Corporation; it
is just one of many ventilators that can deliver BPAP.
Modes 25
• Modes
– S (Spontaneous) – In spontaneous mode the device triggers IPAP when flow sensors detect
spontaneous inspiratory effort and then cycles back to EPAP.
– T (Timed) – In timed mode the IPAP/EPAP cycling is purely machine-triggered, at a set rate,
typically expressed in breaths per minute (BPM).
– S/T (Spontaneous/Timed) – Like spontaneous mode, the device triggers to IPAP on patient
inspiratory effort. But in spontaneous/timed mode a “backup” rate is also set to ensure that
patients still receive a minimum number of breaths per minute if they fail to breathe
spontaneously.
Expiratory Positive Airway Pressure Devices

Nasal expiratory positive airway pressure (Nasal EPAP) is a treatment for obstructive sleep apnea (OSA)
and snoring. Contemporary EPAP devices have two small valves that allow air to be drawn in through each
nostril, but not exhaled; the valves are held in place by adhesive tabs on the outside of the nose. The mechanism
by which EPAP may work is not clear; it may be that the resistance to nasal exhalation leads to a buildup in CO2
which in turn increases respiratory drive, or that resistance to exhalation generates pressure that forces the
upper airway to open wider.
COMPONENTS
• Flow generator (PAP machine) provides the airflow
• Hose connects the flow generator (sometimes via an in-line humidifier) to the interface
• Interface (nasal or full face mask, nasal pillows, or less commonly a lip-seal mouthpiece) provides
the connection to the user’s airway.
OPTIONAL FEATURES
• Humidifier adds moisture to low humidity air
– Heated: Heated water chamber that can increase patient comfort by eliminating the dryness of
the compressed air. The temperature can usually be adjusted or turned off to act as a passive
humidifier if desired. In general, a heated humidifier is either integrated into the unit or has a
separate power source (i.e. plug).
– Passive: Air is blown through an unheated water chamber and is dependent on ambient air
temperature. It is not as effective as the heated humidifier described above, but still can increase
patient comfort by eliminating the dryness of the compressed air. In general, a passive humidifier
is a separate unit and does not have a power source.
• Mask liners: Cloth-based mask liners may be used to prevent excess air leakage and to reduce skin
irritation and dermatitis.
• Ramp may be used to temporarily lower the pressure if the user does not immediately sleep. The
pressure gradually rises to the prescribed level over a period of time that can be adjusted by the
patient and/or the DME provider.
• Exhalation pressure relief: Gives a short drop in pressure during exhalation to reduce the effort
required. This feature is known by the trade name C-Flex or A-Flex in some CPAPs made by
Respironics and EPR in ResMed machines.
• Flexible chin straps may be used to help the patient not breathe through the mouth (full-face
masks avoid this problem), thereby keeping a closed pressure system. The straps are elastic enough
that the patient can easily open his mouth if he feels that he needs to. Modern straps use a quick-
clip instant fit. Velcro-type adjustments allow quick sizing, before or after the machine is turned
on.
• Data logging records basic compliance info or detailed event logging, allowing the sleep physician
(or patient) to download and analyse data recorded by the machine to verify treatment effectiveness.
• Automatic altitude adjustment versus manual altitude adjustment.
• DC power source versus AC power source.
Such features generally increase the likelihood of PAP tolerance and compliance.
CARE AND MAINTENANCE

As with all durable medical equipment, proper maintenance is essential for proper functioning, long unit life
and patient comfort. The care and maintenance required for PAP machines varies with the type and conditions
of use, and are typically spelled out in a detailed instruction manual specific to the make and model. Most
manufacturers recommend that the end user perform daily and weekly maintenance. Units must be checked
regularly for wear and tear and kept clean. Poorly connected, worn or frayed electrical connections may present
a shock or fire hazard; worn hoses and masks may reduce the effectiveness of the unit. Most units employ some
type of filtration, and the filters must be cleaned or replaced on a regular schedule. Sometimes HEPA filters
may be purchased or modified for asthma or other allergy clients. Hoses and masks accumulate exfoliated skin,
particulate matter, and can even develop mold. Humidification units must be kept free of mold and algae.
Because units use substantial electrical power, housings must be cleaned without immersion. For humidification
units, cleaning of the water container is imperative for several reasons. First, the container may build up minerals
from the local water supply which eventually may be become part of the air breathed. Second, the container
may eventually show signs of “sluge” coming from dust and other particles which make their way through the
air filter which must also be changed as it accumulates dirt. To help clean the unit, some patients have used a
very small amount of hydrogen peroxide mixed with the water in the container. They would then let it stand for
a few minutes before emptying and rinsing. If this procedure is used, it is imperative to rinse the unit with soap
and water before reinstalling onto the machine and breathing. Anti-bacterial soap is not recommended by sellers.
To reduce the risk of contamination, distilled water is a good alternative to tap water. If traveling in areas where
the mineral content or purity of the water is unknown or suspect, an alternative is to use a water “purifier” such
as Brita. In cold climates, humidified air may require insulated and/or heated air hoses. These may be bought
ready-made, or modified from commonly available materials.
PORTABILITY
Since continuous compliance is an important factor in the success of treatment, it is of importance that
patients who travel have access to portable equipment. Progressively, PAP units are becoming lighter and more
compact, and often come with carrying cases. Dual-voltage power supplies permit many units to be used
internationally. Long-distance travel or camping presents special considerations. Most airport security inspectors
have seen the portable machines, so screening rarely presents a special problem. Increasingly, machines are
capable of being powered by the 400-Hz power supply used on most commercial aircraft and include manual or
automatic altitude adjustment. Machines may easily fit on a ventilator tray on the bottom or back of a power
wheelchair with an external battery. Some machines allow power-inverter and/or car-battery powering. Some
patients on PAP therapy also use supplementary oxygen. When provided in the form of bottled gas, this can
present an increased risk of fire and is subject to restrictions. (Commercial airlines generally forbid passengers
to bring their own oxygen.) As of November 2006, most airlines permit the use of oxygen concentrators.
Modes 27
AVAILABILITY
In many countries, PAP machines are only available by prescription. A sleep study at an accredited sleep lab
is usually necessary before treatment can start. This is because the pressure settings on the PAP machine must
be tailored to a patient’s treatment needs. A sleep medicine doctor, who may also be trained in respiratory
medicine, psychiatry, neurology, paediatrics, family practice or otolaryngology (ear, nose and throat), will
interpret the results from the initial sleep study and recommend a pressure test. This may be done in one night
(a split study with the diagnostic testing done in the first part of the night, and CPAP testing done in the later
part of the night) or with a follow up second sleep study during which the CPAP titration may be done over the
entire night. With CPAP titration (split night or entire night), the patient wears the CPAP mask and pressure is
adjusted up and down from the prescribed setting to find the optimal setting. Studies have shown that split-
night protocol is an effective protocol for diagnosing OSA and titrating CPAP. CPAP compliance rate showed
no difference between the split-night and the two-night protocols.
• In the United States, PAP machines are often available at large discounts online, but a patient
purchasing a PAP personally must handle the responsibility of securing reimbursement from his or
her insurance or Medicare. Many of the internet providers that deal with insurance such as Medicare
will provide upgraded equipment to a patient even if he or she only qualifies for a basic PAP. In
some locations a government programme, separate from Medicare, can be used to claim a
reimbursement for all or part of the cost of the PAP device.
• In the United Kingdom, PAP machines are available on National Health Service prescription after a
diagnosis of sleep apnea or privately from the internet provided a prescription is supplied.
• In Australia, PAP machines can be bought from the Internet or physical stores. There is no requirement
for a doctor’s prescription, however many suppliers will require a referral. Low-income earners who
hold a Commonwealth Health Care Card should enquire with their state’s health department about
programmes that provide free or low-cost PAP machines. Those who have private health insurance
may be eligible for a partial rebate on the cost of a CPAP machine and the mask. Superannuation
may be released for the purchase of essential medical equipment such as PAP machines, on the
provision of letters from two doctors, one of whom must be a specialist, and an application to the
Australian Prudential Regulation Authority (APRA).
• In Canada, CPAP units are widely available in all provinces. Funding for the therapy varies from province
to province. In the province of Ontario, the Ministry of Health and Long-Term Care’s Assistive Devices
Programme will fund a portion of the cost of a CPAP unit based on a sleep study in an approved sleep
lab showing Obstructive Sleep Apnea Syndrome and the signature of an approved physician on the
application form. This funding is available to all residents of Ontario with a valid health card.

Mandatory minute ventilation (MMV) (also called minimum minute ventilation) is a mode of mechanical
ventilation which requires the operator to determine what the appropriate minute ventilation for the patient
should be and the ventilator then monitors the patient’s ability to generate this volume. If the calculation suggests
the volume target will not be met, supplemental breaths are delivered at the targeted volume to achieve the
desired minute ventilation.
APPLICATION
Mandatory minute ventilation is a volume control mode of ventilation and a derivative of intermittent
mandatory ventilation. Mandatory minute ventilation allows spontaneous breathing with automatic adjustments
of mandatory ventilation to meet the patient’s preset minimum minute volume requirement. If the patient maintains
the minute volume settings for VT x f, no mandatory breaths are delivered. If the patient’s minute volume is
insufficient, mandatory delivery of the preset tidal volume will occur until the minute volume is achieved. The
method for monitoring whether or not the patient is meeting the required minute ventilation (VE) is different
per ventilator brand and model, but generally there is a window of time being monitored and a smaller window
being checked against that larger window.
Ventilation of Neonatal Patients

MMV is an optimal mode for weaning in neonatal and pediatric populations and has been shown to reduce
long term complications related to mechanical ventilation.
Ì

High frequency ventilation is a type of mechanical ventilation which utilizes a respiratory rate greater than
4 times the normal value. (>150 (Vf) breaths per minute) and very small tidal volumes. High frequency ventilation
is thought to reduce ventilator-associated lung injury (VALI), especially in the context of ARDS and acute lung
injury. This is commonly referred to as lung protective ventilation. There are different types of High frequency
ventilation. Each type has its own unique advantages and disadvantages. The types of HFV are characterized by
the delivery system and the type of exhalation phase. High frequency ventilation may be used alone, or in
combination with conventional mechanical ventilation. In general, those devices that need conventional
mechanical ventilation do not produce the same lung protective effects as those that can operate without tidal
breathing. Specifications and capabilities will vary depending on the device manufacturer.
PHYSIOLOGY
With conventional ventilation where tidal volumes (VT) exceed dead space(VDEAD), gas exchange is largely
related to bulk flow of gas to the alveoli. With high frequency ventilation, the tidal volumes used are smaller
than anatomical and equipment dead space and therefore alternative mechanisms of gas exchange occur.
PROCEDURE
• Supraglottic Approach—The supraglottic approach is advantageous as it allows a completely tubeless
surgical field.
• Subglottic Approach
• Transtracheal Approach
HIGH FREQUENCY JET VENTILATION (PASSIVE)

In the UK, the Mistral or Monsoon jet ventilator (Acutronic Medical Systems) is most commonly used. In
the United States the Bunnell LifePulse jet ventilator is most commonly used.
Bunnell LifePulse Jet Ventilator

High frequency jet ventilation (HFJV) is provided by the Bunnell Life Pulse High-Frequency Ventilator.
HFJV employs an endotracheal tube adaptor in place for the normal 15 mm ET tube adaptor. A high pressure
“jet” of gas flows out of the adaptor and into the airway. This jet of gas occurs for a very brief duration, about
0.02 seconds, and at high frequency: 4-11 hertz. Tidal volumes ≤ 1 ml/Kg are used during HFJV. This combination
Modes 29
of small tidal volumes delivered for very short periods of time creates the lowest possible distal airway and
alveolar pressures produced by a mechanical ventilator. Exhalation is passive. Jet ventilators utilize various I:E
ratios—between 1:1.1 and 1:12—to help achieve optimal exhalation. Conventional mechanical breaths are
sometimes used to aid in reinflating the lung. Optimal PEEP is used to maintain alveolar inflation and promote
ventilation-to-perfusion matching. Jet ventilation has been shown to reduce ventilator induced lung injury by as
much as 20%. Usage of high frequency jet ventilation is recommended in neonates and adults with severe lung
injury.
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The Bunnell Life Pulse High-Frequency Ventilator is indicated for use in ventilating critically ill infants
with pulmonary interstitial emphysema (PIE). Infants studied ranged in birth weight from 750 to 3529 grams
and in gestation age from 24 to 41 weeks. The Bunnell Life Pulse High-Frequency Ventilator is also indicated
for use in ventilating critically ill infants with respiratory distress syndrome (RDS) complicated by pulmonary
air leaks who are, in the opinion of their physicians, failing on conventional ventilation. Infants of this description
studied ranged in birth weight from 600 to 3660 grams and in gestational age from 24 to 38 weeks.
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The adverse side effects noted during the use of high-frequency ventilation include those commonly found
during the use of conventional positive pressure ventilators. These adverse effects include:
• Pneumothorax
• Pneumopericardium
• Pneumoperitoneum
• Pneumomediastinum
• Pulmonary interstitial emphysema
• Intraventricular hemorrhage
• Necrotizing tracheobronchitis
• Bronchopulmonary dysplasia
65;9(05+0*(;065:
High-frequency jet ventilation is contraindicated in patients requiring tracheal tubes smaller than 2.5 mm
ID.
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The peak inspiratory pressure (PIP) window displays the average PIP. During startup a PIP sample is taken
with every inhalation cycle and is averaged with all other samples taken over the most recent ten-second period.
After regular operation begins, samples are averaged over the most recent twenty-second period.
ΔÇ,3;(È
The value displayed in the ΔP (pressure difference) window represents the difference between the PIP value
and the PEEP value.
Δp = PIP – PEEP
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The servo pressure display indicates the amount of pressure the machine must generate internally in order to
achieve the PIP appearing in the servo-display. Its value can range from 0—20 psi (0—137.9 kPa). If the PIP
sensed or approximated at the distal tip of the tracheal tube deviates from the desired PIP, the machine
automatically generates more or less internal pressure in an attempt to compensate for the change. The servo-
pressure display keeps the operator informed. The servo display is a general clinical indicator of changes in the
compliance or resistance of the patient’s lungs, as well as loss of lung volume due to tension pneumothorax.
High Frequency Percussive Ventilation

HFPV — High frequency percussive ventilation combines HFV plus time cycled, pressure-limited controlled
mechanical ventilation (i.e., pressure control ventilation, PCV).
High Frequency Positive Pressure Ventilation

HFPPV — High frequency positive pressure ventilation is rarely used anymore, having been replaced by
high frequency jet, oscillatory and percussive types of ventilation. HFPPV is delivered through the endotracheal
tube using a conventional ventilator whose frequency is set near its upper limits. HFPV began to be used in
selected centres in the 1980s. It is a hybrid of conventional mechanical ventilation and high-frequency oscillatory
ventilation. It has been used to salvage patients with persistent hypoxemia when on conventional mechanical
ventilation or, in some cases, used as a primary modality of ventilatory support from the start.
High Frequency Flow Interruption

HFFI — High Frequency Flow Interruption is similar to high frequency jet ventilation but the gas control
mechanism is different. Frequently a rotating bar or ball with a small opening is placed in the path of a high
pressure gas. As the bar or ball rotates and the opening lines-up with the gas flow, a small, brief pulse of gas is
allowed to enter the airway. Frequencies for HFFI are typically limited to maximum of about 15 hertz.
High Frequency Ventilation (Active)

High frequency ventilation (active) — HFV-A is notable for the active exhalation mechanic included. Active
exhalation means a negative pressure is applied to force volume out of the lungs. The CareFusion 3100A and
3100B are similar in all aspects except the target patient size. The 3100A is designed for use on patients up to
35 kilograms and the 3100B is designed for use on patients larger than 35 kilograms.
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High frequency oscillatory ventilation was first described in 1972 and is used in neonates and adult patient
populations to reduce lung injury, or to prevent further lung injury. HFOV is characterized by high respiratory
rates between 3.5 and 15 hertz (210 - 900 breaths per minute) and having both inhalation and exhalation maintained
by active pressures. The rates used vary widely depending upon patient size, age, and disease process. In HFOV
the pressure oscillates around the constant distending pressure (equivalent to mean airway pressure [MAP])
which in effect is the same as positive end-expiratory pressure (PEEP). Thus gas is pushed into the lung during
inspiration, and then pulled out during expiration. HFOV generates very low tidal volumes that are generally
less than the dead space of the lung. Tidal volume is dependent on endotracheal tube size, power and frequency.
Different mechanisms (direct bulk flow - convective, Taylorian dispersion, Pendelluft effect, asymmetrical
Modes 31
velocity profiles, cardiogenic mixing and molecular diffusion) of gas transfer are believed to come into play in
HFOV compared to normal mechanical ventilation. It is often used in patients who have refractory hypoxemia
that cannot be corrected by normal mechanical ventilation such as is the case in the following disease processes:
severe ARDS, ALI and other oxygenation diffusion issues. In some neonatal patients HFOV may be used as the
first-line ventilator due to the high susceptibility of the premature infant to lung injury from conventional
ventilation.
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The vibrations are created by an electromagnetic valve that controls a piston. The resulting vibrations are
similar to those produced by a stereo speaker. The height of the vibrational wave is the amplitude. Higher
amplitudes create greater pressure fluctuations which move more gas with each vibration. The number of
vibrations per minute is the frequency. One Hertz equals 60 cycles per minute. The higher amplitudes at lower
frequencies will cause the greatest fluctuation in pressure and move the most gas. Altering the % inspiratory
time (T%i) changes the proportion of the time in which the vibration or sound wave is above the baseline versus
below it. Increasing the % Inspiratory Time will also increase the volume of gas moved or tidal volume. Decreasing
the frequency, increasing the amplitude, and increasing the % inspiratory time will all increase tidal volume and
eliminate CO2. Increasing the tidal volume will also tend to increase the mean airway pressure.
0(: 36>
The bias flow controls and indicates the rate of continuous flow of humidified blended gas through the
patient circuit. The control knob is a 15-turn pneumatic valve which increases flow as it is turned.
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The mean pressure adjust setting adjusts the mean airway pressure (PAW) by controlling the resistance of the
airway pressure control valve. The mean airway pressure will change and requires the mean pressure adjust to
be adjusted when the following settings are changed:
• Frequency (Hertz)
• % Inspiratory time
• Power and Δp change
• Piston centering
During high frequency oscillatory ventilation (HFOV), PAW is the primary variable affecting oxygenation
and is set independent of other variables on the oscillator. Because distal airway pressure changes during
HFOV are minimal, the PAW during HFOV can be viewed in a manner similar to the PEEP level in conventional
ventilation. The optimal PAW can be considered as a compromise between maximal lung recruitment and minimal
overdistention.
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The mean pressure limit controls the limit above which proximal PAW cannot be increased by setting the
control pressure of the pressure limit valve. The mean pressure limit range is 10-45 cmH2O.
Δ(5+4730;<+,
The power setting is set as amplitude to establish a measured change of pressure (ΔP). Amplitude/Power is
a setting which determines the amount of power that is driving the oscillator piston forward and backward
resulting in an air volume (tidal volume) displacement. The effect of the amplitude on the ΔP that it is changed
by the displacement of the oscillator piston and hence the oscillatory pressure (ΔP). The power setting interacts
with PAW conditions existing within the patient circuit to produce the resulting ΔP.
Fig. Tidal volume versus power setting.
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The percent of inspiratory time is a setting which determines the percent of cycle time the piston is traveling
towards (or at its final inspiratory position). The inspiratory percent range is 30—50%.
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The frequency setting is measured in hertz (hz). The control knob is a 10-turn clockwise-increasing
potentiometer covering a range of 3 Hz to 15 Hz. The set frequency is displayed on a digital meter on the face
of the ventilator. One Hertz is (-/+5%) equal to 1 breath per second, or 60 breaths per minute (e.g., 10 Hz = 600
breaths per minute). Changes in frequency are inversely proportional to the amplitude and thus delivered tidal
volume.
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f = Hz • 60seconds
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Oscillation trough pressure is the instantaneous pressure within the HFOV circuit following the oscillating
piston reaching its complete negative deflection.
OTP = MAP – (AMP/3)
TRANSTRACHEAL JET VENTILATION

Transtracheal jet ventilation refers to a type of high-frequency ventilation, low tidal volume ventilation
provided via a laryngeal catheter by specialized ventilators that are usually only available in the operating room
or intensive care unit. This procedure is occasionally employed in the operating room when a difficult airway is
anticipated. Such as Treacher Collins syndrome, Robin sequence, head and neck surgery with supraglottic or
glottic obstruction).
Modes 33
ADVERSE EFFECTS
Pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall.
Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority
of cases the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue,
leading to a tension pneumothorax. This condition can cause a steadily worsening oxygen shortage and low
blood pressure. Unless reversed by effective treatment, it can result in death. Very rarely both lungs may be
affected by a pneumothorax. It is often called a collapsed lung, although that term may also refer to atelectasis.
A primary pneumothorax is one that occurs without an apparent cause and in the absence of significant lung
disease, while a secondary pneumothorax occurs in the presence of existing lung disease. Smoking increases
the risk as do lung diseases including COPD, asthma, and tuberculosis. A pneumothorax can also be caused by
physical trauma to the chest (including a blast injury) or as a complication of a health care intervention, in
which case it is called a traumatic pneumothorax.
Diagnosis of a pneumothorax by physical examination alone can be difficult (particularly in smaller
pneumothoraces). A chest X-ray, computed tomography (CT) scan, or ultrasound is usually used to confirm
its presence. Other conditions that can result in similar symptoms include a hemothorax (buildup of blood in
the pleural space), pulmonary embolism, and heart attack. A large bulla may look similar on a chest X-ray. A
small spontaneous pneumothorax will typically resolve without treatment and requires only monitoring.
This approach may be most appropriate in people who have no underlying lung disease. In a larger
pneumothorax, or if there is shortness of breath, the air may be removed with a syringe or a chest tube
connected to a one-way valve system. Occasionally, surgery may be required if tube drainage is unsuccessful,
or as a preventive measure, if there have been repeated episodes. The surgical treatments usually involve
pleurodesis (in which the layers of pleura are induced to stick together) or pleurectomy (the surgical removal
of pleural membranes). About 17–23 cases of pneumothorax occur per 100,000 people per year. They are
more common in men than women.
0.5:(5+@47;64:
A primary spontaneous pneumothorax (PSP) tends to occur in a young adult without underlying lung problems,
and usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the usual predominant
presenting features. People who are affected by PSPs are often unaware of potential danger and may wait
several days before seeking medical attention. PSPs more commonly occur during changes in atmospheric
pressure, explaining to some extent why episodes of pneumothorax may happen in clusters. It is rare for PSPs
to cause tension pneumothoraces. Secondary spontaneous pneumothoraces (SSPs), by definition, occur in
individuals with significant underlying lung disease. Symptoms in SSPs tend to be more severe than in PSPs, as
the unaffected lungs are generally unable to replace the loss of function in the affected lungs. Hypoxemia
(decreased blood-oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the
lips and skin).
Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause
confusion and – if very severe – may result in comas. The sudden onset of breathlessness in someone with
chronic obstructive pulmonary disease (COPD), cystic fibrosis, or other serious lung diseases should
therefore prompt investigations to identify the possibility of a pneumothorax. Traumatic pneumothorax
most commonly occurs when the chest wall is pierced, such as when a stab wound or gunshot wound
allows air to enter the pleural space, or because some other mechanical injury to the lung compromises the
integrity of the involved structures. Traumatic pneumothoraces have been found to occur in up to half of
all cases of chest trauma, with only rib fractures being more common in this group. The pneumothorax can
be occult (not readily apparent) in half of these cases, but may enlarge – particularly if mechanical ventilation
is required. They are also encountered in patients already receiving mechanical ventilation for some other
reason. Upon physical examination, breath sounds (heard with a stethoscope) may be diminished on the
affected side, partly because air in the pleural space dampens the transmission of sound. Measures of the
conduction of vocal vibrations to the surface of the chest may be altered. Percussion of the chest may be
perceived as hyper-resonant (like a booming drum), and vocal resonance and tactile fremitus can both be
noticeably decreased. Importantly, the volume of the pneumothorax may not be well correlated with the
intensity of the symptoms experienced by the victim, and physical signs may not be apparent if the
pneumothorax is relatively small.
,5:0655,<46;/69(?
Although multiple definitions exist, a tension pneumothorax is generally considered to be present when a
pneumothorax (primary spontaneous, secondary spontaneous, or traumatic) leads to significant impairment
of respiration and/or blood circulation. Tension pneumothorax tends to occur in clinical situations such as
ventilation, resuscitation, trauma, or in patients with lung disease. The most common findings in people with
tension pneumothorax are chest pain and respiratory distress, often with an increased heart rate (tachycardia)
and rapid breathing (tachypnea) in the initial stages. Other findings may include quieter breath sounds on
one side of the chest, low oxygen levels and blood pressure, and displacement of the trachea away from the
affected side.
Rarely, there may be cyanosis (bluish discoloration of the skin due to low oxygen levels), altered level of
consciousness, a hyperresonant percussion note on examination of the affected side with reduced expansion
and decreased movement, pain in the epigastrium (upper abdomen), displacement of the apex beat (heart
impulse), and resonant sound when tapping the sternum. This is a medical emergency and may require
immediate treatment without further investigations. Tension pneumothorax may also occur in someone who
is receiving mechanical ventilation, in which case it may be difficult to spot as the person is typically receiving
sedation; it is often noted because of a sudden deterioration in condition. Recent studies have shown that the
development of tension features may not always be as rapid as previously thought. Deviation of the trachea
to one side and the presence of raised jugular venous pressure (distended neck veins) are not reliable as
clinical signs.
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904(9@765;(5,6<:
Spontaneous pneumothoraces are divided into two types: primary, which occurs in the absence of known
lung disease, and secondary, which occurs in someone with underlying lung disease. The cause of primary
spontaneous pneumothorax is unknown, but established risk factors include male sex, smoking, and a family
history of pneumothorax. Smoking either cannabis or tobacco increases the risk. The various suspected underlying
mechanisms are discussed below.
,*65+(9@765;(5,6<:
Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common
is chronic obstructive pulmonary disease (COPD), which accounts for approximately 70% of cases. Known
lung diseases that may significantly increase the risk for pneumothorax are
Modes 35
Type Causes
Diseases of the airways COPD (especially when emphysema and lung bullae are present), acute severe
asthma, cystic fibrosis
Infections of the lung Pneumocystis pneumonia (PCP), tuberculosis, necrotizing pneumonia
Interstitial lung disease Sarcoidosis, idiopathic pulmonary fibrosis, histiocytosis X,
lymphangioleiomyomatosis (LAM)
Connective tissue diseases Rheumatoid arthritis, ankylosing spondylitis, polymyositis and dermatomyositis,
systemic sclerosis, Marfan’s syndrome and Ehlers–Danlos syndrome
Cancer Lung cancer, sarcomas involving the lung
Miscellaneous Catamenial pneumothorax (associated with the menstrual cycle and related to
endometriosis in the chest)
In children, additional causes include measles, echinococcosis, inhalation of a foreign body, and certain
congenital malformations (congenital cystic adenomatoid malformation and congenital lobar emphysema).
11.5% of people with a spontaneous pneumothorax have a family member who has previously experienced a
pneumothorax. The hereditary conditions – Marfan syndrome, homocystinuria, Ehlers–Danlos syndrome,
alpha 1-antitrypsin deficiency (which leads to emphysema), and Birt–Hogg–Dubé syndrome – have all been
linked to familial pneumothorax. Generally, these conditions cause other signs and symptoms as well, and
pneumothorax is not usually the primary finding. Birt–Hogg–Dubé syndrome is caused by mutations in the
FLCN gene (located at chromosome 17p11.2), which encodes a protein named folliculin. FLCN mutations
and lung lesions have also been identified in familial cases of pneumothorax where other features of Birt–
Hogg–Dubé syndrome are absent. In addition to the genetic associations, the HLA haplotype A2B40 is also a
genetic predisposition to PSP.
9(<4(;0*
A traumatic pneumothorax may result from either blunt trauma or penetrating injury to the chest wall. The
most common mechanism is due to the penetration of sharp bony points at a new rib fracture, which damages
lung tissue. Traumatic pneumothorax may also be observed in those exposed to blasts, even though there is no
apparent injury to the chest. They may be classified as “open” or “closed”. In an open pneumothorax there is a
passage from the external environment into the pleural space through the chest wall. When air is drawn into the
pleural space through this passageway it is known as a sucking chest wound. A closed pneumothorax is when
the chest wall remains intact. Medical procedures, such as the insertion of a central venous catheter into one of
the chest veins or the taking of biopsy samples from lung tissue, may lead to pneumothorax. The administration
of positive pressure ventilation, either mechanical ventilation or non-invasive ventilation, can result in barotrauma
(pressure-related injury) leading to a pneumothorax. Divers who breathe from an underwater apparatus are
supplied with breathing gas at ambient pressure, which results in their lungs containing gas at higher than
atmospheric pressure. Divers breathing compressed air (such as when scuba diving) may suffer a pneumothorax
as a result of barotrauma from ascending just 1 metre (3 ft) while breath-holding with their lungs fully inflated.
An additional problem in these cases is that those with other features of decompression sickness are typically
treated in a diving chamber with hyperbaric therapy; this can lead to a small pneumothorax rapidly enlarging
and causing features of tension.
,*/(50:4
The thoracic cavity is the space inside the chest that contains the lungs, heart, and numerous major blood
vessels. On each side of the cavity, a pleural membrane covers the surface of lung (visceral pleura) and also
lines the inside of the chest wall (parietal pleura). Normally, the two layers are separated by a small amount of
lubricating serous fluid. The lungs are fully inflated within the cavity because the pressure inside the airways is
higher than the pressure inside the pleural space.
Despite the low pressure in the pleural space, air does not enter it because there are no natural connections
to an air-containing passage, and the pressure of gases in the bloodstream is too low for them to be forced into
the pleural space. Therefore, a pneumothorax can only develop if air is allowed to enter, through damage to the
chest wall or damage to the lung itself, or occasionally because microorganisms in the pleural space produce
gas. Chest-wall defects are usually evident in cases of injury to the chest wall, such as stab or bullet wounds
(“open pneumothorax”). In secondary spontaneous pneumothoraces, vulnerabilities in the lung tissue are caused
by a variety of disease processes, particularly by rupturing of bullae (large air-containing lesions) in cases of
severe emphysema. Areas of necrosis (tissue death) may precipitate episodes of pneumothorax, although the
exact mechanism is unclear.
Primary spontaneous pneumothorax (PSP) has for many years been thought to be caused by “blebs” (small
air-filled lesions just under the pleural surface), which were presumed to be more common in those classically
at risk of pneumothorax (tall males) due to mechanical factors. In PSP, blebs can be found in 77% of cases,
compared to 6% in the general population without a history of PSP. As these healthy subjects do not all develop
a pneumothorax later, the hypothesis may not be sufficient to explain all episodes; furthermore, pneumothorax
may recur even after surgical treatment of blebs. It has therefore been suggested that PSP may also be caused by
areas of disruption (porosity) in the pleural layer, which are prone to rupture. Smoking may additionally lead to
inflammation and obstruction of small airways, which account for the markedly increased risk of PSPs in
smokers. Once air has stopped entering the pleural cavity, it is gradually reabsorbed. Tension pneumothorax
occurs when the opening that allows air to enter the pleural space functions as a one-way valve, allowing more
air to enter with every breath but none to escape. The body compensates by increasing the respiratory rate and
tidal volume (size of each breath), worsening the problem. Unless corrected, hypoxia (decreased oxygen levels)
and respiratory arrest eventually follow.
0(.56:0:
The symptoms of pneumothorax can be vague and inconclusive, especially in those with a small PSP;
confirmation with medical imaging is usually required. In contrast, tension pneumothorax is a medical emergency
and may be treated before imaging – especially if there is severe hypoxia, very low blood pressure, or an
impaired level of consciousness. In tension pneumothorax, X-rays are sometimes required if there is doubt
about the anatomical location of the pneumothorax.
/,:;Ì9(@
A plain chest radiograph, ideally with the X-ray beams being projected from the back (posteroanterior,
or “PA”), and during maximal inspiration (holding one’s breath), is the most appropriate first
investigation. It is not believed that routinely taking images during expiration would confer any benefit.
Still, they may be useful in the detection of a pneumothorax when clinical suspicion is high but yet an
inspiratory radiograph appears normal. Also, if the PA X-ray does not show a pneumothorax but there is
a strong suspicion of one, lateral X-rays (with beams projecting from the side) may be performed, but
this is not routine practice.
It is not unusual for the mediastinum (the structure between the lungs that contains the heart, great blood
vessels and large airways) to be shifted away from the affected lung due to the pressure differences. This is
not equivalent to a tension pneumothorax, which is determined mainly by the constellation of symptoms,
hypoxia, and shock. The size of the pneumothorax (i.e. the volume of air in the pleural space) can be determined
with a reasonable degree of accuracy by measuring the distance between the chest wall and the lung. This is
relevant to treatment, as smaller pneumothoraces may be managed differently. An air rim of 2 cm means that
the pneumothorax occupies about 50% of the hemithorax.
Modes 37
Fig. Anteroposterior inspired X-ray, showing subtle left-sided pneumothorax caused by port insertion.
Fig. Lateral inspired X-ray at the same time, more clearly showing the pneumothorax posteriorly in this case.
Fig. Anteroposterior expired X-ray at the same time, more clearly showing the pneumothorax in this case.
British professional guidelines have traditionally stated that the measurement should be performed at the
level of the hilum (where blood vessels and airways enter the lung) with 2 cm as the cutoff, while American
guidelines state that the measurement should be done at the apex (top) of the lung with 3 cm differentiating
between a “small” and a “large” pneumothorax. The latter method may overestimate the size of a pneumothorax
if it is located mainly at the apex, which is a common occurrence. The various methods correlate poorly, but
are the best easily available ways of estimating pneumothorax size. CT scanning can provide a more accurate
determination of the size of the pneumothorax, but its routine use in this setting is not recommended. Not all
pneumothoraces are uniform; some only form a pocket of air in a particular place in the chest. Small amounts
of fluid may be noted on the chest X-ray (hydropneumothorax); this may be blood (hemopneumothorax). In
some cases, the only significant abnormality may be the “deep sulcus sign”, in which the normally small
space between the chest wall and the diaphragm appears enlarged due to the abnormal presence of fluid.
647<;,+646.9(7/@
Computed tomography (CT, or “CAT scan”) is not necessary for the diagnosis of pneumothorax, but it can
be useful in particular situations. In some lung diseases, especially emphysema, it is possible for abnormal lung
areas such as bullae (large air-filled sacs) to have the same appearance as a pneumothorax on chest X-ray, and
it may not be safe to apply any treatment before the distinction is made and before the exact location and size of
the pneumothorax is determined. In trauma, where it may not be possible to perform an upright film, chest
radiography may miss up to a third of pneumothoraces, while CT remains very sensitive. A further use of CT is
Modes 39
in the identification of underlying lung lesions. In presumed primary pneumothorax, it may help to identify
blebs or cystic lesions (in anticipation of treatment), and in secondary pneumothorax it can help to identify
most of the causes listed above.
3;9(:6<5+
Ultrasound is commonly used in the evaluation of people who have sustained physical trauma, for example
with the FAST protocol. Ultrasound may be more sensitive than chest X-rays in the identification of pneumothorax
after blunt trauma to the chest. Ultrasound may also provide a rapid diagnosis in other emergency situations,
and allow the quantification of the size of the pneumothorax. Several particular features on ultrasonography of
the chest can be used to confirm or exclude the diagnosis.
(5(.,4,5;
The treatment of pneumothorax depends on a number of factors, and may vary from discharge with early
follow-up to immediate needle decompression or insertion of a chest tube. Treatment is determined by the
severity of symptoms and indicators of acute illness, the presence of underlying lung disease, the estimated size
of the pneumothorax on X-ray, and – in some instances – on the personal preference of the person involved. In
traumatic pneumothorax, chest tubes are usually inserted. If mechanical ventilation is required, the risk of
tension pneumothorax is greatly increased and the insertion of a chest tube is mandatory. Any open chest wound
should be covered with an airtight seal, as it carries a high risk of leading to tension pneumothorax. Ideally, a
dressing called the “Asherman seal” should be utilized, as it appears to be more effective than a standard “three-
sided” dressing. The Asherman seal is a specially designed device that adheres to the chest wall and, through a
valve-like mechanism, allows air to escape but not to enter the chest. Tension pneumothorax is usually treated
with urgent needle decompression. This may be required before transport to the hospital, and can be performed
by an emergency medical technician or other trained professional. The needle or cannula is left in place until a
chest tube can be inserted. If tension pneumothorax leads to cardiac arrest, needle decompression is performed
as part of resuscitation as it may restore cardiac output.
65:,9=(;0=,
Small spontaneous pneumothoraces do not always require treatment, as they are unlikely to proceed to respiratory
failure or tension pneumothorax, and generally resolve spontaneously. This approach is most appropriate if the
estimated size of the pneumothorax is small (defined as <50% of the volume of the hemithorax), there is no
breathlessness, and there is no underlying lung disease. It may be appropriate to treat a larger PSP conservatively if
the symptoms are limited. Admission to hospital is often not required, as long as clear instructions are given to return
to hospital if there are worsening symptoms. Further investigations may be performed as an outpatient, at which time
X-rays are repeated to confirm improvement, and advice given with regard to preventing recurrence. Estimated rates
of resorption are between 1.25% and 2.2% the volume of the cavity per day. This would mean that even a complete
pneumothorax would spontaneously resolve over a period of about 6 weeks. There is, however, no high quality
evidence comparing conservative to non conservative management. Secondary pneumothoraces are only treated
conservatively if the size is very small (1 cm or less air rim) and there are limited symptoms. Admission to the
hospital is usually recommended. Oxygen given at a high flow rate may accelerate resorption as much as fourfold.
:709(;065
In a large PSP (>50%), or in a PSP associated with breathlessness, some guidelines recommend that reducing
the size by aspiration is equally effective as the insertion of a chest tube. This involves the administration of
local anesthetic and inserting a needle connected to a three-way tap; up to 2.5 liters of air (in adults) are
removed. If there has been significant reduction in the size of the pneumothorax on subsequent X-ray, the
remainder of the treatment can be conservative. This approach has been shown to be effective in over 50% of
cases. Compared to tube drainage, first-line aspiration in PSP reduces the number of people requiring hospital
admission, without increasing the risk of complications. Aspiration may also be considered in secondary
pneumothorax of moderate size (air rim 1–2 cm) without breathlessness, with the difference that ongoing
observation in hospital is required even after a successful procedure. American professional guidelines state
that all large pneumothoraces – even those due to PSP – should be treated with a chest tube. Moderately sized
iatrogenic traumatic pneumothoraces (due to medical procedures) may initially be treated with aspiration.
/,:;<),
A chest tube (or intercostal drain) is the most definitive initial treatment of a pneumothorax. These are
typically inserted in an area under the axilla (armpit) called the “safe triangle”, where damage to internal organs
can be avoided; this is delineated by a horizontal line at the level of the nipple and two muscles of the chest wall
(latissimus dorsi and pectoralis major). Local anesthetic is applied. Two types of tubes may be used. In
spontaneous pneumothorax, small-bore (smaller than 14 F, 4.7 mm diameter) tubes may be inserted by the
Seldinger technique, and larger tubes do not have an advantage. In traumatic pneumothorax, larger tubes (28 F,
9.3 mm) are used. Chest tubes are required in PSPs that have not responded to needle aspiration, in large SSPs
(>50%), and in cases of tension pneumothorax. They are connected to a one-way valve system that allows air to
escape, but not to re-enter, the chest. This may include a bottle with water that functions like a water seal, or a
Heimlich valve. They are not normally connected to a negative pressure circuit, as this would result in rapid re-
expansion of the lung and a risk of pulmonary edema (“re-expansion pulmonary edema”). The tube is left in
place until no air is seen to escape from it for a period of time, and X-rays confirm re-expansion of the lung. If
after 2–4 days there is still evidence of an air leak, various options are available. Negative pressure suction (at
low pressures of –10 to –20 cmH2O) at a high flow rate may be attempted, particularly in PSP; it is thought that
this may accelerate the healing of the leak. Failing this, surgery may be required, especially in SSP. Chest tubes
are used first-line when pneumothorax occurs in people with AIDS, usually due to underlying pneumocystis
pneumonia (PCP), as this condition is associated with prolonged air leakage. Bilateral pneumothorax
(pneumothorax on both sides) is relatively common in people with pneumocystis pneumonia, and surgery is
often required. It is possible for a patient with a chest tube to be managed in an ambulatory care setting by using
a Heimlich valve, although research to demonstrate the equivalence to hospitalization has been of limited
quality.
3,<96+,:0:(5+<9.,9@
Pleurodesis is a procedure that permanently eliminates the pleural space and attaches the lung to the chest wall.
No long-term study (20 years or more) has been performed on its consequences. Good results in the short term are
achieved with a thoracotomy (surgical opening of the chest) with identification of any source of air leakage and
stapling of blebs followed by pleurectomy (stripping of the pleural lining) of the outer pleural layer and pleural
abrasion (scraping of the pleura) of the inner layer. During the healing process, the lung adheres to the chest wall,
effectively obliterating the pleural space. Recurrence rates are approximately 1%. Post-thoracotomy pain is relatively
common. A less invasive approach is thoracoscopy, usually in the form of a procedure called video-assisted
thoracoscopic surgery (VATS). The results from VATS-based pleural abrasion are slightly worse than those achieved
using thoracotomy in the short term, but produce smaller scars in the skin. Compared to open thoracotomy, VATS
offers a shorter in-hospital stays, less need for postoperative pain control, and a reduced risk of lung problems after
surgery. VATS may also be used to achieve chemical pleurodesis; this involves insufflation of talc, which activates
an inflammatory reaction that causes the lung to adhere to the chest wall.
Modes 41
If a chest tube is already in place, various agents may be instilled through the tube to achieve chemical pleurodesis,
such as talc, tetracycline, minocycline or doxycycline. Results of chemical pleurodesis tend to be worse than when
using surgical approaches, but talc pleurodesis has been found to have few negative long-term consequences in
younger people.
-;,9*(9,
If pneumothorax occurs in a smoker, this is considered an opportunity to emphasize the markedly increased
risk of recurrence in those who continue to smoke, and the many benefits of smoking cessation. It may be
advisable for someone to remain off work for up to a week after a spontaneous pneumothorax. If the person
normally performs heavy manual labour, several weeks may be required. Those who have undergone pleurodesis
may need two to three weeks off work to recover. Air travel is discouraged for up to seven days after complete
resolution of a pneumothorax if recurrence does not occur. Underwater diving is considered unsafe after an
episode of pneumothorax unless a preventative procedure has been performed. Professional guidelines suggest
that pleurectomy be performed on both lungs and that lung function tests and CT scan normalize before diving
is resumed. Aircraft pilots may also require assessment for surgery.
9,=,5;065
A preventative procedure (thoracotomy or thoracoscopy with pleurodesis) may be recommended after
an episode of pneumothorax, with the intention to prevent recurrence. Evidence on the most effective
treatment is still conflicting in some areas, and there is variation between treatments available in Europe
and the US. Not all episodes of pneumothorax require such interventions; the decision depends largely on
estimation of the risk of recurrence. These procedures are often recommended after the occurrence of a
second pneumothorax. Surgery may need to be considered if someone has experienced pneumothorax on
both sides (“bilateral”), sequential episodes that involve both sides, or if an episode was associated with
pregnancy.
70+,40636.@
The annual age-adjusted incidence rate (AAIR) of PSP is thought to be three to six times as high in males
as in females. Fishman cites AAIR’s of 7.4 and 1.2 cases per 100,000 person-years in males and females,
respectively. Significantly above-average height is also associated with increased risk of PSP – in people
who are at least 76 inches (1.93 meters) tall, the AAIR is about 200 cases per 100,000 person-years. Slim
build also seems to increase the risk of PSP. The risk of contracting a first spontaneous pneumothorax is
elevated among male and female smokers by factors of approximately 22 and 9, respectively, compared to
matched non-smokers of the same sex. Individuals who smoke at higher intensity are at higher risk, with a
“greater-than-linear” effect; men who smoke 10 cigarettes per day have an approximate 20-fold increased
risk over comparable non-smokers, while smokers consuming 20 cigarettes per day show an estimated 100-
fold increase in risk. In secondary spontaneous pneumothorax, the estimated annual AAIR is 6.3 and 2.0
cases per 100,000 person-years for males and females, respectively, with the risk of recurrence depending on
the presence and severity of any underlying lung disease. Once a second episode has occurred, there is a high
likelihood of subsequent further episodes. The incidence in children has not been well studied, but is estimated
to be between 5 and 10 cases per 100,000 person-years. Death from pneumothorax is very uncommon (except
in tension pneumothoraces). British statistics show an annual mortality rate of 1.26 and 0.62 deaths per
million person-years in men and women, respectively. A significantly increased risk of death is seen in older
victims and in those with secondary pneumothoraces.
0:;69@
An early description of traumatic pneumothorax secondary to rib fractures appears in Imperial Surgery by
Turkish surgeon Þerafeddin Sabuncuoðlu (1385–1468), which also recommends a method of simple aspiration.
Pneumothorax was described in 1803 by Jean Marc Gaspard Itard, a student of René Laennec, who provided an
extensive description of the clinical picture in 1819. While Itard and Laennec recognized that some cases were not
due to tuberculosis (then the most common cause), the concept of spontaneous pneumothorax in the absence of
tuberculosis (primary pneumothorax) was reintroduced by the Danish physician Hans Kjærgaard in 1932. In
1941, the surgeons Tyson and Crandall introduced pleural abrasion for the treatment of pneumothorax. Prior to the
advent of anti-tuberculous medications, pneumothoraces were intentionally caused by health care providers in
people with tuberculosis in an effort to collapse a lobe, or entire lung, around a cavitating lesion. This was known
as “resting the lung”. It was introduced by the Italian surgeon Carlo Forlanini in 1888, and publicized by the
American surgeon John Benjamin Murphy in the early 20th century (after discovering the same procedure
independently). Murphy used the (then) recently discovered X-ray technology to create pneumothoraces of the
correct size.
Pneumopericardium
Pneumopericardium is a medical condition where air enters the pericardial cavity. This condition has been
recognized in preterm neonates, in which it is associated with severe lung pathology, after vigorous resuscitation,
or in the presence of assisted ventilation. This is a serious complication, which if untreated may lead to cardiac
tamponade and death. Pneumomediastinum, which is the presence of air in the mediastinum, may mimic and
also coexist with pneumopericardium. It can be congenital, or introduced by a wound.
9,:,5;(;065
The symptomatic patient may present with dyspnea, cyanosis, chest pain, pulsus paradoxus, bradycardia or
tachycardia.
(;/67/@:0636.@
The mechanism responsible for pneumopericardium is the ‘Macklin effect’ – There is initially an increased
pressure gradient between the alveoli and the interstitial space. Increased pressure leads to alveolar rupture,
resulting in air getting through to the pericapillary interstitial pulmonary space. This space is continuous with
the peribronchial and pulmonary perivascular sheaths. From here, the air tracks to the hilum of the lung and
then to the mediastinum. In case of a pericardial tear, this air enters the pericardial cavity and pneumopericardium
develops. The condition may remain asymptomatic or may progress to life-threatening conditions like tension
pneumopericardium or cardiac tamponade.
0(.56:0:
On physical examination, the patient may have the classic “Beck’s triad” – hypotension, raised JVP and
distant heart sounds, when complicated by cardiac tamponade. Extension of the mediastinal air to the subcutaneous
tissues via the fascial planes may lead to subcutaneous emphysema. When air and fluid mix together in the
pericardial sac, a tinkling sound superimposed over a succussion splash is heard. This is known as a “Bruit de
Moulin”, which is French for “Mill–wheel” murmur. Air between the anterior parietal pericardium and the
thoracic cage may also give rise to the “Hamman’s Sign” – which is a crunching sound typically heard on
auscultation of the chest, but may sometimes be heard even with the unaided ear.
Modes 43
Pneumoperitoneum
Pneumoperitoneum is pneumatosis (abnormal presence of air or other gas) in the peritoneal cavity, a
potential space within the abdominal cavity. The most common cause is a perforated abdominal viscus,
generally a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor
or abdominal trauma.
A perforated appendix seldom causes a pneumoperitoneum. In the mid-twentieth century, an “artificial”
pneumoperitoneum was sometimes intentionally administered as a treatment for a hiatal hernia. This was
achieved by insufflating the abdomen with carbon dioxide. The practice is currently used by surgical teams
in order to perform laparoscopic surgery.
(<:,:
• Perforated duodenal ulcer – The most common cause of rupture in the abdomen. Especially of the
anterior aspect of the first part of the duodenum.
• Perforated peptic ulcer
• Bowel obstruction
• Ruptured diverticulum
• Penetrating trauma
• Ruptured inflammatory bowel disease (e.g., megacolon)
• Necrotising enterocolitis/pneumatosis coli
• Bowel cancer
• Ischemic bowel
• Steroids
• After laparotomy
• After laparoscopy
• Breakdown of a surgical anastomosis
• Bowel injury after endoscopy
• Peritoneal dialysis (PD), although the prevalence of pneumoperitoneum is estimated to be less than
4% among people with PD in a more recent study in the United Kingdom.
• Vaginal insufflation (air enters via the fallopian tubes; e.g., water-skiing, oral sex )
• Colonic or peritoneal infection
• From chest (e.g., bronchopleural fistula)
• Non-invasive PAP (positive airway pressure) can force air down duodenum as well as down trachea.
0(.56:0:
When present, pneumoperitoneum can often be seen on projectional radiography, but small amounts are
often missed, and CT scan is nowadays regarded as a criterion standard in the assessment of a pneumoperitoneum.
CT can visualize quantities as small as 5 cm³ of air or gas.
Signs that can be seen on projectional radiography are the double wall sign (also called Rigler’s sign) and the
football sign.
The double wall sign marks the presence of air on both sides of the intestine. However, a false double wall
sign can result from two loops of bowel being in contact with one another. The sign is named after Leo George
Rigler. It is not the same as Rigler’s triad.
The football sign is when the abdomen appears as a large oval radiolucency reminiscent of an American
football on a supine projectional radiograph. The football sign is most frequently seen in infants with spontaneous
or iatrogenic gastric perforation causing pneumoperitoneum. It is also seen in bowel obstruction with secondary
perforation, as in Hirschprung disease, midgut volvulus, meconium ileus and intestinal atresia. Iatrogenic causes
like endoscopic perforation may also give football sign.
0--,9,5;0(30(.56:0:
As differential diagnoses, a subphrenic abscess, bowel interposed between diaphragm and liver (Chilaiditi
syndrome), and linear atelectasis at the base of the lungs can simulate free air under the diaphragm on a chest X-
ray.
Pneumomediastinum
Pneumomediastinum (from Greek pneuma – “air”, also known as mediastinal emphysema) is pneumatosis
(abnormal presence of air or other gas) in the mediastinum. First described in 1819 by René Laennec, the
condition can result from physical trauma or other situations that lead to air escaping from the lungs, airways,
or bowel into the chest cavity.
0.5:(5+@47;64:
The main symptom is usually severe central chest pain. Other symptoms include laboured breathing,
voice distortion (as with helium) and subcutaneous emphysema, specifically affecting the face, neck, and
chest. Pneumomediastinum can also be characterized by the shortness of breath that is typical of a respiratory
system problem.
It is often recognized on auscultation by a “crunching” sound timed with the cardiac cycle (Hamman’s
crunch). Pnemomediastinum may also present with symptoms mimicking cardiac tamponade as a result of
the increased intrapulmonary pressure on venous flow to the heart.
(<:,
It is most commonly caused by:
• Oesophageal rupture, for example in Boerhaave syndrome
• Asthma or other conditions leading to alveolar rupture
• Bowel rupture, where air in the abdominal cavity tracts up into the chest.
It has also been associated with:
• Mycoplasma pneumoniae pneumonia
• Obesity
It can be induced to assist thoracoscopic surgery. It can be caused by a pulmonary barotrauma resulting
when a person moves to or from a higher pressure environment, such as when a SCUBA diver, a free-diver or
an airplane passenger ascends or descends. In rare cases, pneumomediastinum may also arise as a result of
blunt chest trauma (e.g. car accidents, fights, over pressure of breathing apparatus), while still evolving in
the same fashion as the spontaneous form. Pneumomediastinum is most commonly seen in otherwise healthy
young male patients and may not be prefaced by a relevant medical history of similar ailments.
0(.56:0:
Pneumomediastinum is uncommon and occurs when air leaks into the mediastinum. The diagnosis can be
confirmed via chest X-ray showing a radiolucent outline around the heart and mediastinum or via CT scanning
of the thorax.
Modes 45
Fig. Pneumomediastinum and right sided pneumothorax post first rib fracture in a mountain biking accident.
Fig. Pneumomediastinum with Angel wing sign.

Fig. Pneumomediastinum as seen on ultrasound.
9,(;4,5;
The tissues in the mediastinum will slowly resorb the air in the cavity so most pneumomediastinums are treated
conservatively. Breathing high flow oxygen will increase the absorption of the air. If the air is under pressure and
compressing the heart, a needle may be inserted into the cavity, releasing the air. Surgery may be needed to repair
the hole in the trachea, esophagus or bowel. If there is lung collapse, it is imperative the affected individual lies on
the side of the collapse, although painful, this allows full inflation of the unaffected lung.
Intraventricular Hemorrhage
Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain’s
ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid
space. It can result from physical trauma or from hemorrhaging in stroke. 30% of intraventricular hemorrhage
(IVH) are primary, confined to the ventricular system and typically caused by intraventricular trauma, aneurysm,
vascular malformations, or tumors, particularly of the choroid plexus. However 70% of IVH are secondary in
nature, resulting from an expansion of an existing intraparenchymal or subarachnoid hemorrhage. Intraventricular
hemorrhage has been found to occur in 35% of moderate to severe traumatic brain injuries. Thus the hemorrhage
usually does not occur without extensive associated damage, and so the outcome is rarely good.
@47;64:(5+0(.56:0:
Symptoms of IVH are similar to other intracerebral hemorrhages and include sudden onset of headache,
nausea and vomiting, together with an alteration of the mental state and/or level of consciousness. Focal
neurological signs are either minimal or absent, but focal and/or generalized seizures may occur. Xanthochromia,
yellow-tinged CSF, is the rule. Diagnosis can be confirmed by the presence of blood inside the ventricles on CT.
9,(;4,5;
Treatment focuses on monitoring and should be accomplished with inpatient floor service for individuals
responsive to commands or neurological ICU observation for those with impaired levels of consciousness.
Extra attention should be placed on intracranial pressure (ICP) monitoring via an intraventricular catheter and
medications to maintain ICP, blood pressure, and coagulation. In more severe cases an external ventricular
drain may be required to maintain ICP and evacuate the hemorrhage, and in extreme cases an open craniotomy
may be required. In cases of unilateral IVH with small intraparenchymal hemorrhage the combined method of
stereotaxy and open craniotomy has produced promising results.
Modes 47
96.56:0:
Prognosis is also very poor when IVH results from intracerebral hemorrhage related to high blood pressure
and is even worse when hydrocephalus follows. It can result in dangerous increases in ICP and can cause
potentially fatal brain herniation. Even independently, IVH can cause morbidity and mortality. First,
intraventricular blood can lead to a clot in the CSF conduits blocking its flow and leading to obstructive
hydrocephalus which may quickly result in increased intracranial pressure and death. Second, the breakdown
products from the blood clot may generate an inflammatory response that damages the arachnoid granulations,
inhibiting the regular reabsorption of CSF and resulting in permanent communicating hydrocephalus.
::6*0(;,+
65+0;065:
Brain contusions and subarachnoid hemorrhages are commonly associated with IVH. The bleeding can
involve the anterior communicating artery or the posterior communicating artery. In both adults and infants,
IVH can cause dangerous increases in ICP, damage to the brain tissue, and hydrocephalus.
()0,:
IVH in the preterm brain usually arises from the germinal matrix whereas IVH in the term infants originates
from the choroid plexus. However, it is particularly common in premature infants or those of very low birth
weight. The cause of IVH in premature infants, unlike that in older infants, children or adults, is rarely due to
trauma. Instead it is thought to result from changes in perfusion of the delicate cellular structures that are
present in the growing brain, augmented by the immaturity of the cerebral circulatory system, which is especially
vulnerable to hypoxic ischemic encephalopathy. The lack of blood flow results in cell death and subsequent
breakdown of the blood vessel walls, leading to bleeding. While this bleeding can result in further injury, it is
itself a marker for injury that has already occurred. Most intraventricular hemorrhages occur in the first 72
hours after birth. The risk is increased with use of extracorporeal membrane oxygenation in preterm infants.
Congenital cytomegalovirus infection can be an important cause.
The amount of bleeding varies. IVH is often described in four grades:
• Grade I - bleeding occurs just in the germinal matrix
• Grade II - bleeding also occurs inside the ventricles, but they are not enlarged
• Grade III - ventricles are enlarged by the accumulated blood
• Grade IV - bleeding extends into the brain tissue around the ventricles.
Grades I and II are most common, and often there are no further complications. Grades III and IV are the
most serious and may result in long-term brain injury to the infant. After a grade III or IV IVH, blood clots may
form which can block the flow of cerebrospinal fluid, leading to increased fluid in the brain (hydrocephalus).
There have been various therapies employed into preventing the high rates of morbidity and mortality, including
diuretic therapy, repeated lumbar puncture, streptokinase therapy and most recently combination a novel
intervention called DRIFT (drainage, irrigation and fibrinolytic therapy). In 2002, a Dutch retrospective study
analysed cases where neonatologists had intervened and drained CSF by lumbar or ventricular punctures if
ventricular width (as shown on ultrasound) exceeded the 97th centile as opposed to the 97th centile plus 4 mm.
Professors Whitelaw’s original Cochrane review published in 2001 as well as evidence from previous randomised
control trials indicated that interventions should be based on clinical signs and symptoms of ventricular dilatation.
An international trial has instead looked an early (97th centile) versus late (97th centile plus 4 mm) for intervening
and draining CSF. DRIFT has been tested in an international randomised clinical trial; although it did not
significantly lower the need for shunt surgery, severe cognitive disability at two years Bayley (MDI <55) was
significantly reduced. Repeated lumbar punctures are used widely to reduce the effects in increased intracranial
pressure and an alternative to ventriculoperitoneal (VP) shunt surgery that cannot be performed in case of
intraventricular haemorrhage. The relative risk of repeated lumbar puncture is close to 1.0, therefore it is not
statistically therapeutic when compared to conservative management and does raise the risk of subsequent CSF
infection.
Bronchopulmonary Dysplasia
Bronchopulmonary dysplasia (BPD; formerly chronic lung disease of infancy) is a chronic lung disease in
which premature infants, usually those who were treated with supplemental oxygen, require long-term oxygen.
It is more common in infants with low birth weight and those who receive prolonged mechanical ventilation to
treat respiratory distress syndrome (RDS). It results in significant morbidity and mortality. The definition of
BPD has continued to evolve since then primarily due to changes in the population, such as more survivors at
earlier gestational ages, and improved neonatal management including surfactant, antenatal glucocorticoid
therapy, and less aggressive mechanical ventilation. Currently the description of BPD includes the grading of
its severity into mild, moderate and severe. This correlates with the infant’s maturity, growth and overall severity
of illness. The new system offers a better description of underlying pulmonary disease and its severity.
0(.56:0:
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90;,90(
The classic diagnosis of BPD may be assigned at 28 days of life if the following criteria are met:
1. Positive pressure ventilation during the first 2 weeks of life for a minimum of 3 days.
2. Clinical signs of abnormal respiratory function.
3. Requirements for supplemental oxygen for longer than 28 days of age to maintain PaO2 above 50 mm
Hg.
4. Chest radiograph with diffuse abnormal findings characteristic of BPD.
,>,9
90;,90(
The newer National Institute of Health (US) criteria for BPD (for neonates treated with more than 21%
oxygen for at least 28 days) is as follows:,
Mild:
• Breathing room air at 36 weeks’ post-menstrual age or discharge (whichever comes first) for babies
born before 32 weeks, or
• Breathing room air by 56 days’ postnatal age, or discharge (whichever comes first) for babies born
after 32 weeks’ gestation.
Moderate:
• Need for <30% oxygen at 36 weeks’ postmenstrual age, or discharge (whichever comes first) for
babies born before 32 weeks, or
• Need for <30% oxygen to 56 days’ postnatal age, or discharge (whichever comes first) for babies
born after 32 weeks’ gestation.
Severe:
• Need for >30% oxygen, with or without positive pressure ventilation or continuous positive pressure
at 36 weeks’ postmenstrual age, or discharge (whichever comes first) for babies born before 32
weeks, or
• Need for >30% oxygen with or without positive pressure ventilation or continuous positive pressure at
56 days’ postnatal age, or discharge (whichever comes first) for babies born after 32 weeks’ gestation.
Modes 49
(<:,(5+(50-,:;(;065:
Prolonged high oxygen delivery in premature infants causes necrotizing bronchiolitis and alveolar septal injury,
with inflammation and scarring. This results in hypoxemia. Today, with the advent of surfactant therapy and high
frequency ventilation and oxygen supplementation, infants with BPD experience much milder injury without
necrotizing bronchiolitis or alveolar septal fibrosis. Instead, there are usually uniformly dilated acini with thin
alveolar septa and little or no interstitial fibrosis. It develops most commonly in the first 4 weeks after birth.
64730*(;065:
Feeding problems are common in infants with BPD, often due to prolonged intubation. Such infants often
display oral-tactile hypersensitivity (also known as oral aversion). Physical findings:
• Hypoxemia;
• Hypercapnia;
• Crackles, wheezing, and decreased breath sounds;
• Increased bronchial secretions;
• Hyperinflation;
• Frequent lower respiratory infections;
• Delayed growth and development;
• Cor pulmonale;
• CXR shows with hyperinflation, low diaphragm, atelectasis, cystic changes.
(5(.,4,5;
There is evidence to show that steroids given to babies less than 8 days old can prevent bronchopulmonary
dysplasia. However, the risks of treatment may outweigh the benefits. It is unclear if starting steroids more than
7 days after birth is harmful or beneficial. It is thus recommended that they only be used in those who cannot be
taken off of a ventilator.
70+,40636.@
The rate of BPD varies among institutions, which may reflect neonatal risk factors, care practices (e.g.,
target levels for acceptable oxygen saturation), and differences in the clinical definitions of BPD.
Pulmonary Interstitial Emphysema

Pulmonary interstitial emphysema (PIE) is a collection of air outside of the normal air space of the pulmonary
alveoli, found instead inside the connective tissue of the peribronchovascular sheaths, interlobular septa, and
visceral pleura. (This supportive tissue is called the pulmonary interstitium.) This collection of air develops as
a result of alveolar and terminal bronchiolar rupture. Pulmonary interstitial emphysema is more frequent in
premature infants who require mechanical ventilation for severe lung disease. Infants suffering from pulmonary
interstitial emphysema are typically recommended for admission to a neonatal intensive care unit.
(<:,
Pulmonary interstitial emphysema is a concern in any of the following diagnosis:
• Prematurity
• Respiratory distress syndrome (RDS)
• Meconium aspiration syndrome (MAS)

• Amniotic fluid aspiration
• Sepsis, or other infections
• Mechanical ventilation
(;/67/@:0636.@
Pulmonary interstitial emphysema is created when air bursts or ruptures through tissue from the alveoli and
bronchioles into the perivascular tissue of the lung.
9,(;4,5;
Different treatments have been used to manage pulmonary interstitial emphysema with variable success.
Admission/transfer to a neonatal intensive care unit (NICU) is common and expected for patients with PIE.
Treatments include:
• Lateral decubitus position with the affected side down
• High-frequency ventilation
• Lobectomy
• Selective Main Bronchial Intubation and Occlusion.
96.56:0:
Pulmonary interstitial emphysema often resolves gradually and may take 2–3 weeks. For longer durations of
PIE the length of time of mechanical ventilation needed may increase and the incidence of bronchopulmonary
dysplasia becomes higher. Some infants may develop chronic lobar emphysema, which may require surgical
lobectomies.
70+,40636.@
50;,+;(;,:
The prevalence of pulmonary interstitial emphysema widely varies with the population studied. In a 1987
study 3% of infants admitted to the neonatal intensive care unit (NICU) developed pulmonary interstitial
emphysema.
5;,95(;065(3
Studies reflecting international frequency demonstrated that 2-3% of all infants in NICUs develop pulmonary
interstitial emphysema. When limiting the population studied to premature infants, this frequency increases to
20-30%, with the highest frequencies occurring in infants weighing fewer than 1000 g.
Mechanical Ventilation during Cardiopulmonary Resuscitation 51
Chapter 3
Mechanical Ventilation during

Cardiopulmonary Resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure that combines chest compressions often
with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken
to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. It is recommended
in those who are unresponsive with no breathing or abnormal breathing, for example, agonal respirations. CPR
involves chest compressions for adults between 5 cm (2.0 in) and 6 cm (2.4 in) deep and at a rate of at least 100
to 120 per minute. The rescuer may also provide artificial ventilation by either exhaling air into the subject’s
mouth or nose (mouth-to-mouth resuscitation) or using a device that pushes air into the subject’s lungs (mechanical
ventilation). Current recommendations place emphasis on early and high-quality chest compressions over artificial
ventilation; a simplified CPR method involving chest compressions only is recommended for untrained rescuers.
In children, however, only doing compressions may result in worse outcomes.
Chest compression to breathing ratios is set at 30 to 2 in adults. CPR alone is unlikely to restart the heart. Its
main purpose is to restore partial flow of oxygenated blood to the brain and heart. The objective is to delay
tissue death and to extend the brief window of opportunity for a successful resuscitation without permanent
brain damage. Administration of an electric shock to the subject’s heart, termed defibrillation, is usually needed
in order to restore a viable or “perfusing” heart rhythm. Defibrillation is effective only for certain heart rhythms,
namely ventricular fibrillation or pulseless ventricular tachycardia, rather than asystole or pulseless electrical
activity. Early shock when appropriate is recommended. CPR may succeed in inducing a heart rhythm that may
be shockable. In general, CPR is continued until the person has a return of spontaneous circulation (ROSC) or
is declared dead.

Cardiopulmonary resuscitation, also known by the acronym CPR is an emergency procedure performed in
an effort to manually preserve intact brain function until further measures are taken to restore spontaneous
blood circulation and breathing in a person who is in cardiac arrest. It is a basic but proven first aid skill,
practiced throughout the world. It is an effective method of keeping a victim of cardiac arrest alive long enough
for definitive treatment to be delivered (usually defibrillation and intravenous cardiac drugs). Prior to the
inception of Cardiopulmonary Resuscitation, there had been some techniques to keep people alive developed in
the 18th century, both in Japan and in Europe, however it was not until the mid-20th century that James Elam
and Peter Safar discovered and published the method now known as CPR. Safar conducted research on existing
basic life support procedures including controlling a person’s breathing airway by tilting back his or her head
with an open mouth; and using mouth-to-mouth breathing. He combined these with a procedure known as
closed-chest cardiac massage to become the basic life support method of CPR. Throughout his life Safar was
hesitant to take credit for “inventing” CPR. The way he saw it, he merely brought to light effective procedures
that humans had already discovered, putting them together into what he called “the ABCs” – maintaining a
patient’s Airway, Breathing and Circulation. He worked hard to popularize the procedure around the world and
collaborated with Norwegian toy maker Asmund Laerdal to create “Resusci Anne,” the CPR training mannequin.
Laerdal now is a medical equipment manufacturer. Safar also created the first guidelines for community-wide
emergency medical services, or EMS; he founded the International Resuscitation Research Center (IRRC) at
the University of Pittsburgh, which he directed until 1994; and he was nominated three times for the Nobel
Prize in medicine.
FIRST ATTEMPTS AT RESUSCITATION IN THE 18TH CENTURY

In August 1767 a few wealthy and civic-minded citizens in Amsterdam gathered to form the Society for
Recovery of Drowned Persons. This society was the first organized effort to respond to sudden death. The
society’s techniques involved a range of methods to stimulate the body.
The members of the society recommended:
1. Warming the victim;
2. Removing swallowed or aspirated water by positioning the victim’s head lower than feet;
3. Applying manual pressure to the abdomen;
4. Respirations into the victim’s mouth, either using a bellows or with a mouth-to-mouth method;
5. Tickling the victim’s throat;
6. ‘Stimulating’ the victim by such means as rectal and oral fumigation with tobacco smoke; bellows
were used to drive tobacco smoke, a known irritant, into the intestine through the anus, as this was
thought to be enough of a stimulant to engender a response in the “almost” dead; and
7. Bloodletting.
The society in Amsterdam claimed to have saved 150 persons, within four years of their founding, with
their recommendations. The first four of these techniques, or variations of them, are in use today. Following
successes of this first society, rescue societies soon sprang up in most European capitals, all with the goal to
find a way of successfully resuscitating victims of sudden death. This theory proved so popular that Hamburg,
Germany passed an ordinance in 1769 providing notices to be read in churches describing assistance for
drowned, strangled, and frozen persons and those overcome by noxious gases, probably the first example of
mass medical training. The Royal Humane Society in London, founded in 1774, served as the model for
societies in New York, Philadelphia, and Boston. These rescue societies of the 18th century were the precursors
of today’s emergency medical services. Similar techniques were described in early 20th century jujutsu and
judo books, as being used as far back as early 17th century. A New York Times correspondent reported those
techniques being used successfully in Japan in 1910. In jujutsu (and later on, judo), those techniques were
called kappo or kutasu.
MODERN RESUSCITATION
Scientists and doctors started to try and address the problem from many different sides including developing
new medications, devising new surgical techniques and identifying risk factors. Doctors James Elam, Peter
Safar and Archer S. Gordon set to educating the world about rescue breathing, preventive measures and trying
to discover a way to treat acute cardiac arrest. Gordon initially did not support rescue breathing until he performed
a study of his own using pediatric patients, reproducing Elam’s results. Safar had also been working on the
feasibility of rescue breathing, so they agreed that a concerted effort would be much more valuable than each
working separately and possibly reproducing each other’s work. Prior to the 1950s, the accepted method of
resuscitation was the chest-pressure and arm-lift technique that was shown to be ineffective by Safar and Elam.
In 1954, Elam was the first to demonstrate experimentally that exhaled air ventilation was a sound technique.
Elam and Safar (and later Gordon) performed many experiments demonstrating the superiority of the rescue
breathing technique.
The problem then became one of popularizing the method. Organizations such as the American Red Cross
provide training at local chapters in the proper administration of artificial respiration procedures. The Red
Cross has been teaching this technique since the mid-1950s. For example, in Kalamazoo, Michigan, volunteer
Roger Mehalek introduced a breathing trainer called Miss Sweet Breath 1959, a plaster and plastic training
mannequin he created. In New York, then State Health Commissioner, Herman Hilliboe was impressed with the
technique. He commissioned Elam to write the instructional booklet titled “Rescue Breathing,” which was
distributed nationally in 1959. The success of the booklet spurred Elam to produce films demonstrating this
new life-saving technique. By 1960, rescue breathing had been adopted by the National Academy of Science,
American Society of Anesthesiologists, Medical Society of the State of New York and the American Red Cross
as the preferred method of resuscitation.
Several key discoveries and understandings were required to treat the problem, which would take decades to
work out, and even now is not ‘solved’. Doctors speak of the natural history of diseases as a way to understand
how therapy alters the usual progression of a disease. For example, the natural history of breast cancer may be
measured in months but treated with surgery or chemotherapy the disease can be measured in years or even
cured. Sudden cardiac arrest is a disease with an extremely rapid natural history, measured in minutes, with an
inexorable outcome. But when treated with CPR the course of death can be extended (CPR will delay the dying
process) and if treated with timely defibrillation death can be aborted. The modern elements of resuscitation for
sudden cardiac arrest are cardiopulmonary resuscitation (CPR in turn consists of mouth-to-mouth ventilation
and chest compression), defibrillation and emergency medical services (the means to bring these techniques to
the patient quickly).
Mouth-to-mouth Ventilation
Mouth-to-mouth resuscitation, a form of artificial ventilation, is the act of assisting or stimulating respiration,
a metabolic process referring to the overall exchange of gases in the body, where a rescuer presses his or her
mouth against that of the victim and blows air into the person’s lungs. Assistance takes many forms, but generally
entails providing air for a person who is not breathing or is not making sufficient respiratory effort on his/her
own. It is used on a patient with a beating heart or as part of cardiopulmonary resuscitation (CPR) to achieve the
internal respiration). Pulmonary anton ventilation (and hence external parts of respiration) is achieved through
manual insufflation of the lungs either by the rescuer blowing into the patient’s lungs, or by using a mechanical
device to do so.
This method of insufflation has been proved more effective than methods which involve mechanical
manipulation of the patient’s chest or arms, such as the Silvester method. It is also known as expired air
resuscitation (EAR), expired air ventilation (EAV), rescue breathing or colloquially the kiss of life. It was
introduced as a life saving measure in 1950. Mouth-to-mouth resuscitation is a part of most protocols for
performing cardiopulmonary resuscitation (CPR) making it an essential skill for first aid. In some situations,
mouth-to-mouth resuscitation is also performed separately, for instance in near-drowning and opiate overdoses.
The performance of mouth-to-mouth resuscitation on its own is now limited in most protocols to health
professionals, whereas lay first aiders are advised to undertake full CPR in any case where the patient is not
breathing sufficiently.
0:;69@
In 1773, English physician William Hawes (1736–1808) began publicising the power of artificial respiration
to resuscitate people who superficially appeared to have drowned. For a year he paid a reward out of his own
pocket to any one bringing him a body rescued from the water within a reasonable time of immersion. Thomas
Cogan, another English physician, who had become interested in the same subject during a stay at Amsterdam,
where was instituted in 1767 a society for preservation of life from accidents in water, joined Hawes in his
crusade. In the summer of 1774 Hawes and Cogan each brought fifteen friends to a meeting at the Chapter
Coffee-house, St Paul’s Churchyard, where they founded the Royal Humane Society as a campaigning group
for first aid and resuscitation. Gradually, branches of the Royal Humane Society were set up in other parts of the
country, mainly in ports and coastal towns where the risk of drowning was high and by the end of the 19th
century the society had upwards of 280 depots throughout the UK, supplied with life-saving apparatus. The
earliest of these depots was the Receiving House in Hyde Park, on the north bank of the Serpentine, which was
built in 1794 on a site granted by George III. Hyde Park was chosen because tens of thousands of people swam
in the Serpentine in the summer and ice-skated in the winter. Boats and boatmen were kept to render aid to
bathers, and in the winter ice-men were sent round to the different skating grounds in and around London. The
society distributed money-rewards, medals, clasps and testimonials, to those who saved or attempted to save
drowning people. It further recognized “all cases of exceptional bravery in rescuing or attempting to rescue
persons from asphyxia in mines, wells, blasting furnaces, or in sewers where foul gas may endanger life.”
5:<--3(;065:
Insufflation, also known as ‘rescue breaths’ or ‘ventilations’, is the act of mechanically forcing air into a
patient’s respiratory system. This can be achieved via a number of methods, which will depend on the situation
and equipment available. All methods require good airway management to perform, which ensures that the
method is effective.
These methods include:
• Mouth-to-mouth - This involves the rescuer making a seal between his or her mouth and the patient’s
mouth and ‘blowing’, to pass air into the patient’s body
• Mouth-to-nose - In some instances, the rescuer may need or wish to form a seal with the patient’s
nose. Typical reasons for this include maxillofacial injuries, performing the procedure in water or
the remains of vomit in the mouth
• Mouth-to-mouth and nose - Used on infants (usually up to around 1 year old), as this forms the most
effective seal
• Mouth-to-mask – Most organisations recommend the use of some sort of barrier between rescuer
and patient to reduce cross infection risk. One popular type is the ‘pocket mask’. This may be able
to provide higher tidal volumes than a Bag Valve Mask.
+1<5*;:;65:<--3(;065
Most training organisations recommend that in any of the methods involving mouth-to-patient, that a protective
barrier is used, to minimise the possibility of cross infection (in either direction). Barriers available include
pocket masks and keyring-sized face shields. These barriers are an example of Personal Protective Equipment
to guard the face against splashing, spraying or splattering of blood or other potentially infectious materials.
These barriers should provide a one-way filter valve which lets the air from the rescuer deliver to the patient
while any substances from the patient (e.g. vomit, blood) cannot reach the rescuer. Many adjuncts are single
use, though if they are multi use, after use of the adjunct, the mask must be cleaned and autoclaved and the filter
replaced. It is very important for the mask to be replaced or cleaned because it can act as a transporter of various
diseases. The CPR mask is the preferred method of ventilating a patient when only one rescuer is available.
Many feature 18mm inlets to support supplemental oxygen, which increases the oxygen being delivered from
the approximate 17% available in the expired air of the rescuer to around 40-50%.
--0*0,5*@6-6<;/Ì;6Ì7(;0,5;5:<--3(;065
Normal atmospheric air contains approximately 21% oxygen when inhaled in. After gaseous exchange has
taken place in the lungs, with waste products (notably carbon dioxide) moved from the bloodstream to the
lungs, the air being exhaled by humans normally contains around 17% oxygen. This means that the human body
utilises only around 19% of the oxygen inhaled, leaving over 80% of the oxygen available in the exhalatory
breath. This means that there is more than enough residual oxygen to be used in the lungs of the patient, which
then enters the blood.
?@.,5
The efficiency of artificial respiration can be greatly increased by the simultaneous use of oxygen therapy.
The amount of oxygen available to the patient in mouth-to-mouth is around 16%. If this is done through a
pocket mask with an oxygen flow, this increases to 40% oxygen. If either a bag valve mask or a mechanical
ventilator is used with an oxygen supply, this rises to 99% oxygen. The greater the oxygen concentration, the
more efficient the gaseous exchange will be in the lungs.
Chest Compressions
Unlike cessation of respiration, an obvious sign of sudden death, the cessation of circulation, and particularly
the rhythm of the heart, is not as easy to spot for a lay observer, although a trained eye now can see signs such
as lack of perfusion. Perhaps as a result of this being less obvious, the appreciation of artificial circulation as a
key factor in resuscitation lagged considerably behind the obvious need for artificial respirations. If the scientists
working on the problem appreciated the need to circulate blood, there was simply no effective means to do so.
Even though closed chest massage was described in 1904, its benefit was not appreciated and anecdotal case
reports did little to promote the benefit of closed chest massage. The prevailing belief was described in a
physician’s quote from 1890, “We are powerless against paralysis of the circulation.” The formalised system of
chest compression was really an accidental discovery made in 1958 by William Bennett Kouwenhoven, Guy
Knickerbocker, and James Jude at Johns Hopkins University. They were studying defibrillation in dogs when
they noticed that by forcefully applying the paddles to the chest of the dog, they could achieve a pulse in the
femoral artery. Further meticulous experimentation involving dogs answered such basic questions as how fast
to press, where to press, and how deep to press. This information gave them the belief that they were ready for
human trials.
The first person saved with this technique was recalled by Jude: “She was rather an obese female who …
went into cardiac arrest as a result of flurothane anesthetic. This woman had no blood pressure, no pulse, and
ordinarily we would have opened up her chest. Instead, since we weren’t in the operating room, we applied
external cardiac massage. Her blood pressure and pulse came back at once. We didn’t have to open her chest.
They went ahead and did the operation on her, and she recovered completely.” In 1960 the three investigators
reported their findings on 20 cases of in-hospital cardiac arrest in JAMA. Fourteen of the 20 patients (70%)
survived and were discharged from the hospital. Many of the patients were in cardiac arrest as a result of
anaesthesia. Three patients were documented to be in ventricular fibrillation. The duration of chest compression
varied from less than 1 minute to 65 minutes. The JAMA article was very straightforward: chest compression
buys time until the external defibrillator arrives on the scene. As the authors write in the article, “Anyone,
anywhere, can now initiate cardiac resuscitative procedures. All that is needed is two hands”. However, respiration
received relatively little attention in the 1960 JAMA article. Many of the patients had been intubated and thus
the need for mouth-to-mouth ventilation was not necessary. It was not long however, before this newly discovered
technique was used in conjunction with the longer held techniques of artificial respiration.
The Use of Compression and Ventilation Together

The formal connection of chest compression with mouth-to-mouth ventilation to create CPR as it is practiced
today occurred when Safar, Jude, and Kouwenhoven presented their findings at the annual Maryland Medical
Society meeting on September 16, 1960 in Ocean City. In the opening remarks the moderator said, “Our purpose
today is to bring to you, then, this new idea.” It was so new that it was still without a name. The moderator stated
that the two techniques “cannot be considered any longer as separate units, but as parts of a whole and complete
approach to resuscitation”. In his remarks Safar stressed the importance of combining ventilation and circulation.
He presented convincing data that chest compression alone did not provide effective ventilation; mouth-to-
mouth respiration had to be part of the equation. To promote CPR, Jude, Knickerbocker, and Safar began a
world speaking tour. In 1962 Gordon, along with David Adams, produced a 27-minute training film called “The
Pulse of Life.” The film was used in CPR classes and viewed by millions of students. For the film, Gordon and
Adams devised the easy to remember mnemonic of A, B & C standing for the sequence of steps in CPR, airway,
breathing, circulation. However the order has been revised to C, A, B, putting the emphasis on compressions
first. The reason being that oxygen reserves in the body have been found to be adequate to maintain oxygenation
of the blood. In 1963 cardiologist Leonard Scherlis started the American Heart Association’s CPR Committee,
and in the same year, the Heart Association formally endorsed CPR. In May 1966 the National Research Council
of the National Academy of Sciences convened an ad hoc conference on cardiopulmonary resuscitation. The
conference was the direct result of requests from the American National Red Cross and other agencies to
establish standardized training and performance standards for CPR. Over 30 national organizations were
represented at the conference. Recommendations from this conference were reported in JAMA in 1966.
DEFIBRILLATION
Defibrillation is a treatment for life-threatening cardiac dysrhythmias, specifically ventricular fibrillation
(VF) and non-perfusing ventricular tachycardia (VT). A defibrillator delivers a dose of electric current (often
called a countershock) to the heart. This depolarizes a large amount of the heart muscle, ending the dysrhythmia.
Subsequently, the body’s natural pacemaker in the sinoatrial node of the heart is able to re-establish normal
sinus rhythm. In contrast to defibrillation, synchronized electrical cardioversion is an electrical shock delivered
in synchrony to the cardiac cycle. Although the person may still be critically ill, cardioversion normally aims to
end poorly perfusing cardiac dysrhythmias, such as supraventricular tachycardia. Defibrillators can be external,
transvenous, or implanted (implantable cardioverter-defibrillator), depending on the type of device used or
needed. Some external units, known as automated external defibrillators (AEDs), automate the diagnosis of
treatable rhythms, meaning that lay responders or bystanders are able to use them successfully with little or no
training.
Medical Uses
Defibrillation is often an important step in cardiopulmonary resuscitation (CPR). CPR is an algorithm-based
intervention aimed to restore cardiac and pulmonary function. Defibrillation is indicated only in certain types
of cardiac dysrhythmias, specifically ventricular fibrillation (VF) and pulseless ventricular tachycardia. If the
heart has completely stopped, as in asystole or pulseless electrical activity (PEA), defibrillation is not indicated.
Defibrillation is also not indicated if the patient is conscious or has a pulse. Improperly given electrical shocks
can cause dangerous dysrhythmias, such as ventricular fibrillation. Survival rates for out-of-hospital cardiac
arrests are poor, often less than 10%. Outcome for in-hospital cardiac arrests are higher at 20%. Within the
group of people presenting with cardiac arrest, the specific cardiac rhythm can significantly impact survival
rates. Compared to people presenting with a non-shockable rhythm (such as asystole or PEA), people with a
shockable rhythm (such as VF or pulseless ventricular tachycardia) have improved survival rates, ranging
between 21-50%.
Types
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Manual external defibrillators require the expertise of a health care professional. They are used in conjunction
with an electrocardiogram, which can be separate or built-in. A health care provider first diagnose the cardiac
rhythm and then manually determine the voltage and timing for the electrical shock. These units are primarily
found in hospitals and on some ambulances. For instance, every NHS ambulance in the United Kingdom is
equipped with a manual defibrillator for use by the attending paramedics and technicians. In the United States,
many advanced EMTs and all paramedics are trained to recognize lethal arrhythmias and deliver appropriate
electrical therapy with a manual defibrillator when appropriate.
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Manual internal defibrillators delivers the shock through paddles placed directly on the heart. They are
mostly used in the operating room and, in rare circumstances, in the emergency room during an open heart
procedure.
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Automated external defibrillators are designed for use by untrained or briefly trained laypersons. AEDs
contain technology for analysis of heart rhythms. As a result, it does not require a trained health provider to
determine whether or not a rhythm is shockable. By making these units publicly available, AEDs have improved
outcomes for sudden out-of-hospital cardiac arrests. Trained health professionals have more limited use for
AEDs than manual external defibrillators. Recent studies show that AEDs does not improve outcome in patients
with in-hospital cardiac arrests. AEDs have set voltages and does not allow the operator to vary voltage according
need. AEDs may also delay delivery of effective CPR. For diagnosis of rhythm, AEDs often require the stopping
of chest compressions and rescue breathing. For these reasons, certain bodies, such as the European Resuscitation
Council, recommend using manual external defibrillators over AEDs if manual external defibrillators are readily
available. As early defibrillation can significantly improve VF outcomes, AEDs have become publicly available
in many easily accessible areas. AEDs have been incorporated into the algorithm for basic life support (BLS).
Many first responders, such as firefighters, policemen, and security guards, are equipped with them. AEDs can
be fully automatic or semi-automatic. A semi-automatic AED automatically diagnoses heart rhythms and
determines if a shock is necessary. If a shock is advised, the user must then push a button to administer the
shock. A fully automated AED automatically diagnoses the heart rhythm and advises the user to stand back
while the shock is automatically given. Some types of AEDs come with advanced features, such as a manual
override or an ECG display.
473(5;()3,
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Also known as automatic internal cardiac defibrillator (AICD). These devices are implants, similar to
pacemakers (and many can also perform the pacemaking function). They constantly monitor the patient’s heart
rhythm, and automatically administer shocks for various life-threatening arrhythmias, according to the device’s
programming. Many modern devices can distinguish between ventricular fibrillation, ventricular tachycardia,
and more benign arrhythmias like supraventricular tachycardia and atrial fibrillation. Some devices may attempt
overdrive pacing prior to synchronised cardioversion.
When the life-threatening arrhythmia is ventricular fibrillation, the device is programmed to proceed
immediately to an unsynchronized shock. There are cases where the patient’s ICD may fire constantly or
inappropriately. This is considered a medical emergency, as it depletes the device’s battery life, causes significant
discomfort and anxiety to the patient, and in some cases may actually trigger life-threatening arrhythmias.
Some emergency medical services personnel are now equipped with a ring magnet to place over the device,
which effectively disables the shock function of the device while still allowing the pacemaker to function (if the
device is so equipped). If the device is shocking frequently, but appropriately, EMS personnel may administer
sedation.
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A wearable cardioverter defibrillator is a portable external defibrillator that can be worn by at-risk patients.
The unit monitors the patient 24 hours a day and can automatically deliver a biphasic shock if VF or VT is
detected. This device is mainly indicated in patients who are not immediate candidates for ICDs.
5;,95(3,-0)9033(;69
A pair of electrodes used to defibrillate the heart during or after cardiac surgery such as a heart bypass.
Interface with Person

The connection between the defibrillator and the patient consists of a pair of electrodes, each provided
with electrically conductive gel in order to ensure a good connection and to minimize electrical resistance,
also called chest impedance (despite the DC discharge) which would burn the patient. Gel may be either wet
(similar in consistency to surgical lubricant) or solid (similar to gummi candy). Solid-gel is more convenient,
because there is no need to clean the used gel off the person’s skin after defibrillation. However, the use of
solid-gel presents a higher risk of burns during defibrillation, since wet-gel electrodes more evenly conduct
electricity into the body. Paddle electrodes, which were the first type developed, come without gel, and must
have the gel applied in a separate step. Self-adhesive electrodes come prefitted with gel. There is a general
division of opinion over which type of electrode is superior in hospital settings; the American Heart Association
favours neither, and all modern manual defibrillators used in hospitals allow for swift switching between
self-adhesive pads and traditional paddles. Each type of electrode has its merits and demerits, as discussed
below.
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The most well-known type of electrode (widely depicted in films and television) is the traditional metal
paddle with an insulated (usually plastic) handle. This type must be held in place on the patient’s skin with
approximately 25 lbs of force while a shock or a series of shocks is delivered. Paddles offer a few advantages
over self-adhesive pads. Many hospitals in the United States continue the use of paddles, with disposable gel
pads attached in most cases, due to the inherent speed with which these electrodes can be placed and used. This
is critical during cardiac arrest, as each second of non-perfusion means tissue loss. Modern paddles allow for
monitoring (electrocardiography), though in hospital situations, separate monitoring leads are often already in
place. Paddles are reusable, being cleaned after use and stored for the next patient. Gel is therefore not preapplied,
and must be added before these paddles are used on the patient. Paddles are generally only found on manual
external units.
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Newer types of resuscitation electrodes are designed as an adhesive pad, which includes either solid or wet
gel. These are peeled off their backing and applied to the patient’s chest when deemed necessary, much the
same as any other sticker. The electrodes are then connected to a defibrillator, much as the paddles would be. If
defibrillation is required, the machine is charged, and the shock is delivered, without any need to apply any
additional gel or to retrieve and place any paddles. Most adhesive electrodes are designed to be used not only
for defibrillation, but also for transcutaneous pacing and synchronized electrical cardioversion. These adhesive
pads are found on most automated and semi-automated units and are replacing paddles entirely in non-hospital
settings.
In hospital, for cases where cardiac arrest is likely to occur (but has not yet), self-adhesive pads may be
placed prophylactically. Pads also offer an advantage to the untrained user, and to medics working in the sub-
optimal conditions of the field. Pads do not require extra leads to be attached for monitoring, and they do not
require any force to be applied as the shock is delivered. Thus, adhesive electrodes minimize the risk of the
operator coming into physical (and thus electrical) contact with the patient as the shock is delivered by allowing
the operator to be up to several feet away. (The risk of electrical shock to others remains unchanged, as does
that of shock due to operator misuse.) Self-adhesive electrodes are single-use only. They may be used for
multiple shocks in a single course of treatment, but are replaced if (or in case) the patient recovers then reenters
cardiac arrest.
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Resuscitation electrodes are placed according to one of two schemes. The anterior-posterior scheme is the
preferred scheme for long-term electrode placement. One electrode is placed over the left precordium (the
lower part of the chest, in front of the heart). The other electrode is placed on the back, behind the heart in the
region between the scapula. This placement is preferred because it is best for non-invasive pacing. The
anterior-apex scheme can be used when the anterior-posterior scheme is inconvenient or unnecessary. In this
scheme, the anterior electrode is placed on the right, below the clavicle. The apex electrode is applied to the
left side of the patient, just below and to the left of the pectoral muscle. This scheme works well for
defibrillation and cardioversion, as well as for monitoring an ECG. Researchers have created a software
modeling system capable of mapping an individual’s chest and determining the best position for an external
or internal cardiac defibrillator.
Mechanism of Action
The exact mechanism of defibrillation is not well understood. One theory is that successful defibrillation
affects a critical mass of the heart, resulting in insufficient remaining heart muscle to continue the arrhythmia.
Recent mathematical models of defibrillation are providing new insight into how cardiac tissue responds to a
strong electrical shock.
History
Defibrillators were first demonstrated in 1899 by Jean-Louis Prévost and Frédéric Batelli, two physiologists
from University of Geneva, Switzerland. They discovered that small electrical shocks could induce ventricular
fibrillation in dogs, and that larger charges would reverse the condition. In 1933, Dr. Albert Hyman, heart
specialist at the Beth Davis Hospital of New York City and C. Henry Hyman, an electrical engineer, looking
for an alternative to injecting powerful drugs directly into the heart, came up with an invention that used an
electrical shock in place of drug injection. This invention was called the Hyman Otor where a hollow needle
is used to pass an insulated wire to the heart area to deliver the electrical shock. The hollow steel needle
acted as one end of the circuit and the tip of the insulated wire the other end. Whether the Hyman Otor was
a success is unknown. The external defibrillator as known today was invented by Electrical Engineer William
Kouwenhoven in 1930. William studied the relation between the electric shocks and its effects on human
heart when he was a student at Johns Hopkins University School of Engineering. His studies helped him to
invent a device for external jump start of the heart. He invented the defibrillator and tested on a dog, like
Prévost and Batelli.
The first use on a human was in 1947 by Claude Beck, professor of surgery at Case Western Reserve
University. Beck’s theory was that ventricular fibrillation often occurred in hearts which were fundamentally
healthy, in his terms “Hearts that are too good to die”, and that there must be a way of saving them. Beck first
used the technique successfully on a 14-year-old boy who was being operated on for a congenital chest
defect. The boy’s chest was surgically opened, and manual cardiac massage was undertaken for 45 minutes
until the arrival of the defibrillator. Beck used internal paddles on either side of the heart, along with
procainamide, an antiarrhythmic drug, and achieved return of normal sinus rhythm. These early defibrillators
used the alternating current from a power socket, transformed from the 110–240 volts available in the line,
up to between 300 and 1000 volts, to the exposed heart by way of “paddle” type electrodes. The technique
was often ineffective in reverting VF while morphological studies showed damage to the cells of the heart
muscle post mortem. The nature of the AC machine with a large transformer also made these units very hard
to transport, and they tended to be large units on wheels.
36:,+Ì*/,:;,;/6+
Until the early 1950s, defibrillation of the heart was possible only when the chest cavity was open during
surgery. The technique used an alternating voltage from a 300 or greater volt source derived from standard AC
power, delivered to the sides of the exposed heart by “paddle” electrodes where each electrode was a flat or
slightly concave metal plate of about 40 mm diameter. The closed-chest defibrillator device which applied an
alternating voltage of greater than 1000 volts, conducted by means of externally applied electrodes through the
chest cage to the heart, was pioneered by Dr V. Eskin with assistance by A. Klimov in Frunze, USSR (today
known as Bishkek, Kyrgyzstan) in the mid-1950s. The duration of AC shocks was typically in the range of 100-
150 milliseconds
09,*;
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Early successful experiments of successful defibrillation by the discharge of a capacitor performed on animals
were reported by N. L. Gurvich and G. S. Yunyev in 1939. In 1947 their works were reported in western medical
journals. Serial production of Gurvich’s pulse defibrillator started in 1952 at the electromechanical plant of the
institute, and was designated model. It is described in detail in Gurvich’s 1957 book, Heart Fibrillation and
Defibrillation. The first Czechoslovak “universal defibrillator Prema” was manufactured in 1957 by the company
Prema, designed by dr. Bohumil Peleška.
In 1958 his device was awarded Grand Prix at Expo 58. In 1958, US senator Hubert H. Humphrey visited
Nikita Khrushchev and among other things he visited the Moscow Institute of Reanimatology, where, among
others, he met with Gurvich. Humphrey immediately recognized importance of reanimation research and after
that a number of American doctors visited Gurvich. At the same time, Humphrey worked on establishing of a
federal programme in the National Institute of Health in physiology and medicine, telling to the Congress:
“Let’s compete with U.S.S.R. in research on reversibility of death”. In 1959 Bernard Lown commenced research
in his animal laboratory in collaboration with engineer Barouh Berkovits into a technique which involved
charging of a bank of capacitors to approximately 1000 volts with an energy content of 100-200 joules then
delivering the charge through an inductance such as to produce a heavily damped sinusoidal wave of finite
duration (~5 milliseconds) to the heart by way of paddle electrodes.
This team further developed an understanding of the optimal timing of shock delivery in the cardiac cycle,
enabling the application of the device to arrhythmias such as atrial fibrillation, atrial flutter, and supraventricular
tachycardias in the technique known as “cardioversion”. The Lown-Berkovits waveform, as it was known, was
the standard for defibrillation until the late 1980s. Earlier in the 1980s, the “MU lab” at the University of
Missouri had pioneered numerous studies introducing a new waveform called a biphasic truncated waveform
(BTE). In this waveform an exponentially decaying DC voltage is reversed in polarity about halfway through
the shock time, then continues to decay for some time after which the voltage is cut off, or truncated. The
studies showed that the biphasic truncated waveform could be more efficacious while requiring the delivery of
lower levels of energy to produce defibrillation. An added benefit was a significant reduction in weight of the
machine. The BTE waveform, combined with automatic measurement of transthoracic impedance is the basis
for modern defibrillators.
69;()3,50;:),*64,=(03()3,
A major breakthrough was the introduction of portable defibrillators used out of the hospital. Already Peleška’s
Prema defibrillator was designed to be more portable than original Gurvich’s model. In Soviet Union, a portable
version of Gurvich’s defibrillator, model (DPA-3), was reported in 1959. In the west this was pioneered in the
early 1960s by Prof. Frank Pantridge in Belfast. Today portable defibrillators are among the many very important
tools carried by ambulances. They are the only proven way to resuscitate a person who has had a cardiac arrest
unwitnessed by Emergency Medical Services (EMS) who is still in persistent ventricular fibrillation or ventricular
tachycardia at the arrival of pre-hospital providers. Gradual improvements in the design of defibrillators, partly
based on the work developing implanted versions, have led to the availability of Automated External
Defibrillators. These devices can analyse the heart rhythm by themselves, diagnose the shockable rhythms, and
charge to treat. This means that no clinical skill is required in their use, allowing lay people to respond to
emergencies effectively.
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Until the mid 90s, external defibrillators delivered a Lown type waveform which was a heavily damped
sinusoidal impulse having a mainly uniphasic characteristic. Biphasic defibrillation alternates the direction of
the pulses, completing one cycle in approximately 12 milliseconds. Biphasic defibrillation was originally
developed and used for implantable cardioverter-defibrillators. When applied to external defibrillators, biphasic
defibrillation significantly decreases the energy level necessary for successful defibrillation, decreasing the
risk of burns and myocardial damage. Ventricular fibrillation (VF) could be returned to normal sinus rhythm in
60% of cardiac arrest patients treated with a single shock from a monophasic defibrillator. Most biphasic
defibrillators have a first shock success rate of greater than 90%.
473(5;()3,,=0*,:
A further development in defibrillation came with the invention of the implantable device, known as an
implantable cardioverter-defibrillator (or ICD). This was pioneered at Sinai Hospital in Baltimore by a team that
included Stephen Heilman, Alois Langer, Jack Lattuca, Morton Mower, Michel Mirowski, and Mir Imran, with
the help of industrial collaborator Intec Systems of Pittsburgh. Mirowski teamed up with Mower and Staewen, and
together they commenced their research in 1969 but it was 11 years before they treated their first patient. Similar
developmental work was carried out by Schuder and colleagues at the University of Missouri. The work was
commenced, despite doubts amongst leading experts in the field of arrhythmias and sudden death. There was
doubt that their ideas would ever become a clinical reality. In 1962 Bernard Lown introduced the external DC
defibrillator. This device applied a direct current from a discharging capacitor through the chest wall into the heart
to stop heart fibrillation. In 1972, Lown stated in the journal Circulation — “The very rare patient who has
frequent bouts of ventricular fibrillation is best treated in a coronary care unit and is better served by an effective
antiarrhythmic programme or surgical correction of inadequate coronary blood flow or ventricular malfunction. In
fact, the implanted defibrillator system represents an imperfect solution in search of a plausible and practical
application.” The problems to be overcome were the design of a system which would allow detection of ventricular
fibrillation or ventricular tachycardia. Despite the lack of financial backing and grants, they persisted and the first
device was implanted in February 1980 at Johns Hopkins Hospital by Dr. Levi Watkins, Jr. assisted by Vivien
Thomas. Modern ICDs do not require a thoracotomy and possess pacing, cardioversion, and defibrillation
capabilities. The invention of implantable units is invaluable to some regular sufferers of heart problems, although
they are generally only given to those people who have already had a cardiac episode. People can live long normal
lives with the devices. Many patients have multiple implants. A patient in Houston, Texas had an implant at the age
of 18 in 1994 by the recent Dr. Antonio Pacifico. He was awarded “Youngest Patient with Defibrillator” in 1996.
Though today these devices are implanted into small babies shortly after birth.
Society and Culture

As devices that can quickly produce dramatic improvements in patient health, defibrillators are often depicted
in movies, television, video games and other fictional media. Their function, however, is often exaggerated,
with the defibrillator inducing a sudden, violent jerk or convulsion by the patient; in reality, although the
muscles may contract, such dramatic patient presentation is rare. Similarly, medical providers are often depicted
defibrillating patients with a “flat-line” ECG rhythm (also known as asystole). This is not normal medical
practice, as the heart cannot be restarted by the defibrillator itself. Only the cardiac arrest rhythms ventricular
fibrillation and pulseless ventricular tachycardia are normally defibrillated. The purpose of defibrillation is to
depolarize the entire heart all at once so that it is synchronized, in the hope that it will resume beating normally.
Someone who is already in asystole cannot be helped by electrical means, and usually needs urgent CPR and
intravenous medication. There are also several heart rhythms that can be “shocked” when the patient is not in
cardiac arrest, such as supraventricular tachycardia and ventricular tachycardia that produces a pulse; this
more-complicated procedure is known as cardioversion, not defibrillation.
90=0(
In Australia up until the 1990s it was relatively rare for ambulances to carry defibrillators. This changed in
1990 after Australian media mogul Kerry Packer had a heart attack and, purely by chance, the ambulance that
responded to the call carried a defibrillator. After recovering, Kerry Packer donated a large sum to the Ambulance
Service of New South Wales in order that all ambulances in New South Wales should be fitted with a personal
defibrillator, which is why defibrillators in Australia are sometimes colloquially called “Packer Whackers”.
THE DEVELOPMENT OF EMERGENCY MEDICAL SERVICES

The extensive international readership of the Lancet helps explain why Pantridge’s idea spread so rapidly to
other countries. Within 2 years, similar physician staffed MCCU programmes began in Australia and Europe.
The first programme in the United States was started in 1968 by William Grace out of St. Vincent’s Hospital in
Greenwich Village in New York City. The programme was a clone of the Belfast programme and utilized
specially equipped ambulances with physicians on board to provide advanced resuscitation care directly at the
scene of cardiac emergencies. Calls for medical emergencies in which chest pain was a complaint were passed
on from the police 911 operator to the hospital. There an ambulance would fight New York traffic to arrive at
the scene. Grace described the rather full ambulance and how it was sent:
“The personnel includes an attending physician, resident physician, emergency room nurse, ECG technician,
as well as a student nurse observer, in addition to the driver and his assistant. This team is summoned from
various points in the hospital to the emergency room by a personal paging system which each member of the
team carries. This team has four and one half minutes to get to the emergency room, obtain their equipment and
board the ambulance. Anyone who is not there within this time is left behind.”
In a scientific report of the St. Vincent’s programme, Grace described the experience with the first 161
patients (ref). Only two instances occurred in which the physician did not make the 4½-minute deadline and the
ambulance left without the physician. The ambulance reached the scene usually within 14 minutes, plus of
course the 4½-minute pre-response time. One call took 25 minutes owing to heavy traffic. Among the first
group of patients seen by the MCCU were three patients treated for ventricular fibrillation. One of the three
survived. Grace took this concept, imported from overseas, and made it work in his community. Physicians with
defibrillators rushing through the city to reach a non-breathing, unconscious person whose heart had stopped
were quite unusual by 1968 standards. However, the programme was limited in vision, and although it could
work in some communities, it was not nationally applicable. An evolution in prehospital emergency care was
needed. The evolution from physician-staffed mobile intensive care units to paramedic-staffed units in the
United States occurred independently and almost simultaneously in several communities. Two communities
that led the way were Miami and Seattle, but others included Portland, Oregon, Los Angeles, and Columbus,
Ohio. These communities were a major evolutional advance compared to the Belfast or New York City
programmes. Not only were paramedics used instead of physicians, but from their inception the programmes
were established to deal with the problem of sudden cardiac arrest. Pantridge’s programme was established
primarily to reach the victim of MI fast and thereby prevent mortality in the vulnerable early stage of this event.
Thus cardiac arrest was successfully treated only if it occurred as a complication of MI and only if the ambulance
was already at the scene or en route. The new paramedic programmes were far more nimble than physician-
based programmes and were specifically designed not only to treat the early stages of MI, but also to attempt
resuscitation for sudden cardiac arrest wherever and whenever it occurred. Reversal of death itself would be a
major purpose and goal of the new paramedic programmes.
Eugene Nagel became aware of Pantridge’s work in 1967. He believed that the physician-staffed model of
prehospital care was not going to work for the United States in general or for Miami in particular. Physicians
were too expensive to sit around fire stations waiting for calls, and if they had to be picked up in hospitals, it
would take too long to arrive at the scene. When Nagel or his colleague James Hirschman, rode on the ambulance
themselves they could, of course, defibrillate and provide medications, but they could not be present on all
shifts. Nagel became convinced it was time to move away from a programme using physicians to one staffed by
paramedics. Nagel moved incrementally. He did not think he could initially sell the idea of paramedics working
alone, even if they had authorization to perform medical procedures signed by physicians. So instead his first
step was to establish a radio link and telemetry between the paramedic fire fighters and the hospital. Nagel’s
had a hidden agenda in promoting telemetry. For Nagel it gained him access through the legal impediments
stopping fire fighters from defibrillating patients and administering medications. Nagel reasoned that if the fire
department could send the ECG signal to the hospital via telemetry, then the fire fighters (with special training)
could be authorized by the physician to administer needed drugs and procedures before arriving in the emergency
department. He believed a paramedic at the scene was a legal extension of a physician. He recalled later, “We
saw telemetry as the key to extending our treatment to outside the hospital where hitherto trying to legislate it
was the dark side of the moon in those days. The telemetry looked like it might be the ‘open sesame’ to doing
some treatment pre-hospital.” Nagel hoped to find support from the medical community; instead he only
encountered discouragement. Nagel recalled this opposition, “It was a rare doctor that favoured us doing any of
this stuff – very rare. We had incidents in the street when we were just sending an ECG, where doctors on the
scene would tell the firemen to quit fooling around and haul the victim in.” Nagel recalled the first save of the
Miami paramedic programme. The collapse occurred near Station 1, on the fringe of downtown Miami. He
reminisced:
“There was a guy named Dan Jones who was then about 60 years old, who was a wino who lived in a fleabag
in the bad part of town. Jones was well known to rescue. In June of ’69 they got a call – man down – it was
Jones. They put the paddles on him, he was in VF, started CPR, zapped him, he came back to sinus rhythm,
brought him into ER and three days later he was out and walking around. In gratitude, about a week later, he
came down to Station 1, which he had never done before, and he said he would like to talk to the man who saved
his life. They told me they had never seen Dan Jones in a clean shirt and sober, both of which he was that day.
He would periodically come to the fire house and just say hello and he seemed to be sober. In my talks in those
days I said this was the new cure for alcoholism. That was our first true save.”
Pantridge’s article also energized Leonard Cobb in Seattle. He knew the Seattle Fire Department was already
involved in first aid and therefore approached the Fire Chief, Gordon Vickery, to propose a new training
programme to treat cardiac arrest. The fire department already had one of the United States’ first computerized
systems for documenting first aid runs. Cobb realized that this system could provide scientific documentation
for the efficacy (or lack thereof) of Pantridge’s suggestions and suggested to Vickery that they pool their
knowledge and resources. Cobb and his colleagues then provided instruction and training in cardiac emergencies
including cardiac arrest to volunteer fire fighters. The programme became operational in March 1970, nine
months after Nagel’s first save in Miami. The mobile unit was stationed outside the Harborview Hospital
emergency department. As Cobb himself points out, the mobile unit was not the real innovation. Rather, it was
the concept of a tiered response to medical emergencies. The idea was “that we would get someone out there
quickly” – via the fire department’s already existing mobile first aid units – “and then a secondary response
would come from the mobile intensive coronary care unit.” The beauty of the tiered response system was the
efficient use of fire department personnel, which allowed aid personnel to reach the scene quickly (on an
average of three minutes) to start CPR. Then a few minutes later the paramedics arrived to provide more
definitive care such as defibrillation. In this way the brain could be kept alive until the electric shock converted
the heart to a normal rhythm. After stabilization the paramedics would transport the patient to the hospital. The
Seattle paramedic programme did more than pioneer paramedics and promote the tiered response system. It was
the first programme in the world to make citizens part of the emergency system. Cobb knew from data the
programme had collected that the sooner CPR was started, the better the chances of survival. He reasoned that
the best way to ensure early initiation of CPR was to train the bystanders. Thus Cobb, with the support of
Vickery, began a programme in 1972 called Medic 2. Its goal was to train over 100,000 people in Seattle how to
do CPR. Cobb recalled how the idea was first proposed: One day Vickery said, “Look, if it’s so important to get
CPR started quickly and if firemen come around to do it, it can’t be that complicated that other folks couldn’t
also learn – firemen are not created by God to do CPR. You could train the public.” Cobb said, “That sounds
like a very good idea.”
Cobb decided to use an abbreviated course of training. “We weren’t going to do it by traditional ways where
they had to come for 20 hours (of training). So they had to do it at one sitting – how long will people participate?
– well, maybe three hours and that’s pretty much the way it was.” Cobb cautiously did not state how long it
would take to train 100,000 people. He had no idea. In fact it took only a few years and by the 20th anniversary
of the citizen training programme over half a million people in Seattle and the surrounding suburbs had received
training in CPR. Some people were sceptical about mass citizen training in CPR; indeed, many felt the potential
for harm was too great to allow such a procedure in the hands of laypersons. The skeptics also had the support
of national medical organizations. The alarmist voices were stilled by some fortunate saves. Cobb recalled one
resuscitation soon after the citizen training programme began. “In March 1973 there were these kids playing
golf at Jackson Park. They came across a victim a quarter of a mile from the clubhouse.” The man was unconscious
and not breathing; later it was confirmed that he was in ventricular fibrillation. “But these kids had taken the
[CPR] course over at the local high school. Two or three of them started doing CPR and the other kid ran off and
phoned the fire department. Shortly they came with the aid car and Medic 1 screaming over the fairways.” Cobb
concluded, “They got him started up again. He survived; he’s alive today [1990]. That was a very convincing
story. I didn’t mind it being written up in the Reader’s Digest.”
RECENT DEVELOPMENTS IN CPR

By the early 1970s CPR, defibrillation, and a rapid means to provide prehospital care were all in place. The
structure to resuscitate sudden death victims had been built and was proving successful. That most of the world did
not have this structure in place in the 1970s was largely due to lack of diffusion and spread of the ideas, rather than
the impossibility of carrying them out. However, the story of resuscitation does not stop in the early 1970s. Major
advances have continued. In 1980 the first programme to train EMTs to perform defibrillation began in King
County, Washington, and similar programmes spread throughout the United States. This training required 10
hours, and in the first demonstration project, survival from ventricular fibrillation increased from 7% to 26%. In
1984 the first programme with fire fighter EMTs using automated external defibrillators (AEDs) also began in
King County, Washington. The use of AEDs simplified the training of EMTs and thus allowed the procedure to
spread more rapidly throughout communities. Automated external defibrillators require considerably less training
time compared to manual defibrillators since the EMT does not have to interpret the cardiac rhythm. The idea for
an automated defibrillator was first conceived by Dr. Arch Diack, a surgeon in Portland, Oregon. His prototype,
literally assembled in a basement, utilized a unique defibrillatory pathway – tongue to chest. There was a breath
detector that was a safeguard to prevent shocking breathing persons. The electrode was essentially a rate counter,
far cruder than today’s sophisticated VF detectors. The production model weighed 35 pounds and gave verbal
instructions. It was an idea ahead of its time. Most people viewed it as a curiosity. By the late 1980s, however,
other manufacturers entered the field leading to the automated external defibrillators (AEDs) we have today.
Current AEDs, like regular defibrillators, use electrode pads attached to the chest. AEDs are programmed to
guide the operator (with a series of voice prompts) through the procedure. The pads once attached automatically
detect the type of heart rhythm and if VF is present the AED instructs the operator to press a button (usually
flashing red) to shock the patient. From EMT defibrillation with AEDs, there was a natural and logical progression
to first responder defibrillation (AEDs used by police or security personnel), next widespread Public Access
Defibrillation (AEDs used by lay persons in public locations such as airports, schools, exercise facilities, etc.)
and finally home AED including the opportunity to purchase AEDs over the counter without a prescription. In
1981 a programme to provide telephone instructions in CPR began in King County, Washington. This programme
used the emergency dispatchers to give instant directions while the fire department EMT personnel were en
route to the scene. This demonstration project increased the rate of bystander-provided CPR by 50%. Dispatcher-
assisted CPR is now standard care for dispatcher centers throughout the United States and in other countries
such as Israel, Great Britain, Sweden, and Norway. The American Heart Association uses a metaphor of four
links in a chain to describe the elements of successful resuscitation. These links are early access (recognizing
cardiac arrest and calling 911), early CPR, early defibrillation, and early advanced care (such as medications,
endotracheal intubation) The early paramedic programmes were all designed to provide CPR, defibrillation,
and advanced care quickly enough to resuscitate patients in cardiac arrest. CPR has continued to advance, with
recent developments including an emphasis on constant, rapid heart stimulation, without respiration. Studies
have shown that people who had rapid, constant hands-only chest compression 22% more likely to survive than
those receiving conventional, CPR that included breathing. What’s more, because people tend to be reluctant to
do mouth-to-mouth, chest-only CPR nearly doubles the chances of survival overall, by increasing the odds of
receiving CPR in the first place.

CPR is indicated for any person unresponsive with no breathing or breathing only in occasional agonal
gasps, as it is most likely that they are in cardiac arrest. If a person still has a pulse but is not breathing
(respiratory arrest) artificial ventilations may be more appropriate, but, due to the difficulty people have in
accurately assessing the presence or absence of a pulse, CPR guidelines recommend that lay persons should not
be instructed to check the pulse, while giving health care professionals the option to check a pulse. In those with
cardiac arrest due to trauma, CPR is considered futile but still recommended. Correcting the underlying cause
such as a pneumothorax or pericardial tamponade may help.
EFFECTIVENESS
CPR serves as the foundation of successful cardiopulmonary resuscitation, preserving the body for
defibrillation and advanced life support. Even in the case of a “non-shockable” rhythm, such as pulseless
electrical activity (PEA) where defibrillation is not indicated, effective CPR is no less important. Used alone,
CPR will result in few complete recoveries, though the outcome without CPR is almost uniformly fatal. Studies
have shown that immediate CPR followed by defibrillation within 3–5 minutes of sudden VF cardiac arrest
dramatically improves survival. In cities such as Seattle where CPR training is widespread and defibrillation by
EMS personnel follows quickly, the survival rate is about 20 percent for all causes and as high as 57 percent if
a witnessed “shockable” arrest. In cities such as New York, without those advantages, the survival rate is only
5 percent for witnessed shockable arrest.
Type of Arrest ROSC Survival
Witnessed in-hospital cardiac arrest 52% 19%
Unwitnessed in-hospital cardiac arrest 33% 8%
Out-of-hospital cardiac arrest overall 59% 10%
Unwitnessed out-of-hospital cardiac arrest 21% 4%
Witnessed out-of-hospital cardiac arrest 41% 15%
Witnessed and “shockable” with bystander CPR 53% 37%
Bystander compression-only resuscitation - 13%
Bystander conventional CPR - 8%
In adults compression-only CPR by bystanders appears to be better than chest compressions with rescue
breathing. Compression-only CPR may be less effective in children than in adults, as cardiac arrest in children
is more likely to have a non-cardiac cause. In a 2010 prospective study of cardiac arrest in children (age 1–17)
for arrests with a non-cardiac cause, provision by bystanders of conventional CPR with rescue breathing yielded
a favourable neurological outcome at one month more often than did compression-only CPR (OR 5.54). For
arrests with a cardiac cause in this cohort, there was no difference between the two techniques (OR 1.20). This
is consistent with American Heart Association guidelines for parents. When done by trained responders, 30
compressions interrupted by two breaths appears to have a slightly better result than continuous chest
compressions with breaths being delivered while compressions are ongoing. There is a higher proportion of
patients who achieve spontaneous circulation (ROSC), where their heart starts beating on its own again, than
ultimately survive to be discharged from hospital. This may be due to medical staff being ultimately unable to
address the cause of the cardiac arrest, to other co-morbidities, or to the patient being gravely ill in more than
one way. Ultimately, only 5–10% of patients in cardiac arrest will survive after an attempted resuscitation.

While CPR is a last resort intervention, without which a person without a pulse will all but certainly die, the
physical nature of how CPR is performed does lead to complications that may need to be rectified. Common
complications due to CPR are rib fractures, sternal fractures, bleeding in the anterior mediastinum, heart contusion,
hemopericardium, upper airway complications, damage to the abdominal viscera “ lacerations of the liver and
spleen, fat emboli, pulmonary complications “ pneumothorax, hemothorax, lung contusions. The most common
injuries sustained from CPR are rib fractures, with literature suggesting an incidence between 13% and 97%,
and sternal fractures, with an incidence between 1% to 43%. While these iatrogenic injuries can require further
intervention (assuming the patient survives the cardiac arrest), only 0.5% of them are life-threatening in their
own right. The type and frequency of injury can be affected by factors such as gender and age. For instance,
women have a higher risk of sternal fractures than men, and risk for rib fractures increases significantly with
age. Children and infants have a low risk of rib fractures during CPR, with an incidence less than 2%, although,
when they do occur, they are usually anterior and multiple. Where CPR is performed in error by a bystander, on
a person not in cardiac arrest, around 2% have injury as a result (although 12% experienced discomfort).

In 2010, the American Heart Association and International Liaison Committee on Resuscitation updated
their CPR guidelines. The importance of high quality CPR (sufficient rate and depth without excessively
ventilating) was emphasized. The order of interventions was changed for all age groups except newborns from
airway, breathing, chest compressions (ABC) to chest compressions, airway, breathing (CAB). An exception to
this recommendation is for those believed to be in a respiratory arrest (airway obstruction, drug overdose, etc.).
The most important aspect of CPR are: few interruptions of chest compressions, a sufficient speed and depth of
compressions, completely relaxing pressure between compressions, and not ventilating too much. It is unclear
if a few minutes of CPR before defibrillation results in different outcomes than immediate defibrillation.
COMPRESSIONS WITH RESCUE BREATHS

A universal compression to ventilation ratio of 30:2 is recommended for adults. With children, if at least 2
trained rescuers are present a ratio of 15:2 is preferred. In newborns a rate of 3:1 is recommended unless a cardiac
cause is known in which case a 15:2 ratio is reasonable. If an advanced airway such as an endotracheal tube or
laryngeal mask airway is in place, artificial ventilation should occur without pauses in compressions at a rate of 8–
10 per minute. The recommended order of interventions is chest compressions, airway, breathing or CAB in most
situations, with a compression rate of at least 100 per minute in all groups. Recommended compression depth in
adults and children is at least 5 cm (2 inches) and in infants it is 4 centimetres (1.6 in). As of 2010 the Resuscitation
Council (UK) still recommends ABC for children. As it can be difficult to determine the presence or absence of a
pulse, the pulse check has been removed for lay providers and should not be performed for more than 10 seconds
by health care providers. In adults, rescuers should use two hands for the chest compressions, while in children
they should use one, and with infants two fingers (index and middle fingers).
COMPRESSION ONLY
For adults with cardiac arrest, compression-only (hands-only or cardiocerebral resuscitation) CPR which
involves chest compressions without artificial ventilation is recommended as the method of choice for the
untrained rescuer or those who are not proficient as it is easier to perform and instructions are easier to give
over a phone. In adults with out-of-hospital cardiac arrest, compression-only CPR by the lay public has an equal
or higher success rate than standard CPR. It is hoped that the use of compression-only delivery will increase the
chances of the lay public delivering CPR. Compression-only CPR is not as good for children who are more
likely to have cardiac arrest from respiratory causes. Two reviews have found that compression-only CPR had
no more success than no CPR whatsoever.
Rescue breaths for children and especially for babies should be relatively gentle. Either a ratio of compressions
to breaths of 30:2 or 15:2 was found to have better results for children. Both children and adults should receive
a hundred chest compressions per minute. Other exceptions besides children include cases of drownings and
drug overdose. In both these cases, compressions and rescue breaths are recommended if the bystander is
trained and is willing to do so. As per the American Heart Association, the beat of the Bee Gees song “Stayin’
Alive” provides an ideal rhythm in terms of beats per minute to use for hands-only CPR. One can also hum
Queen’s “Another One Bites The Dust”, which is 110 beats-per-minute and contains a memorable repeating
drum pattern. For those in cardiac arrest due to non heart related causes and in people less than 20 years of age,
standard CPR is superior to compression-only CPR.
PRONE CPR
Standard CPR is performed with the person in supine position. Prone CPR or reverse CPR is CPR performed
on a person lying on their chest, by turning the head to the side and compressing the back. Due to the head’s
being turned, the risk of vomiting and complications caused by aspiration pneumonia may be reduced. The
American Heart Association’s current guideline recommends to perform CPR in the supine position, and limits
prone CPR to situations where the patient cannot be turned.
PREGNANCY
During pregnancy when a woman is lying on her back, the uterus may compress the inferior vena cava and
thus decrease venous return. It is therefore recommended that the uterus be pushed to the woman’s left; if this
is not effective, either roll the woman 30° or health care professionals should consider emergency resuscitative
hysterotomy.
FAMILY PRESENCE
Evidence generally supports family being present during CPR. This includes in CPR for children.
OTHER
Interposed abdominal compressions may be beneficial in the hospital environment. There is no evidence of
benefit pre-hospital or in children. Cooling during CPR is being studied as currently results are unclear whether
or not it improves outcomes.
Internal cardiac massage is manual squeezing of the exposed heart itself carried out through a surgical
incision into the chest cavity, usually when the chest is already open for cardiac surgery. Active compression-
decompression methods using mechanical decompression of the chest have not been shown to improve outcome
in cardiac arrest.

CPR is used on people in cardiac arrest in order to oxygenate the blood and maintain a cardiac output to keep
vital organs alive. Blood circulation and oxygenation are required to transport oxygen to the tissues. The
physiology of CPR involves generating a pressure gradient between the arterial and venous vascular beds; CPR
achieves this via multiple mechanisms The brain may sustain damage after blood flow has been stopped for
about four minutes and irreversible damage after about seven minutes. Typically if blood flow ceases for one to
two hours, then body cells die. Therefore, in general CPR is effective only if performed within seven minutes of
the stoppage of blood flow. The heart also rapidly loses the ability to maintain a normal rhythm. Low body
temperatures, as sometimes seen in near-drownings, prolong the time the brain survives. Following cardiac
arrest, effective CPR enables enough oxygen to reach the brain to delay brain stem death, and allows the heart
to remain responsive to defibrillation attempts.

While several adjunctive devices are available, none other than defibrillation, as of 2010, have consistently
been found to be better than standard CPR for out-of-hospital cardiac arrest. These devices can be split into
three broad groups: timing devices; devices that assist the rescuer in achieving the correct technique, especially
depth and speed of compressions; and devices that take over the process completely.
TIMING DEVICES
Timing devices can feature a metronome (an item carried by many ambulance crews) in order to assist the
rescuer in achieving the correct rate. Some units can also give timing reminders for performing compressions,
ventilating and changing operators.
MANUAL ASSIST DEVICES

Mechanical chest compression devices are not currently recommended for widespread use. There have not
been enough high quality studies performed to determine if using mechanical assist devices for chest compression
saves more lives compared with using the traditional hand compression technique. Audible and visual prompting
may improve the quality of CPR and prevent the decrease of compression rate and depth that naturally occurs
with fatigue, and to address this potential improvement, a number of devices have been developed to help
improve CPR technique. These items can be devices to be placed on top of the chest, with the rescuer’s hands
going over the device, and a display or audio feedback giving information on depth, force or rate, or in a
wearable format such as a glove. Several published evaluations show that these devices can improve the
performance of chest compressions. As well as its use during actual CPR on a cardiac arrest victim, which relies
on the rescuer carrying the device with them, these devices can also be used as part of training programmes to
improve basic skills in performing correct chest compressions.
AUTOMATIC DEVICES
Mechanical CPR has not seen as much use as mechanical ventilation. Devices on the market include LUCAS-
2, developed at the University Hospital of Lund, and return of spontaneous circulation. and AutoPulse. Both
use straps around the chest, LUCAS-2 uses a gas driven piston and motor driven constricting band. There are
several advantages to automated devices: they allow rescuers to focus on performing other interventions; they
do not fatigue and begin to perform less effective compressions, as humans do; they are able to perform effective
compressions in limited-space environments such as air ambulances, where manual compressions are difficult,
and they allow ambulance workers to be strapped in safely rather than standing over a patient in a speeding
vehicle. However the disadvantages are cost to purchase, time to train emergency personnel to use them,
interruption to CPR to implement, potential for incorrect application and the need for multiple device sizes.
Several studies have shown little or no improvement in survival rates but acknowledge the need for more study.
MOBILE APPS
To support training and incident management, mobile apps have been published on the largest app markets.
An evaluation of 61 available apps has revealed that a large number do not follow international guidelines for
basic life support and many apps are not designed in a user-friendly way. As a result, the Red Cross updated and
endorsed its emergency preparedness application, which uses pictures, text and videos to assist the user. The
UK Resuscitation Council, has an app, called Lifesaver, which shows how to perform CPR.

CHANCE OF RECEIVING CPR

Various studies suggest that in out-of-home cardiac arrest, bystanders in the USA attempt CPR in between
14% and 45% of the time, with a median of 32%. Internationally, rates of bystander CPR reported to be as low
as 1% and as high as 44%. However, the effectiveness of this CPR is variable, and the studies suggest only
around half of bystander CPR is performed correctly. One study found that members of the public having
received CPR training in the past lack the skills and confidence needed to save lives. The report’s authors
suggested that better training is needed to improve the willingness to respond to cardiac arrest. Factors that
influence bystander CPR in out-of-hospital cardiac arrest include:
• Affordable training.
• Target CPR training to family members of potential cardiac arrest
• CPR classes should be simplified and shortened.
• Offer reassurance and education about CPR.
• Provide clearer information about legal implications for specific regions.
• Focus on reducing the stigma and fears around providing bystander CPR.
There is a relation between age and the chance of CPR being commenced. Younger people are far more
likely to have CPR attempted on them before the arrival of emergency medical services. Bystanders more
commonly administer CPR when in public than when at the person’s home, although health care professionals
are responsible for more than half of out-of-hospital resuscitation attempts. People with no connection to the
person are more likely to perform CPR than are a member of their family. There is also a clear relation between
cause of arrest and the likelihood of a bystander initiating CPR. Lay persons are most likely to give CPR to
younger people in cardiac arrest in a public place when it has a medical cause; those in arrest from trauma,
exsanguination or intoxication are less likely to receive CPR. It is believed that there is a higher chance that
CPR will be performed if the bystander is told to perform only the chest compression element of the resuscitation.
CHANCE OF RECEIVING CPR IN TIME

CPR is likely to be effective only if commenced within 6 minutes after the blood flow stops because permanent
brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become
dormant in as little as 4–6 minutes in an oxygen deprived environment and, therefore, cannot survive the reintroduction
of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate
with cardiac arrest intervals of 72±43 minutes, traditional methods achieve a 15% survival rate in this scenario, by
comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual
resuscitation techniques will have with this new knowledge. A notable exception is cardiac arrest that occurs in
conjunction with exposure to very cold temperatures. Hypothermia seems to protect by slowing down metabolic and
physiologic processes, greatly decreasing the tissues’ need for oxygen. There are cases where CPR, defibrillation,
and advanced warming techniques have revived victims after substantial periods of hypothermia.

PORTRAYED EFFECTIVENESS
CPR is often severely misrepresented in movies and television as being highly effective in resuscitating a
person who is not breathing and has no circulation. A 1996 study published in the New England Journal of
Medicine showed that CPR success rates in television shows was 75% for immediate circulation, and 67%
survival to discharge. This gives the general public an unrealistic expectation of a successful outcome. When
educated on the actual survival rates, the proportion of patients over 60 years of age desiring CPR should they
suffer a cardiac arrest drops from 41% to 22%.
STAGE CPR
Chest compressions are capable of causing significant local blunt trauma, including bruising or fracture of
the sternum or ribs. Performing CPR on a healthy person may or may not disrupt normal heart rhythm, but
regardless the technique should not be performed on a healthy person because of the risk of trauma. The
portrayal of CPR technique on television and film often is purposely incorrect. Actors simulating the performance
of CPR may bend their elbows while appearing to compress, to prevent force from reaching the chest of the
actor portraying the victim.
SELF-CPR HOAX
A form of “self-CPR” termed “cough CPR” was the subject of a hoax chain e-mail entitled “How to Survive a
Heart Attack When Alone,” which wrongly cited “ViaHealth Rochester General Hospital” as the source of the
technique. Rochester General Hospital has denied any connection with the technique. “Cough CPR” in the sense
of resuscitating oneself is impossible because a prominent symptom of cardiac arrest is unconsciousness, which
makes coughing impossible. In cases of myocardial infarction (heart attack), during which the person may well
remain conscious but which is not by itself a form of arrest, attempting “cough CPR” will increase the workload
on the heart and will likely prove harmful. The American Heart Association (AHA) and other resuscitation bodies
do not endorse “cough CPR”, which it terms a misnomer as it is not a form of resuscitation. The AHA does
recognize a limited legitimate use of the coughing technique: “This coughing technique to maintain blood flow
during brief arrhythmias has been useful in the hospital, particularly during cardiac catheterization. In such cases
the patient’s ECG is monitored continuously, and a physician is present.” When coughing is used on trained and
monitored patients in hospitals, it has been shown to be effective only for 90 seconds.
LEARNING FROM FILM

In at least one case, it has been alleged that CPR learned from a film was used to save a person’s life. In April
2011, it was claimed that nine-year-old Tristin Saghin saved his sister’s life by administering CPR on her after
she fell into a swimming pool, using only the knowledge of CPR that he had gleaned from a motion picture,
Black Hawk Down.
HANDS-ONLY CPR PORTRAYAL

Less than 1/3 of those people who experience a cardiac arrest at home, work or in a public location have
CPR performed on them. Most bystanders are worried that they might do something wrong. On October 28,
2009 the American Heart Association and the Ad Council launched a Hands-Only CPR public service
announcement and web site as a means to address this issue. In July 2011, new content was added to the web
site including a digital app that helps a user learn how to perform Hands-Only CPR.

It is feasible to perform CPR on animals, including cats and dogs. The principles and practices are similar to
CPR for humans, except that resuscitation is usually done through the animal’s nose, not the mouth. CPR
should only be performed on unconscious animals to avoid the risk of being bitten; a conscious animal would
not require chest compressions. Animals, depending on species, may have a lower bone density than humans
and so CPR can cause bones to become weakened after it is performed.

Cerebral performance category (CPC scores) are used as a research tool to describe “good” and “poor”
outcomes. Level 1 is conscious and alert with normal function. Level 2 is only slight disability. Level 3 is
moderate disability. Level 4 is severe disability. Level 5 is comatose or persistent vegetative state. Level 6 is
brain dead or death from other causes.
Artificial Airways and Management 73
Chapter 4
Artificial Airways and Management

Advanced airway management is the subset of airway management that involves advanced training, skill
and invasiveness. It encompasses various techniques performed to create an open or patent airway - a clear path
between a patient’s lungs and the outside world. This is accomplished by clearing or preventing obstructions of
airways. Obstructions can be caused by many things, including the patient’s own tongue, other anatomical
components of the airway, foreign bodies, excessive amounts of blood, or aspiration of food particles, liquid or
even saliva. Unlike basic airway management such as head-tilt or jaw-thrust maneuver, advanced airway
management relies on the use of medical equipment and advanced training. Certain invasive airway management
techniques can be performed “blind” or with visualization of the glottis. Visualization of the glottis can be
accomplished either directly by using a laryngoscope blade or by utilizing newer video technology options. In
roughly increasing order of invasiveness are the use of supraglottic devices such as oropharyngeal (OPA),
nasopharyngeal (NPA) and laryngeal mask airways (LMA). Laryngeal mask airways can even be used to deliver
general anesthesia. These are followed by infraglottic techniques, such as tracheal intubation, and finally surgical
techniques. Advanced airway management is a key component in cardiopulmonary resuscitation, anaesthesia,
emergency medicine and intensive care medicine. The A in the ABC initialism mnemonic, for dealing with
critacal ill patients, stands for airway management.
REMOVAL OF FOREIGN OBJECTS

In advanced airway management foreign objects are either removed by suction or with e.g. a Magill forceps
under inspection of the airway with a laryngoscope or bronchoscope. If removal is not possible surgical methods
should be considered.
SUPRAGLOTTIC TECHNIQUES
Supraglottic techniques includes the use of supraglottic tubes, such as oropharyngeal and nasopharyngeal
airways, and supraglottic devises such as laryngeal masks. Common for all supraglottic devises are that they are
introduced into the pharynx, ensuring the upper respiratory tract remains open, without passing through the
glottis and thereby entering the trachea.
Oropharyngeal Airway
An oropharyngeal airway (also known as an oral airway, OPA or Guedel pattern airway) is a medical device
called an airway adjunct used to maintain or open a patient’s airway. It does this by preventing the tongue from
covering the epiglottis, which could prevent the person from breathing. When a person becomes unconscious,
the muscles in their jaw relax and allow the tongue to obstruct the airway.
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The oropharyngeal airway was designed by Arthur Guedel. Oropharyngeal airways come in a variety of
sizes, from infant to adult, and are used commonly in pre-hospital emergency care and for short term airway
management post anaesthetic or when manual methods are inadequate to maintain an open airway. This piece
of equipment is utilized by certified first responders, emergency medical technicians, paramedics and other
health professionals when tracheal intubation is either not available, not advisable or the problem is of short
term duration. Oropharyngeal airways are indicated only in unconscious people, because of the likelihood that
the device would stimulate a gag reflex in conscious or semi-conscious persons. This could result in vomit and
potentially lead to an obstructed airway. Nasopharyngeal airways are mostly used instead as they do not stimulate
a gag reflex. In general, oropharyngeal airways need to be sized and inserted correctly to maximize effectiveness
and minimize possible complications, such as oral trauma.
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The correct size OPA is chosen by measuring from the first incisors to the angle of the jaw. The airway is
then inserted into the person’s mouth upside down. Once contact is made with the back of the throat, the airway
is rotated 180 degrees, allowing for easy insertion, and assuring that the tongue is secured. An alternative
method for insertion, the method that is recommended for OPA use in children and infants, involves holding the
tongue forward with a tongue depressor and inserting the airway right side up. The device is removed when the
person regains swallow reflex and can protect their own airway, or it is substituted for an advanced airway. It is
removed simply by pulling on it without rotation.
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Use of an OPA does not remove the need for the recovery position and ongoing assessment of the airway and it
does not prevent obstruction by liquids (blood, saliva, food, cerebrospinal fluid) or the closing of the glottis. It can,
however, facilitate ventilation during CPR (cardiopulmonary resuscitation) and for persons with a large tongue.
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The main risks of its use are:
• If the person has a gag reflex, they may vomit
• When it is too large, it can close the glottis and thus close the airway
• Improper sizing can cause bleeding in the airway
Supraglottic Airway
Supraglottic airways (or extraglottic devices) are a family of devices that are inserted through the mouth to sit
on top of the larynx. Supraglottic airways are used in the majority of operations performed under general anaesthesia.
Compared to a cuffed tracheal tube, they give less protection against aspiration but are easier to insert and cause
less laryngeal trauma. The best-known example is the laryngeal mask airway. A laryngeal mask airway is an
airway placed into the mouth and set over the glottis and inflated. Other variations include devices with oesophageal
access ports, so that a separate tube can be inserted from the mouth to the stomach to decompress accumulated
gases and drain liquid contents. Some devices can have an endotracheal tube passed through them into the trachea.
INFRAGLOTTIC TECHNIQUES
Indications
There are specific indications or guidelines for deciding a more invasive and more secure airway is worth
the associated risk:
• Respiratory failure
• Apnea or the suspension of breathing
• Decreased or altered level of consciousness, rapid mental status change, Glasgow Coma Scale score
less than 8 (GCS<8).
• Major trauma, such as penetrating injury to abdomen or chest
• Direct airway injury or facial burns
• High risk of aspiration.
Confirming Placement
The absolute gold standard for confirming successful placement of an endotracheal tube is direct visualization
of the tube passing through the vocal cords. Other methods used as secondary confirmation include carbon
dioxide detectors, capnography, oxygen saturation, chest x-ray, or equal chest rise and equal breath sounds
heard on both sides of the chest.

Surgical airway management (bronchotomy or laryngotomy) is the medical procedure of ensuring there is an
open airway between a patient’s lungs and the outside world. Surgical methods for airway management rely on
making a surgical incision is made below the glottis in order to achieve direct access to the lower respiratory
tract, bypassing the upper respiratory tract. Surgical airway management is often performed as a last resort in
cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Surgical airway
management is also used when a person will need a mechanical ventilator for a longer period. The surgical
creation of a permanent opening in the larynx is referred to as laryngostomy. Surgical airway management is a
primary consideration in anaesthesia, emergency medicine and intensive care medicine. Surgical methods for
airway management include cricothyrotomy and tracheostomy.
HISTORY
Asclepiades of Bithynia is credited with being the first person who proposed bronchotomy as a surgical
procedure, though he never attempted to perform one. Aretaeus of Cappadocia thought the procedure dangerous
even as a remedy for choking, since the resulting incision “would not heal, as being cartilaginous”; Caelius
Aurelianus also rejected its usefulness.
NEEDLE CRICOTHYROTOMY
A needle cricothyrotomy is similar to a cricothyrotomy, but instead of making a scalpel incision, a large
over-the-needle catheter is inserted (10- to 14-gauge). This is considerably simpler, particularly if using specially
designed kits. This technique provides very limited airflow. The delivery of oxygen to the lungs through an
over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered
a form of conventional ventilation called percutaneous transtracheal ventilation (PTV).
TRACHEOTOMY
Tracheotomy or tracheostomy, is a surgical procedure which consists of making an incision on the anterior
aspect of the neck and opening a direct airway through an incision in the trachea (windpipe). The resulting
stoma (hole) can serve independently as an airway or as a site for a tracheal tube or tracheostomy tube to be
inserted; this tube allows a person to breathe without the use of the nose or mouth.
Indications
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In the chronic (long term) setting, indications for tracheotomy include the need for long-term mechanical
ventilation and tracheal toilet (e.g. comatose patients, or extensive surgery involving the head and neck).
Tracheotomy may result in a significant reduction in the administration of sedatives and vasopressors, as well
as the duration of stay in the intensive care unit. In extreme cases, the procedure may be indicated as a treatment
for severe obstructive sleep apnea (OSA) seen in patients intolerant of continuous positive airway pressure
(CPAP) therapy. The reason tracheostomy works well for OSA is because it is the only surgical procedure that
completely bypasses the upper airway. This procedure was commonly performed for obstructive sleep apnea
until the 1980s, when other procedures such as the uvulopalatopharyngoplasty, genioglossus advancement, and
maxillomandibular advancement surgeries were described as alternative surgical modalities for OSA.
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In the acute (short term) setting, indications for tracheotomy include such conditions as severe facial trauma,
tumors of the head and neck (e.g., cancers, branchial cleft cysts), and acute angioedema and inflammation of
the head and neck. In the context of failed orotracheal or nasotracheal intubation, either tracheotomy or
cricothyrotomy may be performed.
Parts
A tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The
obturator is used when inserting the tracheostomy tube to guide the placement of the outer cannula and is
removed once the outer cannula is in place. The outer cannula remains in place but, because of the buildup of
secretions, there is an inner cannula that may be removed for cleaning or replaced. Tracheostomy tubes may
have cuffs, inflatable balloons at the end of the tube to secure it in place. A tracheostomy tube may be fenestrated
with one or several holes to let air through the larynx, allowing speech.
Surgical Procedure
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As with most other surgical procedures, some cases are more difficult than others. Surgery on children is
more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the
trachea hard to open. There are other difficulties with patients with irregular necks, the obese, and those with a
large goitre. The many possible complications include hemorrhage, loss of airway, subcutaneous emphysema,
wound infections, stomal cellulites, fracture of tracheal rings, poor placement of the tracheostomy tube, and
bronchospasm”.
By the late 19th century, some surgeons had become proficient in performing the tracheotomy procedure.
The main instruments used were:
• “Two small scalpels, one short grooved director, a tenaculum, two aneurysm needles which may be
used as retractors, one pair of artery forceps, haemostatic forceps, two pairs of dissecting forceps, a
pair of scissors, a sharp-pointed tenotome, a pair of tracheal forceps, a tracheal dilator, tracheotomy
tubes, ligatures, sponges, a flexible catheter, and feathers”.
• Haemostatic forceps were used to control bleeding from separated vessels that were not ligatured
because of the urgency of the operation. Generally, they were used to expose the trachea by clamping
the isthmus thyroid gland on both sides. To open the trachea physically, a sharp-pointed tentome
allowed the surgeon easily to place the ends into the opening of the trachea. The thin points
permitted the doctor a better view of his incision. Tracheal dilators, such as the “Golding Bird”,
were placed through the opening and then expanded by “turning the screw to which they are
attached.” Tracheal forceps, as displayed on the right, were commonly used to extract foreign
bodies from the larynx. The optimum tracheal tube at the time caused very little damage to the
trachea and “mucus membrane”.
The best position for a tracheotomy was and still is one that forces the neck into the biggest prominence.
Usually, the patient was laid on his back on a table with a cushion placed under his shoulders to prop him up.
The arms were restrained to ensure they would not get in the way later. The tools and techniques used today in
tracheotomies have come a long way. The tracheotomy tube placed into the incision through the windpipe
comes in various sizes, thus allowing a more comfortable fit and the ability to remove the tube in and out of the
throat without disrupting support from a breathing machine. In today’s world general anesthesia is used when
performing these surgeries, which makes it much more tolerable for the patient. Special tracheostomy tube
valves (such as the Passy-Muir valve) have been created to assist people in their speech. The patient can inhale
through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the
tube, past the vocal folds, producing sound. Significant improvements to surgical instruments for tracheotomy
include the direct suction tracheotomy tube invented by Josephine G. Fountain (RN); she was awarded patent
no. 3039469 in 1962 for the direct suction tracheotomy tube, which improved the ways mucus could be cleared
from the trachea and increased patient breathing and comfort.
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While there were some earlier false starts, the first widely accepted percutaneous tracheotomy technique
was described by Pat Ciaglia, a New York surgeon, in 1985. This technique involves a series of sequential
dilatations using a set of seven dilators of progressively larger size. The next widely used technique was developed
in 1989 by Bill Griggs, an Australian intensive care specialist. This technique involves the use of a specially
modified pair of forceps with a central hole enabling them to pass over a guidewire enabling the performance of
the main dilation in a single step. Since then a number of other techniques have been described. In 1995,
Fantoni developed a translaryngeal approach of percutaneous tracheostomy which involves passing a guidewire
through the larynx and over it railroading a tracheostomy tube with a cone shaped structure. It is also known as
the In-and-out procedure.
A variant of the original Ciaglia technique, using a single tapered dilator known as a “blue rhino”, is the most
commonly used of these newer techniques and has largely taken over from the early multiple dilator technique.
Ambesh SP (2005) introduced a T-Trach kit (T-Dagger) which contains a T-shaped dilator with an elliptical
shaft. The shaft of the dilator is marked in its length according to the sizes of tracheostomy tube to be introduced
and has a number of holes. This T-shaped dilator provides better grip during its introduction and its elliptical
shaft forms a calibrated tracheal stoma between two tracheal rings and minimizes tracheal ring fracture. The
Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison
studies have been undertaken between these two techniques with no clear differences emerging
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The translaryngeal tracheostomy is a percutaneous technique characterized by the exclusive procedure to
carry out the stoma. A cone of soft plastic material, welded to a flexible cannula, is passed into trachea through
the glottis, and then extracted outside of the neck through the pretracheal layers. The direction of this dilational
manoeuvre is from the inside of the tracheal lumen to the outside of the neck (In/Out) and therefore completely
opposite to the Out/In of other traditional percutaneous tracheostomies. The cone is then separated from the
cannula, which results in it being positioned in the trachea. This method ensures considerable advantages, two
of which are of particular importance: the abolition of the risk of perforation of the posterior wall and the
reduction of local trauma to a level that is unlikely to be further lowered. The use of a ventilation catheter
during the time of the procedure allows full control of the airway and to extend the indications of the technique
to patients with severe respiratory failure.
Complications
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15%
and a procedural mortality of 0%, which is comparable to those of other series reported in the literature from the
Netherlands and the United States. A 2003 American cadaveric study identified multiple tracheal ring fractures
with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. The
comparative study above also identified ring fractures in 9 of 30 live patients while another small series identified
ring fractures in 5 of their 20 patients. The long term significance of tracheal ring fractures is unknown. But the
main complication of this procedure is obstruction of the hole due to accumulation of mucus produced by
respiratory normal flora, which in turn will lead to hypoxia and further complications due to reduced level of
oxygen received by lungs.
Alternatives
Biphasic cuirass ventilation is a form of non-invasive mechanical ventilation that can in many cases allow
patients an alternative mode of respiratory support, allowing patients to avoid an invasive tracheostomy and its
many complications. While this method has not been proven to help in every case, it has been shown to be an
effective alternative for many.
Routine Care
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Caring for a tracheotomy mostly includes suctioning to prevent occlusions and replacing supplies. Because
of the lack of filtering and humidifying by the nose and the ineffective cough mechanism, there is a buildup of
secretions. Suctioning is only performed when clinically necessary because there are many potential risks.
Risks include hypoxia and so suctioning is limited to 10 to 20 seconds at a time and the patient is hyperoxygenated
just before and after suctioning. Risks also include atelectasis, or collapsing lung tissue from high suction
pressure, and so pressure is limited to 80–120 mm Hg. Risks also include tissue damage. The suction catheter is
inserted no more than 1 cm past the length of the tube to avoid contact with trachea tissue. Suctioning is only
done during withdrawing the catheter at least 1/2 inch. Risks also include infection.

It is always important not to think of children as just small adults. They are unique in far more ways than
simply being smaller in size. There are many basic differences in anatomy compared to adults that can effect
airway management. For example children’s heads are proportionally larger in relation to their overall body
size. This can cause alignment issues that have the potential to make it substantially more difficult to obtain
good visualization of the appropriate airway landmarks. The differences in a child’s anatomy can also effect
equipment choices, such as choosing a straight laryngoscope blade instead of a curved one to achieve better
control of a more elastic airway. Making the right equipment choices is so important that a colour-coded tape
measure called the Broselow tape was created to help facilitate rapid and accurate decisions in pediatric emergency
situations. Birth complications, congenital syndromes (such as Down syndrome) and even recent illness or
nasal congestion can effect how airway management is approached in a child. When ventilation, various airway
options and even intubation are unsuccessful, this is a terrifying situation known as “cannot ventilate, cannot
intubate”. Typically this is when a cricothyrotomy would be attempted as mentioned above in Surgical techniques.
However, this tricky procedure is even more difficult in kids due to their extra flexible airways. The chance of
accidentally puncturing all the way through the trachea to the esophagus increases substantially. The risk is
considered so high that the procedure is contraindicated in children under the age of 5-6 years old.

CARDIOPULMONARY RESUSCITATION
The optimal method of airway management during CPR is not well established at this time given that the
majority of studies on the topic are observational in nature. These studies, however, guide recommendations
until prospective, randomized controlled trials are conducted. Current evidence suggests that for out-of-hospital
cardiac arrest, basic airway interventions (head-tilt–chin-lift maneuvers, bag-valve-masking or mouth-to-mouth
ventilations, nasopharyngeal and/or oropharyngeal airways) resulted in greater short-term and long-term survival,
as well as improved neurological outcomes in comparison to advanced airway interventions (endotracheal
intubation, laryngeal mask airway, all types of supraglottic airways (SGA), and trans-tracheal or trans-cricothyroid
membrane airways). Given that these are observational studies, caution must be given to the possibility of
confounding by indication. That is, patients requiring an advanced airway may have had a poorer prognosis in
relation to those requiring basic interventions to begin with. For the management of in-hospital cardiac arrest
however, studies currently support the establishment of an advanced airway. It is well documented that quality
chest compressions with minimal interruption result in improved survival. This is suggested to be due, in part,
to decreased no-flow-time in which vital organs, including the heart are not adequately perfused. Establishment
of an advanced airway (endotracheal tube, laryngeal mask airway) allows for asynchronous ventilation, reducing
the no-flow ratio, as compared to the basic airway (bag-valve mask) for which compressions must be paused to
adequately ventilate the patient. Bystanders without medical training who see an individual suddenly collapse
should call for help and begin chest compressions immediately. The American Heart Association currently
supports “Hands-only”™ CPR, which advocates chest compressions without rescue breaths for teens or adults.
This is to minimize the reluctance to start CPR due to concern for having to provide mouth-to-mouth resuscitation.
TRAUMA
Airway represents the “A” in the ABC mnemonic for trauma resuscitation. Management of the airway in
trauma can be particularly complicated, and is dependent on the mechanism, location, and severity of injury to
the airway and its surrounding tissues. Injuries to the cervical spine, traumatic disruption of the airway itself,
edema in the setting of caustic or thermal trauma, and the combative patient are examples of scenarios a provider
may need to take into account in assessing the urgency of securing an airway and the means of doing so. The
pre-hospital setting provides unique challenges to management of the airway including tight spaces, neck
immobilization, poor lighting, and often the added complexity of attempting procedures during transport. When
possible, basic airway management should be prioritized including head-tilt-chin-lift maneuvers, and bag-valve
masking. If ineffective, a supraglottic airway can be utilized to aid in oxygenation and maintenance of a patent
airway. An oropharyngeal airway is acceptable, however nasopharyngeal airways should be avoided in trauma,
particularly if a basilar skull fracture is suspected. Endotracheal intubation carries with it many risks, particularly
when paralytics are used, as maintenance of the airway becomes a challenge if intubation fails. It should therefore
be attempted by experienced personnel, only when less invasive methods fail or when it is deemed necessary
for safe transport of the patient, to reduce risk of failure and the associated increase in morbidity and mortality
due to hypoxia.
Management of the airway in the emergency department is optimal given the presence of trained personnel
from multiple specialties, as well as access to “difficult airway equipment” (videolaryngoscopy, eschmann
tracheal tube introducer, fibreoptic bronchoscopy, surgical methods, etc.). Of primary concern is the condition
and patency of the maxillofacial structures, larynx, trachea, and bronchi as these are all components of the
respiratory tract and failure anywhere along this path may impede ventilation. Excessive facial hair, severe
burns, and maxillofacial trauma may prevent acquisition of a good mask seal, rendering bag-valve mask ventilation
difficult. Edema of the airway can make laryngoscopy difficult, and therefore in those with suspected thermal
burns, intubation is recommended in attempts to quickly secure an airway prior to progression of the swelling.
Furthermore, blood and vomitus in the airway may prove visualization of the vocal cords difficult rendering
direct and video laryngoscopy, as well as fibreoptic bronchoscopy challenging. Establishment of a surgical
airway is challenging in the setting of restricted neck extension (such as in a c-collar), laryngotracheal disruption,
or distortion of the anatomy by a penetrating force or hematoma. Tracheotomy in the operating room by trained
professionals is recommended over cricothyroidotomy in the case of complete laryngotracheal disruption or
children under the age of 12.

Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve
airway obstruction. This ensures an open pathway for gas exchange between a patient’s lungs and the atmosphere.
This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in
cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the
tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents
(aspiration).
Airway management is commonly divided into two categories: basic and advanced.
Basic techniques are generally non-invasive and do not require specialized medical equipment or
advanced training. These include head and neck maneuvers to optimize ventilation, abdominal thrusts,
and back blows.
Advanced techniques require specialized medical training and equipment, and are further categorized
anatomically into supraglottic devices (such as oropharyngeal and nasopharyngeal airways), infraglottic
techniques (such as tracheal intubation), and surgical methods (such as cricothyrotomy, and tracheotomy).
Airway management is a primary consideration in the fields of cardiopulmonary resuscitation, anaesthesia,
emergency medicine, intensive care medicine, and first aid. The “A” in the ABC treatment mnemonic is for
airway.
BASIC AIRWAY MANAGEMENT

Basic airway management are a set of medical procedures performed in order to prevent airway obstruction
and thus ensuring an open pathway between a patient’s lungs and the outside world. This is accomplished by
clearing or preventing obstructions of airways, often referred to as choking, cause by the tongue, the airways
themselves, foreign bodies or materials from the body itself, such as blood or aspiration. Contrary to advanced
airway management; minimal-invasive techniques does not rely on the use of medical equipment and can be
performed without or with little training. Airway management is a primary consideration in cardiopulmonary
resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.
Evaluation
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Symptoms of airway obstructions includes:
• The person cannot speak or cry out, or has great difficulty and limited ability to do so.
• Breathing, if possible, is labored, producing gasping or wheezing.
• The person has a violent and largely involuntary cough, gurgle, or vomiting noise, though more
serious choking victims will have a limited (if any) ability to produce these symptoms since they
require at least some air movement.
• The person desperately clutches his or her throat or mouth, or attempts to induce vomiting by putting
their fingers down their throat.
• If breathing is not restored, the person’s face turns blue (cyanosis) from lack of oxygen.
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Evaluation of an unconscious patients breathing is often performed by the look, listen, and feel method. The ear
is placed over person’s mouth so breathing can be heard and felt while looking for rising chest or abdomen. The
procedure should not take longer than 10 seconds. As in conscious patients stridor can be heard if there is an
airway obstruction. Back fall of the tongue however results in snoring. In the unconscious patient agonal breathing
is often mistaken for airway obstructions. If there is respiratory arrest or agonal breathing CPR is indicated.
Treatment
Treatment includes a number of procedures aiming at removing foreign bodies from the airways. Most
modern protocols, including those of the American Heart Association, American Red Cross and the European
Resuscitation Council, recommend several stages, designed to apply increasingly more pressure. Basic treatment
includes a number of procedures aiming at removing foreign bodies from the airways. Most protocols recommend
encouraging the victim to cough, followed by hard back slaps and if none of these things work; abdominal
thrusts (Heimlich maneuver) or chest thrusts. Some guidelines recommend alternating between abdominal
thrusts and back slaps.
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This stage was introduced in many protocols as it was found that many people were too quick to undertake
potentially dangerous interventions, such as abdominal thrusts, for items which could have been dislodged
without intervention. Also, if the choking is caused by an irritating substance rather than an obstructing one,
and if conscious, the patient should be allowed to drink water on their own to try to clear the throat. Since the
airway is already closed, there is very little danger of water entering the lungs. Coughing is normal after most
of the irritant has cleared, and at this point the patient will probably refuse any additional water for a short time.
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Most protocols recommend encouraging the victim to cough, followed by hard back slaps with the heel of
the hand on the upper back of the victim. The number to be used varies by training organization, but is usually
between five and twenty. For example, the European Resuscitation Council and the Mayo Clinic recommends
five blows between the shoulder blades. The back slap is designed to use percussion to create pressure behind
the blockage, assisting the patient in dislodging the article. In some cases the physical vibration of the action
may also be enough to cause movement of the article sufficient to allow clearance of the airway.
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Performing abdominal thrusts involves a rescuer standing behind a patient and using his or her hands to
exert pressure on the bottom of the diaphragm. This compresses the lungs and exerts pressure on any object
lodged in the trachea, hopefully expelling it. The European Resuscitation Council and the Mayo Clinic recommend
alternating between 5 back slaps and 5 abdominal thrusts in severe airway obstructions. In some areas, such as
Australia, authorities believe that there is not enough scientific evidence to support the use of abdominal thrusts
and their use is not recommended in first aid. Instead, chest thrusts are recommended. A person may also
perform abdominal thrusts on himself by using a fixed object such as a railing or the back of a chair to apply
pressure where a rescuer’s hands would normally do so. As with other forms of the procedure, it is possible that
internal injuries may result.
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The American Medical Association advocates sweeping the fingers across the back of the throat to attempt
to dislodge airway obstructions, once the choking victim becomes unconscious. However, many modern protocols
recommend against the use of the finger sweep since, if the patient is conscious, they will be able to remove the
foreign object themselves, or if they are unconscious, the rescuer should simply place them in the recovery
position as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea
due to gravity. There is also a risk of causing further damage (for instance inducing vomiting) by using a finger
sweep technique.
Prevention
Prevention techniques focuses on preventing the tongue from falling back and obstructing the airways,
such as head-tilt/chin-lift and jaw-thrust maneuvers, while use of the recovery position mainly prevents
aspiration of things like stomach content or blood. If head-tilt chin-lift and jaw-thrust maneuvers are
performed with any objects in the airways it may dislodge them further down the airways and thereby
cause more blockage and harder removal. The head-tilt/chin-lift is the primary maneuver used in any
patient in whom cervical spine injury is not a concern. The simplest way of ensuring an open airway in an
unconscious patient is to use a head-tilt/chin-lift technique, thereby lifting the tongue from the back of the
throat. The maneuver is performed by tilting the head backwards in unconscious patients, often by applying
pressure to the forehead and the chin. Head-tilt/chin-lift is taught on most first aid courses as the standard
way of clearing an airway.
The jaw-thrust maneuver is an effective airway technique, particularly in the patient in whom cervical spine
injury is a concern. The jaw thrust is a technique used on patients with a suspected spinal injury and is used on
a supine patient. The practitioner uses their index and middle fingers to physically push the posterior (back)
aspects of the mandible upwards while their thumbs push down on the chin to open the mouth. When the
mandible is displaced forward, it pulls the tongue forward and prevents it from occluding the entrance to the
trachea. The recovery position refers to one of a series of variations on a lateral recumbent or three-quarters
prone position of the body, in to which an unconscious but breathing casualty can be placed. Use of the recovery
position prevents aspiration. Most airway maneuvers are associated with some movement of the cervical spine.
Even though collars for holding the head in-line can cause problems maintaining an airway and maintaining a
blood pressure, it is unrecommended to remove the collar without adequate personnel to manually hold the
head in place.
Life Support System and Equipments 85
Chapter 5
Life Support System and Equipments

ACUTE CARE OF AT-RISK NEWBORNS

Acute Care of at-Risk Newborns (ACoRN) is a Canadian resuscitation educational programme which focuses
on the first few hours of neonatal life. This differs from the Neonatal Resuscitation Programme which focuses
on the first several minutes. It was developed in Winnipeg, Manitoba.
Provinces/Territories Implementing ACoRN

• British Columbia
• Alberta
• Manitoba
• Ontario
• Newfoundland and Labrador
• Nova Scotia
• Prince Edward Island
• The Northwest Territories
ADVANCED CARDIAC LIFE SUPPORT

Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical
interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies,
as well as the knowledge and skills to deploy those interventions. Outside North America, Advanced Life
Support is used.
Providers
Only qualified health care providers can provide ACLS, as it requires the ability to manage the person’s
airway, initiate IV access, read and interpret electrocardiograms, and understand emergency pharmacology;
these include physicians, pharmacists (PharmDs), dentists, advanced practice providers (PAs and NPs), respiratory
therapists (RTs), nurses (RNs), paramedics (EMT-Ps) and other advanced life support EMTs (Advanced EMTs
for example). Other emergency responders may also be trained. Some health professionals, or even lay rescuers,
may be trained in basic life support (BLS), especially cardiopulmonary resuscitation or CPR, which makes up
the core foundation of ACLS.
When a sudden cardiac arrest occurs, immediate CPR is a vital link in the chain of survival. Another important
link is early defibrillation, which has improved greatly with the widespread availability of automated external
defibrillators (AEDs).
Electrocardiogram Interpretation
ACLS often starts with analyzing the patient’s heart rhythms with a manual defibrillator. In contrast to an
AED in BLS, where the machine decides when and how to shock a patient, the ACLS team leader makes those
decisions based on rhythms on the monitor and patient’s vital signs. The next steps in ACLS are insertion of
intravenous (IV) lines and placement of various airway devices. Commonly used ACLS drugs, such as epinephrine
and amiodarone, are then administered. The ACLS personnel quickly search for possible reversible causes of
cardiac arrest (i.e. the H’s and T’s, heart attack). Based on their diagnosis, more specific treatments are given.
These treatments may be medical such as IV injection of an antidote for drug overdose, or surgical such as
insertion of a chest tube for those with tension pneumothoraces or hemothoraces.
Guidelines
The American Heart Association and the International Liaison Committee on Resuscitation performs a science
review every five years and publishes an updated set of recommendations and educational materials. These
guidelines are often synonymously referred to as Emergency Cardiovascular Care (ECC) Guidelines. Following
are recent changes.
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The 2015 ACLS guidelines promoted minor tweaks and improvements to the 2010 guidelines with no major
changes. Some changes included:
• In conjunction with the BLS guidelines, the update promoted the use of mobile phones to activate
the Emergency Response System as well as notify nearby rescuers.
• It was recommended that emergency medical dispatchers receive better guidance on recognizing
potential Cardiac Arrests and agonal breathing to promote more immediate CPR instructions.
• Lay persons are further encouraged to perform continuous hands-only CPR at a minimum until EMS
arrival.
• An upper boundary for the number of chest compressions was added at 120 per minute, making the
current recommendation 100-120 per minute. The 2010 guidelines only stated 100+ per minute.
• An upper boundary on the depth of chest compressions was added at 2.4 inches, making the current
recommendation 2-2.4 inches. The 2010 guidelines only stated at least 2 inches.
• Added BLS and lay person administration of naloxone (IM or IN) for suspected opiate overdoses.
• For simplicity, vasopressin was removed from the Cardiac Arrest Algorithm.
• Waveform capnography was further emphasized and an ETCO2 of less than 10 mmHg after 20
minutes of resuscitation was added as legitimate factor in the decision to terminate resuscitation.
• Targeted temperature management was further refined with a new goal range 32-36 °C.
• Routine atropine use in intubations is no longer recommended unless there is a high risk for
bradycardia.
• The OHCA and IHCA (Out of hospital cardiac arrest) and (In Hospital Cardiac arrest) Chain also
has been added as different ones. Separate Chains of Survival have been recommended that identify
the different pathways of care for patients who experience cardiac arrest in the hospital as distinct
from out-of-hospital settings.
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The ACLS guidelines were updated by the American Heart Association and the International Liaison
Committee on Resuscitation in 2010. New ACLS guidelines focus on BLS as the core component of ACLS.
Foci also include end tidal CO2 monitoring as a measure of CPR effectiveness, and as a measure of ROSC.
Other changes include the exclusion of atropine administration for pulseless electrical activity (PEA) and asystole.
CPR (for ACLS and BLS) was reordered from “ABC” to “CAB” (circulation, airway, breathing) to bring focus
to chest compressions, even recommending compression-only CPR for laypersons. (note, however, that in
pediatric resuscitation, respiratory arrest is more likely to be the main cause of arrest than adults.)
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The 2005 guidelines acknowledged that high quality chest compressions and early defibrillation are the key to
positive outcomes, while other “typical ACLS therapies... “have not been shown to increase rate of survival to
hospital discharge”. In 2004, a study found that the basic interventions of CPR and early defibrillation and not the
advanced support improved survival from cardiac arrest. The 2005 guidelines were published in Circulation. The
major source for ACLS courses and textbooks in the United States is the American Heart Association; in Europe,
it is the European Resuscitation Council (ERC). Most institutions expect their staff to recertify at least every two
years. Many sites offer training in simulation labs with simulated code situations with a dummy. Other hospitals
accept software-based courses for recertification. An ACLS Provider Manual reflecting the new Guidelines is now
available. Stroke is also included in the ACLS course with emphasis on the stroke chain of survival.
Algorithms
The current ACLS guidelines are set into several groups of “algorithms” - a set of instructions that are
followed to standardize treatment, and increase its effectiveness. These algorithms usually come in the form of
a flowchart, incorporating ‘yes/no’ type decisions, making the algorithm easier to memorize.
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• Cardiac Arrest Algorithm
• Acute Coronary Syndromes Algorithm
• PEA/Asystole Algorithm
• VF/Pulseless VT Algorithm
• Bradycardia Algorithm
• Tachycardia Algorithms
• Respiratory Arrest Algorithm
• Opioid Emergency Algorithm
• Post-Cardiac Arrest Algorithm
• Suspected Stroke Algorithm.
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• Search for and correct potentially reversible causes of arrest, brady/tachycardia. The reversible causes
of cardiac arrests are colloquially referred to as the 5 Hs and Ts.
• Exercise caution before using epinephrine in arrests associated with cocaine or other sympathomimetic
drugs. Epinephrine is not required until after the second DC shock in standard ACLS management
as DC shock in itself releases significant quantities of epinephrine
• Administration of atropine 1 mg dose (IV) bolus for asystole or slow PEA (rate<60/min) is no
longer recommended.
• In PEA arrests associated with hyperkalemia, hypocalcemia. or Ca
• channel blocking drug overdose, give 10mL 10% calcium chloride (IV) (6.8 mmol/L)
• Consider amiodarone for ventricular fibrillation/pulseless ventricular tachycardia after 3 attempts at
defibrillation, as there is evidence it improves response in refractory VF/ VT.(Note: as of the 2010
guidelines, amiodarone is preferred as the first-line antiarrythmic, moving lidocaine to a second-line
backup if amiodarone is unavailable
• For torsades de pointes, refractory VF in people with digoxin toxicity or hypomagnesemia, give IV
magnesium sulfate 8 mmol (4mL of 50% solution)
• In the 2010 ACLS pulseless arrest algorithm, vasopressin may replace the first or second dose of
epinephrine.
History
The ACLS guidelines were first published in 1974 by the American Heart Association and were updated in
1980, 1986, 1992, 2000, 2005, 2010 and 2015.
ADVANCED TRAUMA LIFE SUPPORT

Advanced trauma life support (ATLS) is a training programme for medical providers in the management
of acute trauma cases, developed by the American College of Surgeons. Similar programmes exist for
immediate care providers such as paramedics. The programme has been adopted worldwide in over 60
countries, sometimes under the name of Early Management of Severe Trauma, especially outside North
America.
Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for
emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the
standard of care for initial assessment and treatment in trauma centers. The premise of the ATLS programme
is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed
history should not slow the application of indicated treatment for life-threatening injury, with the most time-
critical interventions performed early. However, there is no high quality evidence to show that ATLS improves
patient outcomes as it has not been studied.
Primary Survey
The first and key part of the assessment of patients presenting with trauma is called the primary
survey. During this time, life-threatening injuries are identified and simultaneously resuscitation is begun.
A simple mnemonic, ABCDE, is used as a memory aid for the order in which problems should be
addressed.
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The first stage of the primary survey is to assess the airway. If the patient is able to talk, the airway is likely
to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can
be opened using a chin lift or jaw thrust. Airway adjuncts may be required. If the airway is blocked (e.g., by
blood or vomit), the fluid must be cleaned out of the patient’s mouth by the help of suctioning instruments. In
case of obstruction, pass an endotracheal tube.
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The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema
and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening
thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax,
Flail chest segment with Pulmonary Contusion and Cardiac Tamponade. Flail chest, tracheal deviation, penetrating
injuries and bruising can be recognized by inspection. Subcutaneous emphysema can be recognized by palpation.
Tension Pneumothorax and Haemothorax can be recognized by percussion and auscultation.
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Hemorrhage is the predominant cause of preventable post-injury deaths. Hypovolemic shock is caused by
significant blood loss. Two large-bore intravenous lines are established and crystalloid solution may be given.
If the person does not respond to this, type-specific blood, or O-negative if this is not available, should be given.
External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or
from the long bones. As of 2012, use of rFVIIa is not supported by evidence. While it may help control bleeding,
there is a risk of arterial thrombosis, and other than in those with factor VII deficiency, its use should be limited
to clinical trials.
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During the primary survey a basic neurological assessment is made, known by the mnemonic AVPU (alert,
verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological
evaluation is performed at the end of the primary survey. This establishes the patient’s level of consciousness,
pupil size and reaction, lateralizing signs, and spinal cord injury level. The Glasgow Coma Scale is a quick
method to determine the level of consciousness, and is predictive of patient outcome. If not done in the primary
survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An
altered level of consciousness indicates the need for immediate reevaluation of the patient’s oxygenation,
ventilation, and perfusion status. Hypoglycemia and drugs, including alcohol, may influence the level of
consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to
traumatic brain injury until proven otherwise.
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The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the
patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be
warmed and a warm environment maintained. Patient privacy should be maintained.
Secondary Survey
When the primary survey is completed, resuscitation efforts are well established, and the vital signs are
normalizing, the secondary survey can begin. The secondary survey is a head-to-toe evaluation of the trauma
patient, including a complete history and physical examination, including the reassessment of all vital signs.
Each region of the body must be fully examined. X-rays indicated by examination are obtained. If at any time
during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life
threat may be present. The person should be removed from the hard spine board and placed on a firm mattress
as soon as reasonably feasible as the spine board can rapidly cause skin breakdown and pain while a firm
mattress provides equivalent stability for potential spinal fractures.
Tertiary Survey
A careful and complete examination followed by serial assessments help recognize missed injuries and
related problems, allowing a definitive care management. The rate of delayed diagnosis may be as high as 10%.
Alternatives
Mannequin surgical simulators are widely used in the United States as alternatives to the use of live animals
in ATLS courses. In 2014, PETA announced that it was donating surgical simulators to ATLS training centers in
9 countries that agreed to switch from animal use to training on the simulators. Additionally, Anaesthesia
Trauma and Critical Care (ATACC) is an international trauma course based in the United Kingdom that teaches
an advanced trauma course and represents the next level for trauma care and trauma patient management post
ATLS certification. Accredited by two Royal Colleges and numerous emergency services, the course runs
numerous times per year for candidates drawn from all areas of medicine and trauma care. Specific injuries,
such as major burn injury, may be better managed by other more programmes.
History
ATLS has its origins in the United States in 1976, when James K. Styner, an orthopedic surgeon piloting a
light aircraft, crashed his plane into a field in Nebraska. His wife Charlene was killed instantly and three of his
four children, Richard, Randy, and Kim sustained critical injuries. His son Chris suffered a broken arm. He
carried out the initial triage of his children at the crash site. Dr. Styner had to flag down a car to transport him
to the nearest hospital; upon arrival, he found it closed. Even once the hospital was opened and a doctor called
in, he found that the emergency care provided at the small regional hospital where they were treated was
inadequate and inappropriate. Upon returning to Lincoln, Dr. Styner declared: “When I can provide better care
in the field with limited resources than what my children and I received at the primary care facility, there is
something wrong with the system and the system has to be changed” Upon returning to work, he set about
developing a system for saving lives in medical trauma situations. Styner and his colleague Paul ‘Skip’ Collicott,
with assistance from advanced cardiac life support personnel and the Lincoln Medical Education Foundation,
produced the initial ATLS course which was held in 1978. In 1980, the American College of Surgeons Committee
on Trauma adopted ATLS and began US and international dissemination of the course. Styner himself recently
recertified as an ATLS instructor, teaching his Instructor Candidate course in Nottingham in the UK, July 2007,
and then in the Netherlands. Since its inception, ATLS has become the standard for trauma care in American
emergency departments and advanced paramedical services. Since emergency physicians, paramedics and other
advanced practitioners use ATLS as their model for trauma care it makes sense that programmes for other
providers caring for trauma would be designed to interface well with ATLS. The Society of Trauma Nurses has
developed the Advanced Trauma Care for Nurses (ATCN) course for registered nurses. ATCN meets concurrently
with ATLS and shares some of the lecture portions. This approach allows for medical and nursing care to be
well coordinated with one another as both the medical and nursing care providers have been trained in essentially
the same model of care. Similarly, the National Association of Emergency Medical Technicians has developed
the Prehospital Trauma Life Support (PHTLS) course for basic Emergency Medical Technicians (EMT)s and a
more advanced level class for Paramedics. The International Trauma Life Support committee publishes the
ITLS-Basic and ITLS-Advanced courses for prehospital professionals as well. This course is based around
ATLS and allows the PHTLS-trained EMTs to work alongside paramedics and to transition smoothly into the
care provided by the ATLS and ATCN-trained providers in the hospital. On March 22, 2013 the American
College of Surgeons Committee on Trauma renamed their annual Award for Meritorious Service in ATLS to the
James K. Styner Award for Meritorious Service in honour of Dr. Styner’s contributions to trauma care.
BASIC LIFE SUPPORT

Basic life support (BLS) is a level of medical care which is used for victims of life-threatening illnesses or
injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel,
including emergency medical technicians, paramedics, and by qualified bystanders.
Background
Many countries have guidelines on how to provide basic life support (BLS) which are formulated by
professional medical bodies in those countries. The guidelines outline algorithms for the management of a
number of conditions, such as cardiac arrest, choking and drowning. BLS does not include the use of drugs or
invasive skills, and can be contrasted with the provision of Advanced Life Support (ALS). Firefighters, lifeguards,
and police officers are often required to be BLS certified. BLS skills are also appropriate for many other
professions, such as daycare providers, teachers and security personnel and social workers especially working
in the hospitals and ambulance drivers. CPR provided in the field increases the time available for higher medical
responders to arrive and provide ALS care. An important advance in providing BLS is the availability of the
automated external defibrillator or AED. This improves survival outcomes in cardiac arrest cases.
Basic life support promotes adequate blood circulation in addition to breathing through a clear airway:
• Circulation: providing an adequate blood supply to tissue, especially critical organs, so as to deliver
oxygen to all cells and remove metabolic waste, via the perfusion of blood throughout the body.
• Airway: the protection and maintenance of a clear passageway for gases (principally oxygen and
carbon dioxide) to pass between the lungs and the atmosphere.
• Breathing: inflation and deflation of the lungs (respiration) via the airway.
These goals are codified in mnemonics such as ABC and CAB. The American Heart Association (AHA)
endorses CAB in order to emphasize the primary importance of chest compressions in cardiopulmonary
resuscitation. Healthy people maintain the CABs by themselves. In an emergency situation, due to illness
(medical emergency) or trauma, BLS helps the patient ensure his or her own CABs, or assists in maintaining for
the patient who is unable to do so. For airways, this will include manually opening the patients airway (Head
tilt/Chin lift or jaw thrust) or possible insertion of oral (Oropharyngeal airway) or nasal (Nasopharyngeal
airway) adjuncts, to keep the airway unblocked (patent). For breathing, this may include artificial respiration,
often assisted by emergency oxygen. For circulation, this may include bleeding control or cardiopulmonary
resuscitation (CPR) techniques to manually stimulate the heart and assist its pumping action.
United States
Basic Life Support Emergency Medical Services in the United States is generally identified with Emergency
Medical Technicians-Basic (EMT-B). However, the American Heart Association’s BLS protocol is designed
for use by laypeople, as well as students and others certified first responder, and to some extent, higher medical
function personnel. It includes cardiac arrest, respiratory arrest, drowning, and foreign body airway obstruction
(FBAO, or choking). EMT-B is the highest level of health care provider that is limited to the BLS protocol;
higher medical functions use some or all of the Advanced Cardiac Life Support (ACLS) protocols, in addition
to BLS protocols.
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The medical algorithm for providing basic life support to adults in the USA was published in 2005 in the
journal Circulation by the American Heart Association.
The AHA uses a four-link “chain of survival” to illustrate the steps needed to resuscitate a collapsed victim:
1. Early recognition of the emergency and activation of emergency medical services
2. Early bystander CPR, so as not to delay treatment until arrival of EMS
3. Early use of a defibrillator
4. Early advanced life support and post-resuscitation care.
Bystanders with training in BLS can perform the first three of the four steps.
The AHA-recommended steps for resuscitation are known as DRS CABCDE:
1. Check for Danger
2. Check for a Response
3. Send or shout for help
4. C directs rescuers to first attend to Catastrophic haemorrhage (life-threatening bleeding) and to stop
the bleeding if possible.
5. A directs rescuers to open the Airway and look into the mouth for obvious obstruction. Also to apply
a ‘head tilt chin lift’ or ‘jaw thrust’ to open the airway.
6. B directs rescuers to check Breathing for 10 seconds by listening for breath at the patients nose and
mouth and observe the chest for regular rising and falling breathing movements.
7. C directs rescuers to maintain Circulation which may be through administration of chest compressions
for Cardio Pulmonary Resuscitation (CPR).
8. D directs rescuers to identify Disabilities (e.g. diabetic or any allergies), Damage (identify broken
bones or any minor bleeding), Devices (including use of AED devices available and follow prompts)
and Dry (if casualty is very wet, an AED device will pass current through body surface water and
will harm the casualty).
9. E directs rescuers to take the environment into consideration for weather, location and crowds.
If the patient is unresponsive and not breathing, the responder begins CPR with chest compressions
at a rate of 120 beats per minute in cycles of 30 chest compressions to 2 breaths. If responders are
unwilling or unable to perform rescue breathing, they are to perform compression-only CPR, because
any attempt at resuscitation is better than no attempt. For children, for whom the main cause of cardiac
arrest is from breathing related issues, 5 initial rescue breaths is highly advised followed by the same
30-2 cycles.
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According to the American Heart Association, in order to be certified in BLS, a student must take an online
or in-person course. However, an online BLS course must be followed with an in-person skills session in order
to obtain a certification issued by The American Heart Association.
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• C-A-B is recommended in the new AHA EU guidelines so as to ensure the blood supply to the vital
organs and to prevent degeneration of the brain cells. Keeping these facts as such follow the sequence
introduced by AHA guidelines 2010 recommendations C-A-B should be followed in learning and
teaching BLS.
• Ensure that the scene is safe.
• Assess the victim’s level of consciousness by asking loudly and shaking at the shoulders “Are you
okay?” and scan chest for breathing movement visually. If no response call for help by shouting for
an ambulance and ask for an AED.
Assess:* If the patient is breathing normally, and pulse is present then the patient should be placed in the
recovery position and monitored. Transport if required, or wait for the EMS to arrive and take over.
• If patient is not breathing assess pulse at the carotid on your side for an adult, at the brachial for a
child and infant for 6 seconds and not more than 10 seconds; begin immediately with chest
compressions at a rate of 30 chest compressions in 18 seconds followed by two rescue breaths in 4
seconds each lasting for 2 second.
If the victim has no suspected cervical spine trauma, open the airway using the head-tilt/chin-lift maneuver;
if the victim has suspected neck trauma, the airway should be opened with the jaw-thrust technique. If the
jaw-thrust is ineffective at opening/maintaining the airway, a very careful head-tilt/chin-lift should be
performed.
• Blind finger-sweeps are strongly discouraged and should never be performed, as they may push
foreign objects further into the airway. This procedure has been discarded from current practice as
this may push the foreign body down the airway and increase chances of an obstruction.
Continue chest compression at a rate of 100 compressions per minute for all age groups, allowing chest to
recoil in between. For adults push up to 2-2.4inches,ie,6 cm and for child up to 2 inches,ie,5 cm. For infants 1-
1.5 inches,ie,4 cm or 1/3 of the chest diameter antero-posteriorly.
• Keep counting aloud. Press hard and fast maintaining the rate of at about 100/minute. Allow recoil
of chest fully between each compression. In adults, irrespective of the number or rescuers, for every
30 chest compressions give two rescue breaths and in child victim, give 2 breaths per 30 compression
if only 1 rescuer is present, but 2 breaths per 15 compressions in case where there are 2 rescuers.
• Continue for five cycles or two minutes before re-assessing pulse.
• Attempt to administer two artificial ventilations using the mouth-to-mouth technique, or a bag-valve-
mask (BVM). The mouth-to-mouth technique is no longer recommended, unless a face shield is
present. Verify that the chest rises and falls; if it does not, reposition (i.e. re-open) the airway using
the appropriate technique and try again. If ventilation is still unsuccessful, and the victim is
unconscious, it is possible that they have a foreign body in their airway. Begin chest compressions,
stopping every 30 compressions, re-checking the airway for obstructions, removing any found, and
re-attempting ventilation.
• If the ventilations are successful, assess for the presence of a pulse at the carotid artery. If a pulse is
detected, then the patient should continue to receive artificial ventilations at an appropriate rate and
transported immediately. Otherwise, begin CPR at a ratio of 30:2 compressions to ventilation’s at
100 compressions/minute for 5 cycles.
• After 5 cycles of CPR, the BLS protocol should be repeated from the beginning, assessing the patient’s
airway, checking for spontaneous breathing, and checking for a spontaneous pulse as per new protocol
sequence C-A-B. Laypersons are commonly instructed not to perform re-assessment, but this step is
always performed by health care professionals (HCPs).
• If an AED is available it should be activated immediately and its directives followed and (if indicated),
call for clearance before defibrillation/shock should be performed. If defibrillation is performed,
begin chest compression immediately after shock.
• BLS protocols continue until (1) the patient regains a pulse, (2) the rescuer is relieved by another
rescuer of equivalent or higher training, (3) the rescuer is too physically tired to continue CPR, or
(4) the patient is pronounced dead by a medical doctor, doctor of osteopathic medicine, or other
approved health care provider.
• At the end of five cycles of CPR, always perform assessment via the AED for a shockable rhythm,
and if indicated, defibrillate, and repeat assessment before doing another five cycles.
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Rescuers should provide CPR as soon as an unresponsive victim is removed from the water. In particular,
rescue breathing is important in this situation. A lone rescuer is typically advised to give CPR for a short time
before leaving the victim to call emergency medical services. Since the primary cause of cardiac arrest and death
in drowning and choking victims is hypoxia, it is more important to provide rescue breathing as quickly as possible
in these situations, whereas for victims of VF cardiac arrest chest compressions and defibrillation are more important.
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• In unresponsive victims with hypothermia, the breathing and pulse should be checked for 30 to 45
seconds as both breathing and heart rate can be very slow in this condition.
• If cardiac arrest is confirmed, CPR should be started immediately. Wet clothes should be removed,
and the victim should be insulated from wind. CPR should be continued until the victim is assessed
by advanced care providers.
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Choking can occur from foreign body airway obstruction.
• Rescuers should intervene in victims who show signs of severe airway obstruction, such as a silent
cough, cyanosis, or inability to speak or breathe.
• If a victim is coughing forcefully, rescuers should not interfere with this process.
• If a victim shows signs of severe airway obstruction, abdominal thrusts should be applied in rapid
sequence until the obstruction is relieved. If this is not effective, chest thrusts can also be used.
Chest thrusts can also be used in obese victims or victims in late pregnancy. Abdominal thrusts
should not be used in infants under 1 year of age due to risk of causing injury.
• If a victim becomes unresponsive he should be lowered to the ground, and the rescuer should call
emergency medical services and initiate CPR. When the airway is opened during CPR, the rescuer
should look into the mouth for an object causing obstruction, and remove it if it is evident.
United Kingdom
Adult BLS guidelines in the United Kingdom were also published in 2005 by the Resuscitation Council
(UK), based on the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science with Treatment Recommendations (CoSTR) published in November 2005.
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• Ensure the safety of the victim, the rescuer, and any bystanders.
• Check the victim for a response by gently shaking the victim’s shoulders and asking loudly “Are
you all right?”
• If the victim responds, leave him in the position in which he was found provided there is no further
danger, try to find out what is wrong with him and get help if needed, and reassess him regularly.
• If the victim does not respond, turn him on to his back and open the airway using the head-tilt/chin-
lift. Shout for help.
• Look, listen and feel for normal breathing for no more than 10 seconds. If the victim is breathing
normally, turn him into the recovery position and get help. Continue to check for breathing.
• If the victim is not breathing normally, call for an ambulance.
These guidelines differ from previous versions in a number of ways:

• They allow the rescuer to diagnose cardiac arrest if the victim is unresponsive and not breathing normally.
• Rescuers are taught to give chest compressions in the center of the chest, rather than measuring from
the lower border of the sternum.
• Rescue breaths should be given over 1 second rather than 2 seconds.
• For an adult victim, the initial 2 rescue breaths should be omitted, so that 30 chest compressions are
given immediately after a cardiac arrest has been diagnosed.
These changes were introduced to simplify the algorithm, to allow for faster decision making and to maximize
the time spent giving chest compressions; this is because interruptions in chest compressions have been shown
to reduce the chance of survival. It is also acknowledged that rescuers may either be unable, or unwilling, to
give effective rescue breaths; in this situation, continuing chest compressions alone is advised, although this is
only effective for about 5 minutes.
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• Assess the severity of airway obstruction. If the victim is able to speak and cough effectively, the
obstruction is mild. If the victim is unable to speak or cough effectively, or is unable to breathe or is
breathing with a wheezy sound, the airway obstruction is severe.
• If the victim has signs of mild airway obstruction, encourage him to continue coughing; do nothing else.
• If the victim has signs of severe airway obstruction, and is conscious, give up to 5 back blows (sharp
blows between the shoulder blades with the victim leaning well forwards). Check to see if the
obstruction has cleared after each blow. If 5 back blows fail to relieve the obstruction, give up to 5
abdominal thrusts, again checking if each attempt has relieved the obstruction.
• If the obstruction is still present, and the victim still conscious, continue alternating 5 back blows
and 5 abdominal thrusts.
• If the victim becomes unconscious, lower him to the ground, call an ambulance, and begin CPR.
CARE OF THE CRITICALLY ILL SURGICAL PATIENT

Care of the Critically Ill Surgical Patient (CCrISP) is a training programme for doctors. The course covers
the theoretical basis and practical skills required to manage critically ill surgical patients. Teaching is in small
groups and includes the use of simulated patients. The course duration is 2.5 days.
Background
CCrISP was designed by Mr. Iain Anderson, Senior Lecturer in Surgery, Manchester University, for the
Royal College of Surgeons of England, as a result of the Hillsborough disaster. The first course was run in 1998
by the Hillsborough Trust.
Training Bodies
CCrISP courses are run by the following surgical training bodies:
• Academy of Medicine of Malaysia
• Royal Australasian College of Surgeons
• Royal College of Surgeons in Ireland (RCSI)
• Royal College of Surgeons of Edinburgh
• Royal College of Surgeons of England.
Eligibility
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The Royal Australasian College of Surgeons requires surgical trainees to complete CCrISP within the first 2
years of training (SET 1-2). The course is also mandatory for trainees in oral and maxillofacial surgery.
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The Royal College of Surgeons in Ireland recommends at least 6 months of general surgery training
before taking the course. Irish courses are aimed at surgical trainees in the second year of Basic Surgical
Training (ST2). Candidates must be registered with the Medical Council (Ireland) or the General Medical
Council.
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Courses are open to doctors who have completed the Foundation Programme and is usually taken during
ST1-3 or CT1-2 training.
Content
Candidates receive a course manual and must pass a pre-course multiple choice question assessment.
Successful participants receive a certificate from the Royal College of Surgeons of England.
The main course elements include:
• Presentation of the critically ill patient
• Assessment and detection of illness
• Formulation of a plan of action
• Seeking assistance and support
• Prevention of complications
• Recognition of complications
• Interaction with colleagues
• Requirements of patients and relatives during critical illness
• Legal, ethical, and communication issues.
Theory stations include:
• Cardiac disorders
• Communication skills
• Conducting a surgical ward round
• Pain
• Renal dysfunction
• Respiratory failure
• The multiply injured patient.
Practical skills stations include:
• Advanced shock
• Airway management
• Arterial line insertion
• Central venous pressure line insertion
• Chest x-ray interpretation
• Dysrhythmias
• Pressure monitoring
• Stoma care
• Tracheostomy
• Wound assessment.
FIRST AID
First aid is the assistance given to any person suffering a sudden illness or injury, with care provided to
preserve life, prevent the condition from worsening, or to promote recovery. It includes initial intervention
in a serious condition prior to professional medical help being available, such as performing CPR while
awaiting an ambulance, as well as the complete treatment of minor conditions, such as applying a plaster
to a cut. First aid is generally performed by the layperson, with many people trained in providing basic
levels of first aid, and others willing to do so from acquired knowledge. Mental health first aid is an
extension of the concept of first aid to cover mental health. There are many situations which may require
first aid, and many countries have legislation, regulation, or guidance which specifies a minimum level of
first aid provision in certain circumstances. This can include specific training or equipment to be available
in the workplace (such as an Automated External Defibrillator), the provision of specialist first aid cover
at public gatherings, or mandatory first aid training within schools. First aid, however, does not necessarily
require any particular equipment or prior knowledge, and can involve improvisation with materials available
at the time, often by untrained persons. First aid can be performed on all mammals, although this article
relates to the care of human patients.
Early History and Warfare

Skills of what is now known as first aid have been recorded throughout history, especially in relation to
warfare, where the care of both traumatic and medical cases is required in particularly large numbers. The
bandaging of battle wounds is shown on Classical Greek pottery from circa 500 BCE, whilst the parable of the
Good Samaritan includes references to binding or dressing wounds. There are numerous references to first aid
performed within the Roman army, with a system of first aid supported by surgeons, field ambulances, and
hospitals. Roman legions had the specific role of capsarii, who were responsible for first aid such as bandaging,
and are the forerunners of the modern combat medic.
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During the late 18th century, drowning as a cause of death was a major concern amongst the population. In
1767, a society for the preservation of life from accidents in water was started in Amsterdam, and in 1773,
physician William Hawes began publicizing the power of artificial respiration as means of resuscitation of
those who appeared drowned. This led to the formation, in 1774, of the Society for the Recovery of Persons
Apparently Drowned, later the Royal Humane Society, who did much to promote resuscitation.
Napoleon’s surgeon, Baron Dominique-Jean Larrey, is credited with creating an ambulance corps (the
ambulance volantes), which included medical assistants, tasked to administer first aid in battle.
In 1859 Jean-Henri Dunant witnessed the aftermath of the Battle of Solferino, and his work led to the
formation of the Red Cross, with a key stated aim of “aid to sick and wounded soldiers in the field”. The Red
Cross and Red Crescent are still the largest provider of first aid worldwide.
In 1870, Prussian military surgeon Friedrich von Esmarch introduced formalized first aid to the military, and
first coined the term “erste hilfe” (translating to ‘first aid’), including training for soldiers in the Franco-Prussian
War on care for wounded comrades using pre-learnt bandaging and splinting skills, and making use of the
Esmarch bandage which he designed. The bandage was issued as standard to the Prussian combatants, and also
included aide-memoire pictures showing common uses.
In 1872, the Order of Saint John of Jerusalem in England changed its focus from hospice care, and set out to
start a system of practical medical help, starting with making a grant towards the establishment of the UK’s first
ambulance service. This was followed by creating its own wheeled transport litter in 1875 (the St John
Ambulance), and in 1877 established the St John Ambulance Association (the forerunner of modern-day St
John Ambulance) “to train men and women for the benefit of the sick and wounded”.
Also in the UK, Surgeon-Major Peter Shepherd had seen the advantages of von Esmarch’s new teaching of
first aid, and introduced an equivalent programme for the British Army, and so being the first user of “first aid
for the injured” in English, disseminating information through a series of lectures. Following this, in 1878,
Shepherd and Colonel Francis Duncan took advantage of the newly charitable focus of St John, and established
the concept of teaching first aid skills to civilians. The first classes were conducted in the hall of the Presbyterian
school in Woolwich (near Woolwich barracks where Shepherd was based) using a comprehensive first aid
curriculum. First aid training began to spread through the British Empire through organisations such as St John,
often starting, as in the UK, with high risk activities such as ports and railways.
Aims
The key aims of first aid can be summarized in four key points, sometimes known as ‘the three P’s’:-
• Preserve life: The overriding aim of all medical care which includes first aid, is to save lives and
minimize the threat of death.
• Prevent further harm: Prevent further harm also sometimes called prevent the condition from
worsening, or danger of further injury, this covers both external factors, such as moving a patient
away from any cause of harm, and applying first aid techniques to prevent worsening of the condition,
such as applying pressure to stop a bleed becoming dangerous.
• Promote recovery: First aid also involves trying to start the recovery process from the illness or
injury, and in some cases might involve completing a treatment, such as in the case of applying a
plaster to a small wound.
• First aid help to stop the unwanted injuries to be a big cause by providing the medical aid for
instance the bandage, some kind of medicines, liquids to stop the clotting of blood, tubes for burns
and deep cut to stop the blood coming out of the nerve
Key Skills
Certain skills are considered essential to the provision of first aid and are taught ubiquitously. Particularly
the “ABC”s of first aid, which focus on critical life-saving intervention, must be rendered before treatment of
less serious injuries. ABC stands for Airway, Breathing, and Circulation. The same mnemonic is used by all
emergency health professionals. Attention must first be brought to the airway to ensure it is clear. Obstruction
(choking) is a life-threatening emergency. Following evaluation of the airway, a first aid attendant would determine
adequacy of breathing and provide rescue breathing if necessary. Assessment of circulation is now not usually
carried out for patients who are not breathing, with first aiders now trained to go straight to chest compressions
(and thus providing artificial circulation) but pulse checks may be done on less serious patients. Some
organizations add a fourth step of “D” for Deadly bleeding or Defibrillation, while others consider this as part
of the Circulation step. Variations on techniques to evaluate and maintain the ABCs depend on the skill level of
the first aider. Once the ABCs are secured, first aiders can begin additional treatments, as required. Some
organizations teach the same order of priority using the “3Bs”: Breathing, Bleeding, and Bones (or “4Bs”:
Breathing, Bleeding, Burns, and Bones). While the ABCs and 3Bs are taught to be performed sequentially,
certain conditions may require the consideration of two steps simultaneously. This includes the provision of
both artificial respiration and chest compressions to someone who is not breathing and has no pulse, and the
consideration of cervical spine injuries when ensuring an open airway.
9,:,9=05.0-,
In order to stay alive, all persons need to have an open airway—a clear passage where air can move in
through the mouth or nose through the pharynx and down into the lungs, without obstruction. Conscious people
will maintain their own airway automatically, but those who are unconscious (with a GCS of less than 8) may
be unable to maintain a patent airway, as the part of the brain which automatically controls breathing in normal
situations may not be functioning. If the patient was breathing, a first aider would normally then place them in
the recovery position, with the patient leant over on their side, which also has the effect of clearing the tongue
from the pharynx. It also avoids a common cause of death in unconscious patients, which is choking on
regurgitated stomach contents. The airway can also become blocked through a foreign object becoming lodged
in the pharynx or larynx, commonly called choking. The first aider will be taught to deal with this through a
combination of ‘back slaps’ and ‘abdominal thrusts’. Once the airway has been opened, the first aider would
assess to see if the patient is breathing. If there is no breathing, or the patient is not breathing normally, such as
agonal breathing, the first aider would undertake what is probably the most recognized first aid procedure—
cardiopulmonary resuscitation or CPR, which involves breathing for the patient, and manually massaging the
heart to promote blood flow around the body. The first aider is also likely to be trained in dealing with injuries
such as cuts, grazes or bone fracture. They may be able to deal with the situation in its entirety (a small adhesive
bandage on a paper cut), or may be required to maintain the condition of something like a broken bone, until the
next stage of definitive care (usually an ambulance) arrives.
Training
Basic principles, such as knowing to use an adhesive bandage or applying direct pressure on a bleed, are
often acquired passively through life experiences. However, to provide effective, life-saving first aid
interventions requires instruction and practical training. This is especially true where it relates to potentially
fatal illnesses and injuries, such as those that require cardiopulmonary resuscitation (CPR); these procedures
may be invasive, and carry a risk of further injury to the patient and the provider. As with any training, it is
more useful if it occurs before an actual emergency, and in many countries, emergency ambulance dispatchers
may give basic first aid instructions over the phone while the ambulance is on the way. Training is generally
provided by attending a course, typically leading to certification. Due to regular changes in procedures and
protocols, based on updated clinical knowledge, and to maintain skill, attendance at regular refresher courses
or re-certification is often necessary. First aid training is often available through community organizations
such as the Red Cross and St. John Ambulance, or through commercial providers, who will train people for
a fee. This commercial training is most common for training of employees to perform first aid in their
workplace. Many community organizations also provide a commercial service, which complements their
community programmes.
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There are several types of first aid (and first aider) which require specific additional training. These are
usually undertaken to fulfill the demands of the work or activity undertaken.
• Aquatic/Marine first aid is usually practiced by professionals such as lifeguards, professional mariners
or in diver rescue, and covers the specific problems which may be faced after water-based rescue or
delayed MedEvac.
• Battlefield first aid takes into account the specific needs of treating wounded combatants and non-
combatants during armed conflict.
• Hyperbaric first aid may be practiced by SCUBA diving professionals, who need to treat conditions
such as the bends.
• Oxygen first aid is the providing of oxygen to casualties who suffer from conditions resulting in
hypoxia.
• Wilderness first aid is the provision of first aid under conditions where the arrival of emergency
responders or the evacuation of an injured person may be delayed due to constraints of terrain,
weather, and available persons or equipment. It may be necessary to care for an injured person for
several hours or days.
• Mental health first aid is taught independently of physical first aid. How to support someone
experiencing a mental health problem or in a crisis situation. Also how to identify the first signs of
someone developing mental ill health and guide people towards appropriate help.
First Aid Services

Some people undertake specific training in order to provide first aid at public or private events, during
filming, or other places where people gather. They may be designated as a first aider, or use some other title.
This role may be undertaken on a voluntary basis, with organisations such as the Red Cross and St John
Ambulance, or as paid employment with a medical contractor. People performing a first aid role, whether in a
professional or voluntary capacity, are often expected to have a high level of first aid training and are often
uniformed.
Conditions that Often Require First Aid

• Altitude sickness, which can begin in susceptible people at altitudes as low as 5,000 feet, can cause
potentially fatal swelling of the brain or lungs.
• Anaphylaxis, a life-threatening condition in which the airway can become constricted and the patient
may go into shock. The reaction can be caused by a systemic allergic reaction to allergens such as
insect bites or peanuts. Anaphylaxis is initially treated with injection of epinephrine.
• Battlefield first aid—This protocol refers to treating shrapnel, gunshot wounds, burns, bone fractures,
etc. as seen either in the ‘traditional’ battlefield setting or in an area subject to damage by large-
scale weaponry, such as a bomb blast.
• Bone fracture, a break in a bone initially treated by stabilizing the fracture with a splint.
• Burns, which can result in damage to tissues and loss of body fluids through the burn site.
• Cardiac Arrest, which will lead to death unless CPR preferably combined with an AED is started within
minutes. There is often no time to wait for the emergency services to arrive as 92 percent of people
suffering a sudden cardiac arrest die before reaching hospital according to the American Heart Association.
• Choking, blockage of the airway which can quickly result in death due to lack of oxygen if the
patient’s trachea is not cleared, for example by the Heimlich Maneuver.
• Childbirth.
• Cramps in muscles due to lactic acid build up caused either by inadequate oxygenation of muscle or
lack of water or salt.
• Diving disorders, drowning or asphyxiation.

• Gender-specific conditions, such as dysmenorrhea and testicular torsion.
• Heart attack, or inadequate blood flow to the blood vessels supplying the heart muscle.
• Heat stroke, also known as sunstroke or hyperthermia, which tends to occur during heavy exercise
in high humidity, or with inadequate water, though it may occur spontaneously in some chronically
ill persons. Sunstroke, especially when the victim has been unconscious, often causes major damage
to body systems such as brain, kidney, liver, gastric tract. Unconsciousness for more than two
hours usually leads to permanent disability. Emergency treatment involves rapid cooling of the
patient.
• Hair tourniquet a condition where a hair or other thread becomes tied around a toe or finger tightly
enough to cut off blood flow.
• Heat syncope, another stage in the same process as heat stroke, occurs under similar conditions as
heat stroke and is not distinguished from the latter by some authorities.
• Heavy bleeding, treated by applying pressure (manually and later with a pressure bandage) to the
wound site and elevating the limb if possible.
• Hyperglycemia (diabetic coma) and Hypoglycemia (insulin shock).
• Hypothermia, or Exposure, occurs when a person’s core body temperature falls below 33.7 °C (92.6
°F). First aid for a mildly hypothermic patient includes rewarming, which can be achieved by wrapping
the affected person in a blanket, and providing warm drinks, such as soup, and high energy food,
such as chocolate. However, rewarming a severely hypothermic person could result in a fatal
arrhythmia, an irregular heart rhythm.
• Insect and animal bites and stings.
• Joint dislocation.
• Poisoning, which can occur by injection, inhalation, absorption, or ingestion.
• Seizures, or a malfunction in the electrical activity in the brain. Three types of seizures include a
grand mal (which usually features convulsions as well as temporary respiratory abnormalities, change
in skin complexion, etc.) and petit mal (which usually features twitching, rapid blinking, or fidgeting
as well as altered consciousness and temporary respiratory abnormalities).
• Muscle strains and Sprains, a temporary dislocation of a joint that immediately reduces automatically
but may result in ligament damage.
• Stroke, a temporary loss of blood supply to the brain.
• Toothache, which can result in severe pain and loss of the tooth but is rarely life-threatening, unless
over time the infection spreads into the bone of the jaw and starts osteomyelitis.
• Wounds and bleeding, including lacerations, incisions and abrasions, Gastrointestinal bleeding,
avulsions and Sucking chest wounds, treated with an occlusive dressing to let air out but not in.
First Aid Kit

Many accidents can happen at home, office, schools, laboratories etc. which require immediate attention
before the patient is attended by the doctor.
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Though professional first aid kits are readily available, one can make a simple kit easily at home. Still, ready
made First Aid kits/boxes/pouches/cases are recommended, as they have well organized compartments. To
make a First Aid kit, a strong, durable bag or transparent plastic box should be taken and a white cross in a green
square placed on the sides and on the top. This will make for easy identification of the box to any user. The kit
should be kept such that it is within reach in case of an emergency.
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A First Aid Kit should have the following contents:
• First-aid manual different sizes
• Adhesive tape
• Adhesive bandages in several sizes
• Elastic bandage
• A splint
• Antiseptic wipes
• Soap
• Antibiotic ointment
• Antiseptic solution (like hydrogen peroxide or saline)
• Hydrocortisone cream (1%)
• Acetaminophen and ibuprofen
• Extra prescription medications (if traveling)
• Tweezers
• Sharp scissors
• Safety pins
• Disposable instant cold packs
• Calamine lotion
• Alcohol wipes or ethyl alcohol
• Thermometer
• Tooth preservation kit
• Plastic non-latex gloves(at least 2 pairs)
• Flashlight and extra batteries
• Thermal shock blanket
• Mouthpiece for administering CPR (can be obtained from your local Red Cross)
• Blanket (stored nearby)
• First Aid Card containing emergency personal information, phone numbers, medications, manual,
• Pocket defibrillator.
NEONATAL RESUSCITATION PROGRAMME

The Neonatal Resuscitation Programme (NRP) is an educational programme in neonatal resuscitation that
was developed and is maintained by the American Academy of Pediatrics. This programme focuses on basic
resuscitation skills for newly born infants. With the rollout of the sixth edition of NRP to reflect the 2010
American Heart Association guidelines for resuscitation, the course format has changed considerably. In the
past, a full-day course incorporated lecture, written testing and hands-on skills. Now students study independently,
complete an online examination, then attend an in-person skills session. This reduces the classroom time required
for the course and allows instructors to focus on the practical skills needed to resuscitate the neonate. The
programme is intended for health care providers who perform resuscitation in the delivery room or newborn
nursery. Providers who take NRP are diverse in their scope of practice. The course outline is flexible to allow
providers to complete specific modules directly related to their practice.
PEDIATRIC ADVANCED LIFE SUPPORT

Pediatric Advanced Life Support (PALS) is a 2-day (with an additional self study day) American Heart
Association training programme co-branded with the American Academy of Pediatrics. The goal of the course
is to aid the pediatric health care provider in developing the knowledge and skills necessary to efficiently and
effectively manage critically ill infants and children, resulting in improved outcomes. Professional health care
providers use PALS during the stabilization and transportation phases of a pediatric emergency, in or out of
hospital. Skills taught include recognition and treatment of infants and children at risk for cardiopulmonary
arrest; the systematic approach to pediatric assessment; effective respiratory management; defibrillation and
synchronized cardioversion; intraosseous access and fluid bolus administration; and effective resuscitation
team dynamics. PETA has criticized the use of animals in PALS training which the organization calls “cruel and
unnecessary “. PETA says that hundreds of PALS training centers have begun using simulators in response to
concerns regarding the animals’ welfare. The American Heart Association neither endorses nor requires the use
of animals in intubation training.

ELECTROCARDIOGRAPHY
Electrocardiography (ECG or EKG) is the process of recording the electrical activity of the heart over a
period of time using electrodes placed on the skin. These electrodes detect the tiny electrical changes on the
skin that arise from the heart muscle’s electrophysiologic pattern of depolarizing and repolarizing during each
heartbeat. It is a very commonly performed to detect any cardiac problems. In a conventional 12-lead ECG, ten
electrodes are placed on the patient’s limbs and on the surface of the chest.
Fig. ECG of a heart in normal sinus rhythm.

The overall magnitude of the heart’s electrical potential is then measured from twelve different angles (“leads”)
and is recorded over a period of time (usually ten seconds). In this way, the overall magnitude and direction of
the heart’s electrical depolarization is captured at each moment throughout the cardiac cycle. The graph of
voltage versus time produced by this non-invasive medical procedure is an electrocardiogram. During each
heartbeat, a healthy heart has an orderly progression of depolarization that starts with pacemaker cells in the
sinoatrial node, spreads out through the atrium, passes through the atrioventricular node down into the bundle
of His and into the Purkinje fibres, spreading down and to the left throughout the ventricles. This orderly
pattern of depolarization gives rise to the characteristic ECG tracing. To the trained clinician, an ECG conveys
a large amount of information about the structure of the heart and the function of its electrical conduction
system. Among other things, an ECG can be used to measure the rate and rhythm of heartbeats, the size and
position of the heart chambers, the presence of any damage to the heart’s muscle cells or conduction system, the
effects of cardiac drugs, and the function of implanted pacemakers.
History
The etymology of the word is derived from the Greek electro, because it is related to electrical activity,
kardio, Greek for heart, and graph, a Greek root meaning “to write”.
Alexander Muirhead is reported to have attached wires to a feverish patient’s wrist to obtain a record of the
patient’s heartbeat in 1872 at St Bartholomew’s Hospital. Another early pioneer was Augustus Waller, of St
Mary’s Hospital in London. His electrocardiograph machine consisted of a Lippmann capillary electrometer
fixed to a projector. The trace from the heartbeat was projected onto a photographic plate that was itself fixed
to a toy train. This allowed a heartbeat to be recorded in real time.
An initial breakthrough came when Willem Einthoven, working in Leiden, the Netherlands, used the string
galvanometer (the first practical electrocardiograph) he invented in 1901. This device was much more sensitive than
both the capillary electrometer Waller used and the string galvanometer that had been invented separately in 1897 by
the French engineer Clément Ader. Einthoven had previously, in 1895, assigned the letters P, Q, R, S, and T to the
deflections in the theoretical waveform he created using equations which corrected the actual waveform obtained by
the capillary electrometer to compensate for the imprecision of that instrument. Using letters different from A, B, C,
and D (the letters used for the capillary electrometer’s waveform) facilitated comparison when the uncorrected and
corrected lines were drawn on the same graph. Einthoven probably chose the initial letter P to follow the example set
by Descartes in geometry. When a more precise waveform was obtained using the string galvanometer, which matched
the corrected capillary electrometer waveform, he continued to use the letters P, Q, R, S, and T, and these letters are
still in use today. Einthoven also described the electrocardiographic features of a number of cardiovascular disorders.
In 1924, he was awarded the Nobel Prize in Medicine for his discovery. By 1927, General Electric had developed a
portable apparatus that could produce electrocardiograms without the use of the string galvanometer. This device
instead combined amplifier tubes similar to those used in a radio with an internal lamp and a moving mirror that
directed the tracing of the electric pulses onto film. In 1937, Taro Takemi invented a new portable electrocardiograph
machine. Though the basic principles of that era are still in use today, many advances in electrocardiography have
been made over the years. Instrumentation has evolved from a cumbersome laboratory apparatus to compact electronic
systems that often include computerized interpretation of the electrocardiogram.
Medical Uses
The overall goal of performing electrocardiography is to obtain information about the structure and function
of the heart. Medical uses for this information are varied and generally relate to having a need for knowledge of
the structure and/or function.
Some indications for performing electrocardiography include:

• Suspected myocardial infarction (heart attack) or chest pain
• Suspected pulmonary embolism or shortness of breath
• A third heart sound, fourth heart sound, a cardiac murmur or other findings to suggest structural
heart disease
• Perceived arrhythmia either by pulse or palpitations
• Monitoring of known cardiac dysrhythmias
• Fainting or collapse
• Seizures
• Monitoring the effects of a heart medication (e.g. drug-induced QT prolongation)
• Assessing severity of electrolyte abnormalities, such as hyperkalemia
• Hypertrophic cardiomyopathy screening in adolescents as part of a sports physical out of concern
for sudden cardiac death (varies by country)
• Perioperative monitoring in which any form of anesthesia is involved (e.g. monitored anesthesia
care, general anesthesia); typically both intraoperative and postoperative
• As a part of a pre-operative assessment some time before a surgical procedure (especially for those
with known cardiovascular disease or who are undergoing invasive or cardiac, vascular or pulmonary
procedures, or who will receive general anesthesia)
• Cardiac stress testing
• Computed tomography angiography (CTA) and Magnetic resonance angiography (MRA) of the heart
(ECG is used to “gate” the scanning so that the anatomical position of the heart is steady)
• Biotelemetry of patients for any of the above reasons and such monitoring can include internal and
external defibrillators and pacemakers
The United States Preventive Services Task Force does not recommend electrocardiography for routine
screening procedure in patients without symptoms and those at low risk for coronary heart disease. This is
because an ECG may falsely indicate the existence of a problem, leading to misdiagnosis, the recommendation
of invasive procedures, or overtreatment. However, persons employed in certain critical occupations, such as
aircraft pilots, may be required to have an ECG as part of their routine health evaluations. Continuous ECG
monitoring is used to monitor critically ill patients, patients undergoing general anesthesia, and patients who
have an infrequently occurring cardiac dysrhythmia that would be unlikely to be seen on a conventional ten-
second ECG. Performing a 12-lead ECG in the United States is commonly performed by specialized technicians
that may be certified electrocardiogram technicians. ECG interpretation is a component of many health care
fields (nurses and physicians and cardiac surgeons being the most obvious), but anyone trained to interpret an
ECG is free to do so. However, “official” interpretation is performed by a cardiologist. Certain fields such as
anesthesia utilize continuous ECG monitoring, and knowledge of interpreting ECGs is crucial to their jobs.
One additional form of electrocardiography is used in clinical cardiac electrophysiology in which a catheter is
used to measure the electrical activity. The catheter is inserted through the femoral vein and can have several
electrodes along its length to record the direction of electrical activity from within the heart.
Electrocardiographs
An electrocardiograph is a machine that is used to perform electrocardiography, and produces the
electrocardiogram. The first electrocardiographs are discussed above and are electrically primitive compared to
today’s machines. The fundamental component to electrocardiograph is the Instrumentation amplifier, which is
responsible for taking the voltage difference between leads and amplifying the signal. ECG voltages measured
across the body are on the order of hundreds of microvolts up to 1 millivolt (the small square on a standard ECG
is 100 microvolts). This low voltage necessitates a low noise circuit and instrumentation amplifiers are key.
Early electrocardiographs were constructed with analog electronics and the signal could drive a motor to print
the signal on paper. Today, electrocardiographs use analog-to-digital converters to convert to a digital signal
that can then be manipulated with digital electronics. This permits digital recording of ECGs and use on computers.
There are other components to the electrocardiograph:
• Safety features that include voltage protection for the patient and operator. Since the machines are
powered by mains power, it is conceivable that either person could be subjected to voltage capable
of causing death. Additionally, the heart is sensitive to the AC frequencies typically used for mains
power (50 or 60 Hz).
• Defibrillation protection. Any ECG used in health care may be attached to a person who requires
defibrillation and the electrocardiograph needs to protect itself from this source of energy.
• Electrostatic discharge is similar to defibrillation discharge and requires voltage protection up to
18,000 volts.
• Additionally circuitry called the right leg driver can be used to reduce common-mode interference
(typically the 50/60 Hz mains power).
The typical design for a portable electrocardiograph is a combined unit that includes a screen, keyboard, and
printer on a small wheeled cart. The unit connects to a long cable that branches to each lead and attaches to a
conductive pad on the patient. Lastly, the electrocardiograph may include a rhythm analysis algorithm that
produces a computerized interpretation of the electrocardiogram. The results from these algorithms are considered
“preliminary” until verified and/or modified by someone trained in interpreting electrocardiograms. Included
in this analysis is computation of common parameters that include PR interval, QT duration, corrected QT
(QTc) duration, PR axis, QRS axis, and more. Earlier designs recorded each lead sequentially but current
designs employ circuits that can record all leads simultaneously. The former introduces problems in interpretation
since there may be beat-to-beat changes in the rhythm, which makes it unwise to compare across beats.
Fig. An electrocardiograph with integrated display and keyboard on a wheeled cart.
Electrodes and Leads

A “lead” is not the same as an “electrode”. Whereas an electrode is a conductive pad in contact with the body
that makes an electrical circuit with the electrocardiograph, a lead is a connector to an electrode. Since leads can
share the same electrode, a standard 12-lead ECG happens to need only 10 electrodes (as listed in the table below).
Fig. Proper placement of the limb electrodes. The limb electrodes can be far down
on the limbs or close to the hips/shoulders as long as they are placed symmetrically.
A lead is slightly more abstract and is the source of measurement of a vector. For the limb leads, they are
“bipolar” and are the comparison between two electrodes. For the precordial leads, they are “unipolar” and
compared to a common lead (commonly the Wilson’s central terminal), as described below. Leads are broken
down into three sets: limb; augmented limb; and precordial or chest. The 12-lead ECG has a total of three limb
leads and three augmented limb leads arranged like spokes of a wheel in the coronal plane (vertical), and six
precordial leads or chest leads that lie on the perpendicular transverse plane (horizontal). In medical settings,
the term leads is also sometimes used to refer to the electrodes themselves, although this is not technically a
correct usage of the term, which complicates the understanding of difference between the two.
Fig. Placement of the precordial electrodes.

The 10 electrodes in a 12-lead ECG are listed below.

Electrode name Electrode placement
RA On the right arm, avoiding thick muscle.
LA In the same location where RA was placed, but on the left arm.
RL On the right leg, lower end of medial aspect of calf muscle. (Avoid bony prominences)
LL In the same location where RL was placed, but on the left leg.
V1 In the fourth intercostal space (between ribs 4 and 5) just to the right of the sternum
(breastbone).
V2 In the fourth intercostal space (between ribs 4 and 5) just to the left of the sternum.
V3 Between leads V2 and V4.
V4 In the fifth intercostal space (between ribs 5 and 6) in the mid-clavicular line.
V5 Horizontally even with V4, in the left anterior axillary line.
V6 Horizontally even with V4 and V5 in the midaxillary line.
Two common electrodes used are a flat paper-thin sticker and a self-adhesive circular pad. The former are
typically used in a single ECG recording while the latter are for continuous recordings as they stick longer.
Each electrode consists of an electrically conductive electrolyte gel and a silver/silver chloride conductor. The
gel typically contains potassium chloride – sometimes silver chloride as well – to permit electron conduction
from the skin to the wire and to the electrocardiogram. The common lead, Wilson’s central terminal VW, is
produced by averaging the measurements from the electrodes RA, LA, and LL to give an average potential
across the body:
1
VW = ( RA + LA + LL)
3
In a 12-lead ECG, all leads except the limb leads are unipolar (aVR, aVL, aVF, V1, V2, V3, V4, V5, and V6).
The measurement of a voltage requires two contacts and so, electrically, the unipolar leads are measured from
the common lead (negative) and the unipolar lead (positive). This averaging for the common lead and the
abstract unipolar lead concept makes for a more challenging understanding and is complicated by sloppy usage
of “lead” and “electrode”.
04),(+:
Leads I, II and III are called the limb leads. The electrodes that form these signals are located on the limbs –
one on each arm and one on the left leg. The limb leads form the points of what is known as Einthoven’s
triangle.
Fig. The limb leads and augmented limb leads.

• Lead I is the voltage between the (positive) left arm (LA) electrode and right arm (RA) electrode:
I = LA – RA
• Lead II is the voltage between the (positive) left leg (LL) electrode and the right arm (RA) electrode:
II = LL – RA
• Lead III is the voltage between the (positive) left leg (LL) electrode and the left arm (LA) electrode:
III = LL – LA
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Leads aVR, aVL, and aVF are the augmented limb leads. They are derived from the same three electrodes as
leads I, II, and III, but they use Goldberger’s central terminal as their negative pole. Goldberger’s central
terminal is a combination of inputs from two limb electrodes, with a different combination for each augmented
lead. It is referred to immediately below as “the negative pole”.
• Lead augmented vector right (aVR) has the positive electrode on the right arm. The negative pole is
a combination of the left arm electrode and the left leg electrode:
1 3
aVR = RA − ( LA + LL ) = ( RA – VW )
2 2
• Lead augmented vector left (aVL) has the positive electrode on the left arm. The negative pole is a
combination of the right arm electrode and the left leg electrode:
1 3
aVL = LA − ( RA + LL ) = ( LA − VW )
2 2
• Lead augmented vector foot (aVF) has the positive electrode on the left leg. The negative pole is a
combination of the right arm electrode and the left arm electrode:
1 3
aVF = LL − ( RA + LA) = ( LL − VW )
2 2
Together with leads I, II, and III, augmented limb leads aVR, aVL, and aVF form the basis of the hexaxial
reference system, which is used to calculate the heart’s electrical axis in the frontal plane.
9,*69+0(3,(+:
The precordial leads lie in the transverse (horizontal) plane, perpendicular to the other six leads. The six
precordial electrodes act as the positive poles for the six corresponding precordial leads: (V1, V2, V3, V4, V5
and V6). Wilson’s central terminal is used as the negative pole.
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Additional electrodes may rarely be placed to generate other leads for specific diagnostic purposes. Right-
sided precordial leads may be used to better study pathology of the right ventricle or for dextrocardia (and are
denoted with an R (e.g., V5R)). Posterior leads (V7 to V9) may be used to demonstrate the presence of a
posterior myocardial infarction. A Lewis lead (requiring an electrode at the right sternal border in the second
intercostal space) can be used to study pathological rhythms arising in the right atrium. An esophogeal lead can
be inserted to a part of the esophagus where the distance to the posterior wall of the left atrium is only
approximately 5–6 mm (remaining constant in people of different age and weight). An esophageal lead avails
for a more accurate differentiation between certain cardiac arrhythmias, particularly atrial flutter, AV nodal
reentrant tachycardia and orthodromic atrioventricular reentrant tachycardia. It can also evaluate the risk in
people with Wolff-Parkinson-White syndrome, as well as terminate supraventricular tachycardia caused by re-
entry. An intracardiac electrogram (ICEG) is essentially an ECG with some added intracardiac leads (that is,
inside the heart). The standard ECG leads (external leads) are I, II, III, aVL, V1, and V6. Two to four intracardiac
leads are added via cardiac catheterization. The word “electrogram” (EGM) without further specification usually
means an intracardiac electrogram.
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A standard 12-lead ECG report (an electrocardiograph) shows a 2.5 second tracing of each of the twelve
leads. The tracings are most commonly arranged in a grid of four columns and three rows. the first column is the
limb leads (I, II, and III), the second column is the augmented limb leads (aVR, aVL, and aVF), and the last two
columns are the precordial leads (V1-V6). Additionally, a rhythm strip may be included as a fourth or fifth row.
The timing across the page is continuous and not tracings of the 12 leads for the same time period. In other
words, if the output were traced by needles on paper, each row would switch which leads as the paper is pulled
under the needle. For example, the top row would first trace lead I, then switch to lead aVR, then switch to V1,
and then switch to V4 and so none of these four tracings of the leads are from the same time period as they are
traced in sequence through time.
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Each of the 12 ECG leads records the electrical activity of the heart from a different angle, and therefore
align with different anatomical areas of the heart. Two leads that look at neighbouring anatomical areas are said
to be contiguous.
Category Leads Activity
Inferior leads’ Leads II, III and aVF Look at electrical activity from the vantage point of the inferior surface
(diaphragmatic surface of heart)
Lateral leads I, aVL, V5 and V6 Look at the electrical activity from the vantage point of the lateral wall of
left ventricle
Septal leads V1 and V2 Look at electrical activity from the vantage point of the septal surface of
the heart (interventricular septum)
Anterior leads V3 and V4 Look at electrical activity from the vantage point of the anterior wall of
the right and left ventricles (Sternocostal surface of heart)
In addition, any two precordial leads next to one another are considered to be contiguous. For example,
though V4 is an anterior lead and V5 is a lateral lead, they are contiguous because they are next to one another.
Fig. Diagram showing the contiguous leads in the same colour in the standard 12-lead layout.
Electrophysiology
The formal study of the electrical conduction system of the heart is called cardiac electrophysiology (EP).
An electrophysiology study involves a formal study of the conduction system and can be done for various
reasons. During such a study, catheters are used to access the heart and some of these catheters include electrodes
that can be placed anywhere in the heart to record the electrical activity from within the heart. Some catheters
contain several electrodes and can record the propagation of electrical activity.
Interpretation
Interpretation of the ECG is fundamentally about understanding the electrical conduction system of the
heart. Normal conduction starts and propagates in a predictable pattern, and deviation from this pattern can be
a normal variation or be pathological. An ECG does not equate with mechanical pumping activity of the heart,
for example, pulseless electrical activity produces an ECG that should pump blood but no pulses are felt (and
constitutes a medical emergency and CPR should be performed). Ventricular fibrillation produces an ECG but
is too dysfunctional to produce a life-sustaining cardiac output. Certain rhythms are known to have good cardiac
output and some are known to have bad cardiac output. Ultimately, an echocardiogram or other anatomical
imaging modality is useful in assessing the mechanical function of the heart. Like all medical tests, what
constitutes “normal” is based on population studies. The heart rate range of between 60 and 100 is considered
normal since data shows this to be the usual resting heart rate.
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Interpretation of the ECG is ultimately that of pattern recognition. In order to understand the patterns found,
it is helpful to understand the theory of what ECGs represent.
The theory is rooted in electromagnetics and boils down to the four following points:
• Depolarization of the heart towards the positive electrode produces a positive deflection
• Depolarization of the heart away from the positive electrode produces a negative deflection
• Repolarization of the heart towards the positive electrode produces a negative deflection
• Repolarization of the heart away from the positive electrode produces a positive deflection
Thus, the overall direction of depolarization and repolarization produces a vector that produces positive or
negative deflection on the ECG depending on which lead it points to. For example, depolarizing from right to
left would produce a positive deflection in lead I because the two vectors point in the same direction. In contrast,
that same depolarization would produce minimal deflection in V1 and V2 because the vectors are perpendicular
and this phenomenon is called isoelectric. Normal rhythm produces four entities – a P wave, a QRS complex, a
T wave, and a U wave – that each have a fairly unique pattern.
• The P wave represents atrial depolarization.
• The QRS complex represents ventricular depolarization.
• The T wave represents ventricular repolarization.
• The U wave represents papillary muscle repolarization.
However, the U wave is not typically seen and its absence is generally ignored. Changes in the structure of
the heart and its surroundings (including blood composition) change the patterns of these four entities.
Fig. QRS is upright in a lead when its axis is aligned with that lead’s vector.
Fig. Schematic representation of normal ECG.
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ECGs are normally printed on a grid. The horizontal axis represents time and the vertical axis represents
voltage. The standard values on this grid are shown in the adjacent image:
• A small box is 1 mm x 1 mm big and represents 0.1 mV x 0.04 seconds.
• A large box is 5 mm x 5mm big and represents 0.5 mV x 0.2 seconds wide.
The “large” box is represented by a heavier line weight than the small boxes.
Not all aspects of an ECG rely on precise recordings or having a known scaling of amplitude or time. For
example, determining if the tracing is a sinus rhythm only requires feature recognition and matching, and not
measurement of amplitudes or times (i.e., the scale of the grids are irrelevant). An example to the contrary, the
voltage requirements of left ventricular hypertrophy require knowing the grid scale.
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In a normal heart, the heart rate is the rate in which the sinoatrial node depolarizes as it is the source of
depolarization of the heart. Heart rate, like other vital signs like blood pressure and respiratory rate, change
with age. In adults, a normal heart rate is between 60 and 100 beats per minute (normocardic) where in
children it is higher. A heart rate less than normal is called bradycardia (<60 in adults) and higher than
normal is tachycardia (>100 in adults). A complication of this is when the atria and ventricles are not in
synchrony and the “heart rate” must be specified as atrial or ventricular (e.g., the ventricular rate in
ventricular fibrillation is 300–600 bpm, whereas the atrial rate can be normal (60–100) or faster (100–
150)). In normal resting hearts, the physiologic rhythm of the heart is normal sinus rhythm (NSR). Normal
sinus rhythm produces the prototypical pattern of P wave, QRS complex, and T wave. Generally, deviation
from normal sinus rhythm is considered a cardiac arrhythmia. Thus, the first question in interpreting an
ECG is whether or not there is a sinus rhythm. A criterion for sinus rhythm is that P waves and QRS
complexes appear 1-to-1, thus implying that the P wave causes the QRS complex. Once sinus rhythm is
established, or not, the second question is the rate. For a sinus rhythm this is either the rate of P waves or
QRS complexes since they are 1-to-1. If the rate is too fast then it is sinus tachycardia and if it is too slow
then it is sinus bradycardia. If it is not a sinus rhythm, then determining the rhythm is necessary before
proceeding with further interpretation.
Some arrhythmias with characteristic findings:
• Absent P waves with “irregularly irregular” QRS complexes is the hallmark of atrial fibrillation
• A “saw tooth” pattern with QRS complexes is the hallmark of atrial flutter
• Sine wave pattern is the hallmark of ventricular flutter
• Absent P waves with wide QRS complexes with fast rate is ventricular tachycardia
Determination of rate and rhythm is necessary in order to make sense of further interpretation.
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The heart has several axes, but the most common by far is the axis of the QRS complex (references to “the
axis” imply the QRS axis). Each axis can be computationally determined to result in a number representing
degrees of deviation from zero, or it can be categorized into a few types. The QRS axis is the general direction
of the ventricular depolarization wavefront (or mean electrical vector) in the frontal plane. It is often sufficient
to classify the axis as one of three types: normal, left deviated, or right deviated. Population data shows that a
normal QRS axis is from “30° to 105°, with 0° being along lead I and positive being inferior and negative being
superior (best understood graphically as the hexaxial reference system). Beyond +105° is right axis deviation
and beyond “30° is left axis deviation (the third quadrant of “90° to “180° is very rare and is an indeterminate
axis). A shortcut for determining if the QRS axis is normal is if the QRS complex is mostly positive in lead I and
lead II (or lead I and aVF if +90° is the upper limit of normal). The normal QRS axis is generally down and to
the left, following the anatomical orientation of the heart within the chest. An abnormal axis suggests a change
in the physical shape and orientation of the heart or a defect in its conduction system that causes the ventricles
to depolarize in an abnormal way.
Classification Angle Notes
Normal –30° to 105° Normal
Left axis deviation –30° to –90° May indicate left ventricular hypertrophy, left anterior fascicular block,
or an old inferior q-wave myocardial infarction
Right axis deviation +105° to +180° May indicate right ventricular hypertrophy, left posterior fascicular
block, or an old lateral q-wave myocardial infarction
Indeterminate axis +180° to “90° Rarely seen; considered an ‘electrical no-man’s land’
The extent of a normal axis can be +90° or 105° depending on the source.
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All of the waves on an ECG tracing and the intervals between them have a predictable time duration, a range
of acceptable amplitudes (voltages), and a typical morphology. Any deviation from the normal tracing is potentially
pathological and therefore of clinical significance.
For ease of measuring the amplitudes and intervals, an ECG is printed on graph paper at a standard scale:
each 1 mm (one small box on the standard ECG paper) represents 40 milliseconds of time on the x-axis, and 0.1
millivolts on the y-axis.
Feature Description Pathology Duration
P wave The p-wave represents depolarization The p-wave is typically upright in most <80 ms
of the atria. Atrial depolarization leads except for aVR; an unusual p-wave
spreads from the SA node towards axis (inverted in other leads) can indicate
the AV node, and from the right an ectopic atrial pacemaker. If the p wave
atrium to the left atrium. is of unusually long duration, it may
represent atrial enlargement. Typically a
large right atrium gives a tall, peaked
p-wave while a large left atrium gives a
two-humped bifid p-wave.
PR interval The PR interval is measured from A PR interval shorter than 120 ms suggests 120 to 200 ms
the beginning of the P wave to the that the electrical impulse is bypassing the
beginning of the QRS complex. This AV node, as in Wolf-Parkinson-White
interval reflects the time the electrical syndrome. A PR interval consistently longer
impulse takes to travel from the sinus than 200 ms diagnoses first degree
node through the AV node. atrioventricular block. The PR segment
(the portion of the tracing after the p-wave
and before the QRS complex) is typically
completely flat, but may be depressed in
pericarditis.
QRS complex The QRS complex represents the If the QRS complex is wide (longer than 80 to 100 ms
rapid depolarization of the right and 120 ms) it suggests disruption of the
left ventricles. The ventricles have a heart’s conduction system, such as
large muscle mass compared to the in LBBB, RBBB, or ventricular rhythms
atria, so the QRS complex usually such as ventricular tachycardia.
has a much larger amplitude than Metabolic issues such as severe
the P-wave. hyperkalemia, or TCA overdose can
also widen the QRS complex. An
unusually tall QRS complex may
represent left ventricular hypertrophy
while a very low-amplitude QRS
complex may represent a pericardial
effusion or infiltrative myocardial disease.
J-point The J-point is the point at which the The J point may be elevated as a
QRS complex finishes and the ST normal variant. The appearance of a
segment begins. separate J wave or Osborn wave at
the J point is pathognomonic of
hypothermia or hypercalcemia.
ST segment The ST segment connects the QRS It is usually isoelectric, but may be
complex and the T wave; it represents depressed or elevated with myocardial
the period when the ventricles are infarction or ischemia. ST depression
depolarized. can also be caused by LVH or digoxin.
ST elevation can also be caused by
pericarditis, Brugada syndrome, or can
be a normal variant (J-point elevation).
T wave The T wave represents the Inverted T waves can be a sign of 160 ms
repolarization of the ventricles. It is myocardial ischemia, LVH, high
generally upright in all leads intracranial pressure, or metabolic
except aVR and lead V1. abnormalities. Peaked T waves can
be a sign of hyperkalemia or very
early myocardial infarction.
Corrected QT
interval (QTc) The QT interval is measured from A prolonged QTc interval is a risk factor <440 ms
the beginning of the QRS complex for ventricular tachyarrhythmias and
to the end of the T wave. Acceptable sudden death. Long QT can arise as a
ranges vary with heart rate, so it genetic syndrome, or as a side effect of
must be corrected to the QTc by certain medications. An unusually short
dividing by the square root of the QTc can be seen in severe hypercalcemia.
RR interval.
U wave The U wave is hypothesized to be If the U wave is very prominent, suspect
caused by the repolarization of the hypokalemia, hypercalcemia or
interventricular septum. It normally hyperthyroidism.
has a low amplitude, and even more
often is completely absent.
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Ischemia or non-ST elevation myocardial infarctions may manifest as ST depression or inversion of T waves.
It may also affect the high frequency band of the QRS. ST elevation myocardial infarctions have different
characteristic ECG findings based on the amount of time elapsed since the MI first occurred. The earliest sign
is hyperacute T waves, peaked T-waves due to local hyperkalemia in ischemic myocardium. This then progresses
over a period of minutes to elevations of the ST segment by at least 1 mm. Over a period of hours, a pathologic
Q wave may appear and the T wave will invert.
Over a period of days the ST elevation will resolve. Pathologic q waves generally will remain permanently.
The coronary artery that has been occluded can be identified in an ST-elevation myocardial infarction based on
the location of ST elevation. The LAD supplies the anterior wall of the heart, and therefore causes ST elevations
in anterior leads (V1 and V2). The LCx supplies the lateral aspect of the heart and therefore causes ST elevations
in lateral leads (I, aVL and V6). The RCA usually supplies the inferior aspect of the heart, and therefore causes
ST elevations in inferior leads (II, III and aVF).
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An ECG tracing is affected by patient motion. Some rhythmic motions (such as shivering or tremors) can
create the illusion of cardiac dysrhythmia. Artifacts are distorted signals caused by a secondary internal or
external sources, such as muscle movement or interference from an electrical device. Distortion poses significant
challenges to health care providers, who employ various techniques and strategies to safely recognize these
false signals. Accurately separating the ECG artifact from the true ECG signal can have a significant impact on
patient outcomes and legal liabilities. Improper lead placement (for example, reversing two of the limb leads)
has been estimated to occur in 0.4% to 4% of all ECG recordings, and has resulted in improper diagnosis and
treatment including unnecessary use of thrombolytic therapy.
Diagnosis
Numerous diagnoses and findings can be made based upon electrocardiography, and many are discussed
above. Overall, the diagnoses are made based on the patterns. For example, an “irregularly irregular” QRS
complex without P waves is the hallmark of atrial fibrillation; however, other findings can be present as well,
such as a bundle branch block that alters the shape of the QRS complexes. ECGs can be interpreted in
isolation but should be applied – like all diagnostic tests – in the context of the patient. For example, an
observation of peaked T waves is not sufficient to diagnose hyperkalemia; such a diagnosis should be verified
by measuring the blood potassium level. Conversely, a discovery of hyperkalemia should be followed by an
ECG for manifestations such as peaked T waves, widened QRS complexes, and loss of P waves. The following
is an organized list of possible ECG-based diagnoses.
Rhythm disturbances/arrhythmias:
• Atrial fibrillation and atrial flutter without rapid ventricular response
• Premature atrial contraction (PACs) and Premature ventricular contraction (PVCs)
• Sinus arrhythmia
• Sinus bradycardia and sinus tachycardia
• Sinus pause and sinoatrial arrest
• Sick sinus syndrome: bradycardia-tachycardia syndrome
• Supraventricular tachycardia
– Atrial fibrillation (afib) with rapid ventricular response
– Atrial flutter with rapid ventricular response
– AV nodal reentrant tachycardia
– Atrioventricular reentrant tachycardia
– Junctional ectopic tachycardia
– Atrial tachycardia
i. Ectopic atrial tachycardia (unicentric)
ii. Multifocal atrial tachycardia
iii. Paroxysmal atrial tachycardia
– Sinoatrial nodal reentrant tachycardia
• Torsades de pointes (polymorphic ventricular tachycardia)
• Wide complex tachycardia
– Ventricular flutter
– Ventricular fibrillation
– Ventricular tachycardia (monomorphic ventricular tachycardia)
• Pre-excitation syndrome
– Lown–Ganong–Levine syndrome
– Wolff–Parkinson–White syndrome
• J wave/Osborn wave
Heart block and conduction problems:
• Aberration
• Sinoatrial block: first, second, and third-degree
• AV node
– First-degree AV block
– Second-degree AV block (Mobitz I & II; Mobitz I aka Wenckebach)
– Third-degree AV block/complete AV block
• Right bundle
– Incomplete right bundle branch block
– Complete right bundle branch block (RBBB)
• Left bundle
– Complete left bundle branch block (LBBB)
– Incomplete left bundle branch block
– Left anterior fascicular block (LAFB)
– Left posterior fascicular block (LPFB)
– Bifascicular block (LAFB plus LPFB)
– Trifascicular block (LAFP plus FPFB plus RBBB)
• QT syndromes
– Brugada syndrome
– Short QT syndrome
– Long QT syndromes, genetic and drug-induced
• Right and left atrial abnormality
Electrolytes disturbances and intoxication:
• Digitalis intoxication
• Calcium: hypocalcemia and hypercalcemia
• Potassium: hypokalemia and hyperkalemia
Ischemia and infarction:
• Wellens’ syndrome
• ST elevation and ST depression
• High Frequency QRS changes
• Myocardial infarction (heart attack)
– Non-Q wave myocardial infarction
– NSTEMI
– STEMI
– Sgarbossa’s criteria for ischemia with a LBBB
Structural:
• Acute pericarditis
• Right and left ventricular hypertrophy
• Right ventricular strain/S1Q3T3.
INTRAOSSEOUS INFUSION
Intraosseous infusion (IO) is the process of injecting directly into the marrow of a bone. This provides a non-
collapsible entry point into the systemic venous system. This technique is used to provide fluids and medication
when intravenous access is not available or not feasible. Intraosseous infusions allow for the administered
medications and fluids to go directly into the vascular system. A comparison of intravenous (IV), intramuscular
(IM), and intraosseous (IO) routes of administration concluded that the intraosseous route is demonstrably
superior to intramuscular and comparable to intravenous administration (in delivering paediatric anaesthetic
drugs). This route of fluid and medication administration is an alternative one to the preferred intravascular
route when the latter cannot be established in a timely manner. Intraosseous infusions are utilized when trauma
patients have compromised intravenous access and need immediate delivery of life saving fluids and medications.
Fig. Two pictures of the EZ IO device.
Fig. The tibia IO insertion site is just below the medial condyle, labeled in this picture.
Fig. NIO IO device.
Fig. BIG IO devices.
Fig. Axial CT with left humeral head EZ IO infusion of contrast.

Effectiveness
This American Heart Association guideline cited two randomized controlled trials, one of 60 children and
one of electively cannulated hematology/oncology patients. In addition, uncontrolled studies have been performed,
one of which reported 72% to 87% rates of successful insertion.
Procedure
The needle is injected through the bone’s hard cortex and into the soft marrow interior which allows immediate
access to the vascular system. The IO needle is positioned at a 90 degree angle to the injection site, and the
needle is advanced through manual traction, impact driven force, or power driven. Each IO device has different
designated insertion locations. The most common site of insertion is the antero-medial aspect of the upper,
proximal tibia as it lies just under the skin and is easily located. This is on the upper and inner portion of the
tibia. Other insertion sites include the anterior aspect of the femur, the superior iliac crest and the head of the
humerus. An IO infusion can be used on adult or pediatric patients when traditional methods of vascular access
are difficult or otherwise cause unwanted delayed management of the administration of medications. The IO
site can be used for 24 hours and should be removed as soon as intravenous access has been gained. Prolonged
use of an IO site, lasting longer than 24 hours, is associated with osteomyelitis (an infection in the bone).
Intraosseous infusions have several contraindications. Avoid sites that have known, or suspected fracture, appears
to be infected, or where the skin is burned. Medical conditions that might also preclude the use of intraosseous
infusion include osteopenia, osteopetrosis, and osteogenesis imperfecta as fractures are more likely to occur.
The procedure also only allows for one attempt per bone meaning another route of infusion must be secured, or
a different bone chosen. Although intravascular access is still the preferred method for medication delivery in
the prehospital area, IO access for adults has become more common. As of 2010, American Heart Association
no longer recommends using the endotracheal tube for resuscitation drugs, except as a last resort when IV or IO
access cannot be gained. The IO is becoming more common in civilian and military based pre-hospital emergency
medical services (EMS) systems globally. Intraosseous access has roughly the same absorption rate as IV
access, and allows for fluid resuscitation. For example, sodium bicarbonate can be administered IO during a
cardiac arrest when IV access is unavailable. High flow rates are attainable with an IO infusion, up to 125
milliliters per minute. This high rate of flow is achieved using a pressure bag to administer the infusion directly
into the bone. Large volume IO infusions are known to be painful. 1% lidocaine is used to ease the pain
associated with large volume IO infusions in conscious patients.
Devices
The automatic intra-osseous devices allow quick and safe access to the patient’s vascular system for fluid
and drug administration. There are several FDA approved IO devices: The BIG Bone Injection Gun and The
NIO New Intra Osseous device are automatic intra-osseous infusion device used by military and civilian health
care systems; the battery-powered EZ-IO and hand-powered Fast1, Fast Combat and Fast Responder. Other
devices include the Cook IO needle and the Jamshidi 15G. There have been several studies comparing the EZ-
IO and the BIG. Another paper compared the EZ-IO with the Cook IO needle.
INTRAVENOUS THERAPY
Intravenous therapy (IV) is a therapy that delivers liquid substances directly into a vein (intra- + ven- + -
ous). The intravenous route of administration can be used for injections (with a syringe at higher pressures) or
infusions (typically using only the pressure supplied by gravity). Intravenous infusions are commonly referred
to as drips. The intravenous route is the fastest way to deliver medications and fluid replacement throughout the
body, because the circulation carries them. Intravenous therapy may be used for fluid replacement (such as
correcting dehydration), to correct electrolyte imbalances, to deliver medications, and for blood transfusions.
Fig. Infusion therapy: A person receiving medication via intravenous therapy.
Types of Access
Intravenous systems can be categorized by which type of vein the inserted tube, called the catheter, empties into.
Fig. A peripheral line placed on the hand.

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A peripheral line is used on peripheral veins (the veins in the arms, hands, legs and feet). This is the most
common type of IV therapy used.
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Central IV lines have their catheters that are advanced through a vein and empty into a large central vein (a
vein within the torso), usually the superior vena cava, inferior vena cava or even the right atrium of the heart.
Because these veins have a larger diameter than peripheral veins and have faster blood flow, central lines are
commonly used to administer substances that could irritate the blood vessel lining, such as some chemotherapy
drugs and total parenteral nutrition, whose high glucose content can damage blood vessels. Other advantages
are that because it empties near the heart, medications can also be quickly distributed to the rest of the body. As
there is room for multiple parallel compartments (lumina) within the catheter, multiple medications can be
delivered at once, even if they would not be chemically compatible within a single tube.
Fig. Illustration of a non-tunneled central venous access device.

It is commonly believed that fluid can be pushed faster through a central line; however, the diameter of each
lumen is often smaller than that of a large-bore peripheral cannula. Caregivers can also measure central venous
pressure and other physiological variables through the central line. They are also longer and, as reflected by
Poiseuille’s law, require higher pressure to achieve the same flow, all other variables being equal. Central IV
lines carry risks of bleeding, infection, gangrene, thromboembolism and gas embolism. They are often more
difficult to insert correctly as the veins are not usually palpable and rely on an experienced clinician knowing
the appropriate landmarks and/or using an ultrasound probe to safely locate and enter the vein. Surrounding
structures such as the pleura and carotid artery are also at risk of damage with the potential for pneumothorax
or even cannulation of the artery. There are several types of central IV access, depending on the route that the
catheter takes from the outside of the body to the vein.
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PICC lines are used when intravenous access is required over a prolonged period of time or when the material
to be infused would cause quick damage and early failure of a peripheral IV line and when a conventional central
line may be too dangerous to attempt. Typical uses for a PICC include: long chemotherapy regimens, extended
antibiotic therapy, or total parenteral nutrition. The PICC line is inserted through a sheath into a peripheral vein
sometimes using the Seldinger technique or modified Seldinger technique, under ultrasound guidance, usually in
the arm, and then carefully advanced upward until the catheter is in the superior vena cava or the right atrium. This
is usually done by measuring the distance to an external landmark, such as the suprasternal notch, to estimate the
optimal length. An X-ray must be used to verify that the tip is in the right place when fluoroscopy was not used
during the insertion. A PICC may have a single (single-lumen) tube and connector, two (double-lumen) or three
(triple-lumen) compartments, each with its own external connector. Power-injectable PICCs are now available as
well. From the outside, a single-lumen PICC resembles a peripheral IV line, except that the tubing is slightly
wider. The insertion site requires better protection than that of a peripheral IV line, due to the higher risk of serious
infection if bacteria travel up the catheter. However, a PICC poses less of a systemic infection risk than other
central IV lines, because the insertion site is usually cooler and drier than the sites typically used for other central
lines. This helps to slow the growth of bacteria which could reach the bloodstream by traveling under the skin
along the outside of the catheter. The chief advantage of a PICC over other types of central lines is that it is safer
to insert with a relatively low risk of uncontrollable bleeding and essentially no risks of damage to the lungs or
major blood vessels. Although special training is required, a PICC does not require the skill level of a physician or
surgeon. It is also externally unobtrusive, and with proper hygiene and care can be left in place for months to years
if needed for patients who require extended treatment. The chief disadvantage is that it must be inserted and then
travel through a relatively small peripheral vein which can take a less predictable course on the way to the superior
vena cava and is therefore somewhat more time consuming and more technically difficult to place in some patients.
As a PICC travels through the axilla, it can also become kinked, causing poor function.
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While some central lines have their catheter pass through the skin and then directly into the vein, other
central lines called “tunneled catheters” insert through the skin and then pass or “tunnel” a significant distance
before inserting into the vein. This reduces the risk of infection, since bacteria from the skin surface are not able
to travel directly into the vein. These catheters are often made of materials that resist infection and clotting.
These include the Hickman line or Broviac catheter.
Fig. A Hickman line, a type of tunneled catheter, where it is inserted through the
skin at the chest and tunnels through to insert into the jugular vein in the neck.
473(5;()3,69;:
A port (often referred to by brand names such as Port-a-Cath or MediPort) is a central venous line that does
not have an external connector; instead, it has a small reservoir that is covered with silicone rubber and is
implanted under the skin. Medication is administered intermittently by placing a small needle through the skin,
piercing the silicone, into the reservoir. When the needle is withdrawn, the reservoir cover reseals itself. The
cover can accept hundreds of needle sticks during its lifetime. It is possible to leave the ports in the patient’s
body for years; if this is done, the port must be accessed monthly and flushed with an anti-coagulant, or the
patient risks it getting plugged up. If it is plugged, it becomes a hazard as a thrombus will eventually form with
an accompanying risk of embolisation. Removal of a port is usually a simple outpatient procedure; however,
installation is more complex and a good implant is fairly dependent on the skill of the radiologist. Ports cause
less inconvenience and have a lower risk of infection than PICCs, and are therefore commonly used for patients
on long-term intermittent treatment.
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A third type is a midline catheter which is inserted into a peripheral vein and advances through the vein,
unlike a peripheral IV line, but falls short of emptying into a central vein.
Types of Infusions
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A continuous infusion is primarily used to correct fluid and electrolyte imbalances. This is as opposed to
intermittent infusion, when a patient requires medications only at certain times, such as secondary IV and IV
push.
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The tubing from the bag of fluid being administered that connects to directly to the patient is called the
primary tubing. Any additional IVs to be administered are connected to the primary tubing and are called
secondary IV, or IV piggyback; this is done instead of placing multiple catheters in the patient. When administering
a secondary IV medication, the primary bag is held lower than the secondary bag so that the secondary medication
can flow into the primary tubing, rather than fluid from the primary bag flowing into the secondary tubing. The
fluid from the primary bag is needed to help flush any remaining medication from the secondary IV from the
tubing into the patient.
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Some medications are also given by IV “push” or bolus. A syringe containing the medication is connected to
an access port in the primary tubing and the medication is administered through the port. The syringe plunger is
pressed slowly, if it might irritate the vein or cause a too-rapid effect. Certain medications, such as potassium,
are never to be administered by IV push because the spike in medication in the blood from the IV push could be
fatal. Once a medicine has been injected into the fluid stream of the IV tubing, there must be some means of
ensuring that it gets from the tubing to the patient. Usually this is accomplished by allowing the fluid stream to
flow normally and thereby carry the medicine into the bloodstream; however, a second fluid injection is sometimes
used, a “flush”, following the injection to push the medicine into the bloodstream more quickly.
Medical Uses
Substances that may be infused intravenously include volume expanders, blood-based products, blood
substitutes, medications and nutrition.
Fig. IV bags on a pole connected to IV lines.
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A volume expander is a type of intravenous therapy that has the function of providing volume for the circulatory
system. It may be used for fluid replacement.
Fig. A person receiving intravenous fluid.

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When blood is lost, the greatest immediate need is to stop further blood loss. The second greatest need is
replacing the lost volume. This way remaining red blood cells can still oxygenate body tissue. Normal human
blood has a significant excess oxygen transport capability, only used in cases of great physical exertion. Provided
blood volume is maintained by volume expanders, a rested patient can safely tolerate very low haemoglobin
levels, less than 1/3 that of a healthy person. The body automatically detects the lower hemoglobin level, and
compensatory mechanisms start up.
The heart pumps more blood with each beat. Since the lost blood was replaced with a suitable fluid, the now
diluted blood flows more easily, even in the small vessels. As a result of chemical changes, more oxygen is
released to the tissues. These adaptations are so effective that if only half of the red blood cells remain, oxygen
delivery may still be about 75 percent of normal. A patient at rest uses only 25 percent of the oxygen available
in his blood.
In extreme cases, patients have survived with a haemoglobin level of 2 g/dl, about 1/7 the norm, although
levels this low are very dangerous. With enough blood loss, ultimately red blood cell levels drop too low for
adequate tissue oxygenation, even if volume expanders maintain circulatory volume. In these situations, the
only alternatives are blood transfusions, packed red blood cells, or oxygen therapeutics (if available). However
in some circumstances, hyperbaric oxygen therapy can maintain adequate tissue oxygenation even if red blood
cell levels are below normal life-sustaining levels.
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There are two main types of volume expanders: crystalloids and colloids. Crystalloids are aqueous solutions
of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin;
blood itself is a colloid.
There is no evidence that colloids are better than crystalloids in those who have had trauma, burns or surgery
and as they are more expensive their use is not recommended. The most commonly used crystalloid fluid is
normal saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the
blood (isotonic). Ringer’s lactate or Ringer’s acetate is another isotonic solution often used for large-volume
fluid replacement. The choice of fluids may also depend on the chemical properties of the medications being
given.
Normal saline:
• Normal saline (NS) is the commonly used term for a solution of 0.9% w/v of NaCl, about 300
mOsm/L. Less commonly, this solution is referred to as physiological saline or isotonic saline,
neither of which is technically accurate. NS is used frequently in intravenous drips (IVs) for
patients who cannot take fluids orally and have developed or are in danger of developing
dehydration or hypovolemia. NS is typically the first fluid used when hypovolemia is severe
enough to threaten the adequacy of blood circulation, and has long been believed to be the
safest fluid to give quickly in large volumes. However, it is now known that rapid infusion of
NS can cause metabolic acidosis.
Ringer’s solution:
• Lactated Ringer’s solution contains 28 mmol/L lactate, 4 mmol/L K and 1.5 mmol/L Ca. It is very
similar – though not identical to – Hartmann’s Solution, the ionic concentrations of which differ
slightly.
1/3 NS 2/3D5:
• 2/3 1/3 is no longer recommended as a maintenance intravenous fluid in children as it is hypotonic
and isotonic fluids are preferred.
Glucose (dextrose):
• Intravenous sugar solutions, such as with glucose (also called dextrose), have the advantage of providing
some energy, and may thereby provide the entire or part of the energy component of parenteral nutrition.
• Types of glucose/dextrose include:
• D5W (5% dextrose in water), which consists of 278 mmol/L dextrose
• D5NS (5% dextrose in normal saline), which, in addition, contains normal saline.
Comparison table:
Composition of common crystalloid solutions
Solution Other Name [Na](mmol/L) [Cl](mmol/L) [Glucose](mmol/L) [Glucose](mg/dl)
D5W 5% Dextrose 0 0 278 5000
2/3 D5W & 1/3 3.3% Dextrose / 51 51 185 3333
NS 0.3% saline
Half-normal 0.45% NaCl 77 77 0 0
saline
Normal saline 0.9% NaCl 154 154 0 0
Ringer's lactate Lactated Ringer 130 109 0 0
D5NS 5% Dextrose, Normal 154 154 278 5000
Saline
Effect of adding one litre
Solution Change in ECF Change in ICF
D5W 333 mL 667 mL
2/3 D5W and 1/3 NS 556 mL 444 mL
Half-normal saline 667 mL 333 mL
Normal saline 1000 mL 0 mL
Ringer’s lactate 900 mL 100 mL
Colloids preserve a high colloid osmotic pressure in the blood, while, on the other hand, this parameter is
decreased by crystalloids due to hemodilution. Therefore, they should theoretically preferentially increase the
intravascular volume, whereas crystalloids also increase the interstitial volume and intracellular volume. However,
there is no evidence to support that this results in less mortality than crystalloids. Another difference is that
crystalloids generally are much cheaper than colloids. Common colloids used in the medical context include
albumin and fresh frozen plasma.
Hydroxyethyl starch:
• Hydroxyethyl starch (HES/HAES, common trade names: Hespan, Voluven) is controversial. Its use
in those who are very ill is associated with an increased risk of death and kidney problems and thus
is not recommended in people with known inflammatory conditions such as renal impairment.
Gelofusine:
• Gelofusine is a colloid volume expander that is used as a blood plasma replacement if a significant
amount of blood is lost due to extreme hemorrhagia, trauma, dehydration, or a similar event. It is an
intravenous colloid that behaves much like blood filled with albumins. As a result, it causes an
increase in blood volume, blood flow, cardiac output, and oxygen transportation.
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Medications may be mixed into the fluids mentioned above. Compared with other routes of administration,
such as oral medications, the intravenous route is the fastest way to deliver fluids and medications throughout
the body. The bioavailability of the IV medication is 100%, unlike oral medications where much of the medication
is lost in digestion before entering circulation. Certain types of medications can only be given intravenously,
such as when there is insufficient uptake by other routes of administration such as enterally. Examples include
intravenous immunoglobulin and propofol.
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A blood product (or blood-based product) is any component of blood which is collected from a donor for use
in a blood transfusion. Blood transfusions can be life-saving in some situations, such as massive blood loss due
to trauma, or can be used to replace blood lost during surgery. Blood transfusions may also be used to treat a
severe anaemia or thrombocytopenia caused by a blood disease.
Fig. Saline and 5% glucose solution (Left), levofloxacin 750mg (Right).

People with hemophilia usually need a replacement of clotting factor, which is a small part of whole blood.
People with sickle-cell disease may require frequent blood transfusions. Early blood transfusions consisted of
whole blood, but modern medical practice commonly uses only components of the blood, such as fresh frozen
plasma or cryoprecipitate. Blood substitutes (also called artificial blood or blood surrogates) are artificial
substances aiming to provide an alternative to blood-based products acquired from donors. The main blood
substitutes used today are volume expanders such as crystalloids and colloids mentioned above. Also, oxygen-
carrying substitutes are emerging.
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Buffer solutions are used to correct acidosis or alkalosis. Lactated Ringer’s solution also has some buffering
effect. A solution more specifically used for buffering purpose is intravenous sodium bicarbonate.
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Parenteral nutrition is feeding a person intravenously, bypassing the usual process of eating and digestion.
The person receives nutritional formulas containing salts, glucose, amino acids, lipids and added vitamins.
Equipment
A standard IV infusion set consists of a pre-filled, sterile container (glass bottle, plastic bottle or plastic bag)
of fluids with an attachment that allows the fluid to flow one drop at a time, making it easy to see the flow rate
(and also reducing air bubbles); a long sterile tube with a clamp to regulate or stop the flow; a connector to
attach to the access device; and Y-sets to allow “piggybacking” of another infusion set onto the same line, e.g.,
adding a dose of antibiotics to a continuous fluid drip.
Fig. An infusion pump suitable for a single IV line.
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An infusion pump allows precise control over the flow rate and total amount delivered. The volume to be
infused (VTBI) of the mainline IV bag should usually be programmed for about 50 milliliters less than the
stated volume of that IV bag to avoid letting the IV line or tubing “run dry”. The VTBI for a secondary bag or
piggybag should usually be programmed for 30 to 50 milliliters more than is stated to be in that medication IV
bag, to make sure that in addition to the bag being emptied, the entire medication dose is flushed through the IV
tubing from the mainline bag. Because of its design, the short, secondary IV line cannot run dry. Thus, the
registered nurse should programme the IV pump for a 50 milliliter bag of IV antibiotics “volume to be infused”
or VTBI for at least 80 milliliters. The 100 milliliter bag of antibiotics usually needs a VTBI of about 140
milliliters. In cases where a change in the flow rate would not have serious consequences, or if pumps are not
available, the drip is often left to flow simply by placing the bag above the level of the patient and using the
clamp to regulate the rate; this is a gravity drip.
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The simplest form of intravenous access is by passing a hollow needle through the skin directly into the
vein. This needle can be connected directly to a syringe (used either to withdraw blood or deliver its
contents into the bloodstream) or may be connected to a length of tubing and thence whichever collection
or infusion system is desired. The most convenient site is often the arm, especially the veins on the back of
the hand, or the median cubital vein at the elbow, but any identifiable vein can be used. Often it is necessary
to use a tourniquet which restricts the venous drainage of the limb and makes the vein bulge. Once the
needle is in place, it is common to draw back slightly on the syringe to aspirate blood, thus verifying that
the needle is really in a vein. The tourniquet should be removed before injecting to prevent extravasation
of the medication.
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A drip chamber is a device used to allow gas (such as air) to rise out from a fluid so that it is not passed
downstream. They are commonly employed in delivery systems of intravenous therapy and act to prevent air
embolism. The use of a drip chamber also allows an estimate of the rate at which fluid is administered. For a
fluid of a given viscosity, drips from a hole of known size will be of nearly identical volume, and the number of
drips in a minute can be counted to gauge the rate of flow. In this instance the rate of flow is usually controlled
by a clamp on the infusion tubing; this affects the resistance to flow. However, other sources of resistance (such
as whether the vein is kinked or compressed by the patients position) cannot be so directly controlled and a
change in position may change the rate of flow leading to inadvertently rapid or slow infusion. Where this
might be problematic an infusion pump can be used which gives a more accurate measurement of flow rate.
Drip chambers can be classified into macro-drip(about 10 to 20 gtts/ml) and micro-drip (about 60 gtts/ml)
based on their drop factors. For a given drip chamber (when the fluid drips from the hole into the chamber) drop
factor means number of drops per ml of the IV fluid. Flow rate can be calculated with the help of the observations
from the drip chamber and its drop factor. The unit of flow rate is gtts/min, where gtts means guttae (Latin word
of drop)
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In medicine, a peripheral venous catheter (PVC), peripheral venous line or peripheral venous access catheter
is a catheter (small, flexible tube) placed into a peripheral vein for intravenous therapy such as medication
fluids. Upon insertion, the line can be used to draw blood. The catheter is introduced into the vein by a needle
(similar to blood drawing), which is subsequently removed while the small tube of the cannula remains in
place. The catheter is then fixed by taping it to the patient’s skin (unless there is allergy to adhesives). Newer
catheters have been equipped with additional safety features to avoid needlestick injuries. Modern catheters
consist of synthetic polymers such as teflon (hence the often used term ‘Venflon’ or ‘Cathlon’ for these venous
catheters).
Fig. A nurse inserting an 18-gauge IV needle with cannula.
Fig. An arm board is recommended for immobilizing the extremity

for cannulation of the hand, the foot or the antecubital fossa in children.
In 1950 they consisted of PVC plastic. A peripheral venous catheter is the most commonly used vascular
access in medicine. It is given to most emergency department and surgical patients, and before some radiological
imaging techniques using radiocontrast, for example. In the United States, more than 25 million patients get a
peripheral venous line each year. A peripheral venous catheter is usually placed in a vein on the hand or arm. It
should be distinguished from a central venous catheter which is inserted in a central vein (usually in the internal
jugular vein of the neck or the subclavian vein of the chest), or an arterial catheter which can be placed in a
peripheral as well as a central artery. In children, a local anaesthetic gel (such as lidocaine) is applied to the
insertion site to facilitate placement.
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Insertion of a venous cannula can be a painful procedure that may cause anxiety and stress. Use of a vapocoolant
immediately before cannulation reduces pain during the procedure, without increasing the difficulty of
cannulation. Infection, phlebitis, extravasation, infiltration, air embolism, hemorrhage (bleeding) and formation
of a hematoma (bruise) may occur. Because of the risk of insertion-site infection the CDC advises in their
guideline that the catheter needs to be replaced every 96 hours. Although these catheters can best not be left in
place longer than necessary, the need to replace these catheters routinely is debated. Expert management has
been shown to reduce the complications of peripheral lines.
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Sizes of peripheral venous catheters can be given by Birmingham gauge or French gauge.
Birmingham Diameter (mm) Maximum flow rate Colour
gauge (ml/min)
26 0.46 13-15 Black
24 0.60 36 Yellow
22 0.90 56 Blue
20 1.10 40-80 Pink
18 1.30 75-120 Green
17 1.50 128-133 White
16 1.80 236 Grey
14 2.00 270 Orange
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A rapid infuser can be used if the patient requires a high flow rate and the IV access device is of a large
enough diameter to accommodate it. This is either an inflatable cuff placed around the fluid bag to force the
fluid into the patient or a similar electrical device that may also heat the fluid being infused.
Adverse Effects
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An injection inherently causes pain when the skin is broken and is medically invasive. In cases in which a
choice between intravenous therapy and oral treatment may be made to achieve the same outcome, such as in
the case of mild or moderate dehydration treatment (assuming oral rehydration therapy is an option), then one
should avoid using intravenous therapy in place of the less invasive oral option. Children in emergency
departments being treated for dehydration in particular have better outcomes with oral treatment because it
does not cause the pain or risk the complications of an injection. Cold spray can decrease the pain of putting in
an IV.
Fig. Iranian soldier holding IV bag.
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Any break in the skin carries a risk of infection. Although IV insertion is an aseptic procedure, skin-dwelling
organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion
site around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated
equipment. Moisture introduced to unprotected IV sites through washing or bathing substantially increases the
infection risks. Infection of IV sites is usually local, causing easily visible swelling, redness, and fever. If
bacteria do not remain in one area but spread through the bloodstream, the infection is called septicemia and
can be rapid and life-threatening. An infected central IV poses a higher risk of septicemia, as it can deliver
bacteria directly into the central circulation.
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Phlebitis is inflammation of a vein that may be caused by infection, the mere presence of a foreign body (the
IV catheter) or the fluids or medication being given. Symptoms are warmth, swelling, pain, and redness around
the vein. The IV device must be removed and if necessary re-inserted into another extremity. Due to frequent
injections and recurring phlebitis, scar tissue can build up along the vein. The peripheral veins of intravenous
drug addicts, and of cancer patients undergoing chemotherapy, become sclerotic and difficult to access over
time, sometimes forming a hard, painful “venous cord”.
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Infiltration occurs when an IV fluid or medication accidentally enters the surrounding tissue rather than
the vein. It may occur when the vein itself ruptures (the elderly are particularly prone to fragile veins due
to a paucity of supporting tissues), when the vein is damaged during insertion of the intravascular access
device, when the device is not sited correctly, from increased vein porosity or when the entry point of the
device into the vein becomes the path of least resistance (e.g. if a cannula is in a vein for some time, the
vein may scar and close and the only way for fluid to leave is along the outside of the cannula where it
enters the vein).
Infiltration is an inadvertent administration of a non-vesicant solution/drug into the tissue, which happens
so often when the tourniquet isn’t removed in a timely fashion. Infiltration is characterized by coolness and
pallor to the skin as well as localized swelling or edema. It is treated by removing the intravenous access
device and elevating the affected limb so that the collected fluids can drain away. Sometimes injections of
hyaluronidase can be used to speed the dispersal of the fluid/drug. Infiltration is one of the most common
adverse effects of IV therapy and is usually not serious unless the infiltrated fluid is a medication damaging
to the surrounding tissue, most commonly a vesicant or chemotherapeutic agent, in which case it is called
extravasation and extensive necrosis can occur.
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This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete.
Possible consequences include hypertension, heart failure, and pulmonary edema.
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The human body is at risk of accidentally induced hypothermia when large amounts of cold fluids are
infused. Rapid temperature changes in the heart may precipitate ventricular fibrillation.
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Administering a too-dilute or too-concentrated solution can disrupt the patient’s balance of sodium, potassium,
magnesium, and other electrolytes. Hospital patients usually receive blood tests to monitor these levels. It is
essential to correct these imbalances if they occur, as they can lead to the clinical symptoms of electrolyte
imbalance, which, if left untreated, can lead to acidosis/alkalosis, and ultimately death.
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A blood clot or other solid mass, as well as an air bubble, can be delivered into the circulation through an
IV and end up blocking a vessel; this is called embolism. It is nearly impossible to inject air through a
peripheral IV at a dangerous rate. The risk is greater with a central IV. Air bubbles of less than 30 microliters
are thought to dissolve into the circulation harmlessly. A larger amount of air, if delivered all at once, can
cause life-threatening damage, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop
the heart. One reason veins are preferred over arteries for intravascular administration is because the flow
will pass through the lungs before passing through the body. Air bubbles can leave the blood through the
lungs. A patient with a right-to-left shunt is vulnerable to embolism from smaller amounts of air. Fatality by
air embolism is rare, although this may be in part because it is so difficult to determine when this is the cause
of death.
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Intravenous glucose is used in some Asian countries such as Korea as a pick-me-up, for “energy,” but is not
a part of routine medical care in the United States where a glucose solution is a prescription drug. Asian
immigrants to the United States are at risk if they seek intravenous glucose treatment. It may be had at store-
front clinics catering to Asian immigrants, but, despite having no more effect than drinking sugared water,
poses medical risks such as the possibility of infection. It is commonly called “ringer.”
History
Intravenous technology stems from studies on cholera treatment in 1831 by Dr Thomas Latta of Leith.
Intravenous therapy was further developed in the 1930s by Hirschfeld, Hyman and Wanger but was not widely
available until the 1950s.
Education
Intravenous therapy knowledge and skills among health care providers vary greatly. While initial exposure
to I.V. therapy is usually through formal nursing education programmes, I.V. starting skills only develop from a
combination of theoretical instruction and on the job practice. However, employers usually expect potential
employees to be proficient on this area of clinical practice prior to becoming hired. The gap between actual and
expected knowledge and skills can be extremely wide, especially in I.V. therapy. Part of this gap comes from the
lack of educational experiences and/or the inaccessibility to these offerings.
While not widely offered, interactive multimedia I.V. education, such as hybrid courses combining online
theory with hands-on practice, can provide a way to narrow that gap in a quick and cost-effective manner
which will represent an improvement on patient safety and treatment outcomes. Simulated intravenous
solutions used for training purposes only have been manufactured; in at least one case, the routing of training
solutions into a standard medical setting has led to patient adverse events. The Infusion Nurses Society
offers comprehensive evidence-based educational resources for its members. The Infusion Nurses Certification
Corporation offers the only nationally recognized and accredited certification for infusion nurse through the
CRNI® credential.
TRACHEAL INTUBATION
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube
into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer
certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation
of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway
obstruction. The most widely used route is orotracheal, in which an endotracheal tube is passed through the
mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed
through the nose and vocal apparatus into the trachea. Other methods of intubation involve surgery and
include the cricothyrotomy (used almost exclusively in emergency circumstances) and the tracheotomy, used
primarily in situations where a prolonged need for airway support is anticipated. Because it is an invasive
and uncomfortable medical procedure, intubation is usually performed after administration of general
anesthesia and a neuromuscular-blocking drug. It can however be performed in the awake patient with local
or topical anesthesia or in an emergency without any anesthesia at all. Intubation is normally facilitated by
using a conventional laryngoscope, flexible fibreoptic bronchoscope, or video laryngoscope to identify the
vocal cords and pass the tube between them into the trachea instead of into the esophagus.
Other devices and techniques may be used alternatively. After the trachea has been intubated, a balloon
cuff is typically inflated just above the far end of the tube to help secure it in place, to prevent leakage of
respiratory gases, and to protect the tracheobronchial tree from receiving undesirable material such as stomach
acid. The tube is then secured to the face or neck and connected to a T-piece, anesthesia breathing circuit, bag
valve mask device, or a mechanical ventilator. Once there is no longer a need for ventilatory assistance and/or
protection of the airway, the tracheal tube is removed; this is referred to as extubation of the trachea (or
decannulation, in the case of a surgical airway such as a cricothyrotomy or a tracheotomy). For centuries,
tracheotomy was considered the only reliable method for intubation of the trachea. However, because only a
minority of patients survived the operation, physicians undertook tracheotomy only as a last resort, on patients
who were nearly dead.
It was not until the late 19th century however that advances in understanding of anatomy and physiology, as
well an appreciation of the germ theory of disease, had improved the outcome of this operation to the point that
it could be considered an acceptable treatment option. Also at that time, advances in endoscopic instrumentation
had improved to such a degree that direct laryngoscopy had become a viable means to secure the airway by the
non-surgical orotracheal route. By the mid-20th century, the tracheotomy as well as endoscopy and non-surgical
tracheal intubation had evolved from rarely employed procedures to becoming essential components of the
practices of anesthesiology, critical care medicine, emergency medicine, and laryngology. Tracheal intubation
can be associated with minor complications such as broken teeth or lacerations of the tissues of the upper
airway. It can also be associated with potentially fatal complications such as pulmonary aspiration of stomach
contents which can result in a severe and sometimes fatal chemical aspiration pneumonitis, or unrecognized
intubation of the esophagus which can lead to potentially fatal anoxia. Because of this, the potential for difficulty
or complications due to the presence of unusual airway anatomy or other uncontrolled variables is carefully
evaluated before undertaking tracheal intubation. Alternative strategies for securing the airway must always be
readily available.
Indications
Tracheal intubation is indicated in a variety of situations when illness or a medical procedure prevents a
person from maintaining a clear airway, breathing, and oxygenating the blood. In these circumstances, oxygen
supplementation using a simple face mask is inadequate.
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Perhaps the most common indication for tracheal intubation is for the placement of a conduit through which
nitrous oxide or volatile anesthetics may be administered. General anesthetic agents, opioids, and neuromuscular-
blocking drugs may diminish or even abolish the respiratory drive. Although it is not the only means to maintain
a patent airway during general anesthesia, intubation of the trachea provides the most reliable means of
oxygenation and ventilation and the greatest degree of protection against regurgitation and pulmonary aspiration.
Damage to the brain (such as from a massive stroke, non-penetrating head injury, intoxication or poisoning)
may result in a depressed level of consciousness.
When this becomes severe to the point of stupor or coma (defined as a score on the Glasgow Coma
Scale of less than 8), dynamic collapse of the extrinsic muscles of the airway can obstruct the airway,
impeding the free flow of air into the lungs. Furthermore, protective airway reflexes such as coughing and
swallowing may be diminished or absent. Tracheal intubation is often required to restore patency (the
relative absence of blockage) of the airway and protect the tracheobronchial tree from pulmonary aspiration
of gastric contents.
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Intubation may be necessary for a patient with decreased oxygen content and oxygen saturation of the blood
caused when their breathing is inadequate (hypoventilation), suspended (apnea), or when the lungs are unable
to sufficiently transfer gasses to the blood. Such patients, who may be awake and alert, are typically critically ill
with a multisystem disease or multiple severe injuries. Examples of such conditions include cervical spine
injury, multiple rib fractures, severe pneumonia, acute respiratory distress syndrome (ARDS), or near-drowning.
Specifically, intubation is considered if the arterial partial pressure of oxygen (PaO2) is less than 60 millimeters
of mercury (mm Hg) while breathing an inspired O2 concentration (FIO2) of 50% or greater. In patients with
elevated arterial carbon dioxide, an arterial partial pressure of CO2 (PaCO2) greater than 45 mm Hg in the
setting of acidemia would prompt intubation, especially if a series of measurements demonstrate a worsening
respiratory acidosis. Regardless of the laboratory values, these guidelines are always interpreted in the clinical
context.
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Actual or impending airway obstruction is a common indication for intubation of the trachea. Life-threatening
airway obstruction may occur when a foreign body becomes lodged in the airway; this is especially common in
infants and toddlers. Severe blunt or penetrating injury to the face or neck may be accompanied by swelling and
an expanding hematoma, or injury to the larynx, trachea or bronchi. Airway obstruction is also common in
people who have suffered smoke inhalation or burns within or near the airway or epiglottitis. Sustained generalized
seizure activity and angioedema are other common causes of life-threatening airway obstruction which may
require tracheal intubation to secure the airway.
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Diagnostic or therapeutic manipulation of the airway (such as bronchoscopy, laser therapy or stenting of
the bronchi) may intermittently interfere with the ability to breathe; intubation may be necessary in such
situations.
Equipment
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Laryngoscopy is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain
a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal
intubation during general anaesthesia or cardiopulmonary resuscitation or for surgical procedures on the larynx
or other parts of the upper tracheobronchial tree.
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Direct laryngoscopy is carried out (usually) with the patient lying on his or her back; the laryngoscope is
inserted into the mouth on the right side and flipped to the left to trap and move the tongue out of the line of
sight, and, depending on the type of blade used, inserted either anterior or posterior to the epiglottis and then
lifted with an upwards and forward motion (“away from you and towards the roof “). This move makes a
view of the glottis possible. This procedure is done in an operation theatre with full preparation for resuscitative
measures to deal with respiratory distress. There are at least ten different types of laryngoscope used for this
procedure, each of which has a specialized use for the otolaryngologist and medical speech pathologist. This
procedure is most often employed by anaesthetists for endotracheal intubation under general anaesthesia,
but also in direct diagnostic laryngoscopy with biopsy. It is extremely uncomfortable and is not typically
performed on conscious patients, or on patients with an intact gag reflex.
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Indirect laryngoscopy is performed whenever the provider visualizes the patient’s vocal cords by a means
other than obtaining a direct line of sight (e.g. a mirror). For the purpose of intubation, this is facilitated by
fibreoptic bronchoscopes, video laryngoscopes, fibreoptic stylets and mirror or prism optically-enhanced
laryngoscopes.
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Some historians (for example, Morell Mackenzie) credit Benjamin Guy Babington (1794–1866), who
called his device the “glottiscope”, with the invention of the laryngoscope. Philipp von Bozzini (1773–1809)
and Garignard de la Tour were other early physicians to use mouth mirrors to inspect the oropharynx and
hypopharynx. In 1854, a Spanish vocal pedagogist named Manuel García (1805–1906) became the first man
to view the functioning glottis and larynx in a living human. García developed a tool that used two mirrors
for which the Sun served as an external light source. Using this device, he was able to observe the function
of his own glottic apparatus and the uppermost portion of his trachea. He presented his findings at the Royal
Society of London in 1855. All previous observations of the glottis and larynx had been performed under
indirect vision (using mirrors) until 23 April 1895, when Alfred Kirstein (1863–1922) of Germany first
described direct visualization of the vocal cords. Kirstein performed the first direct laryngoscopy in Berlin,
using an esophagoscope he had modified for this purpose; he called this device an autoscope. It is believed
that the death in 1888 of Emperor Frederick III motivated Kirstein to develop the autoscope. In 1913, Chevalier
Jackson was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate
the trachea. Jackson introduced a new laryngoscope blade that had a light source at the distal tip, rather than
the proximal light source used by Kirstein.
This new blade incorporated a component that the operator could slide out to allow room for passage of an
endoracheal tube or bronchoscope. That same year, Henry Harrington Janeway (1873–1921) published results
he had achieved using another new laryngoscope he had recently developed. An American anesthesiologist
practicing at Bellevue Hospital in New York City, Janeway believed that direct intratracheal insufflation of
volatile anesthetics would provide improved conditions for surgery of the nose, mouth and throat. With this
in mind, he developed a laryngoscope designed for the sole purpose of tracheal intubation. Similar to Jackson’s
device, Janeway’s instrument incorporated a distal light source. Unique however was the inclusion of batteries
within the handle, a central notch in the blade for maintaining the tracheal tube in the midline of the oropharynx
during intubation, and a slight curve to the distal tip of the blade to help guide the tube through the glottis.
The success of this design led to its subsequent use in other types of surgery. Janeway was thus instrumental
in popularizing the widespread use of direct laryngoscopy and tracheal intubation in the practice of
anesthesiology.
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• Helps in intubation during the administration of general anaesthesia or for mechanical ventilation.
• Detects causes of voice problems, such as breathing voice, hoarse voice, weak voice, or no voice.
• Detects causes of throat and ear pain.
• Evaluates difficulty in swallowing: a persistent sensation of lump in the throat, or mucous with
blood.
• Detects strictures or injury to the throat, or obstructive masses in the airway.
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The vast majority of tracheal intubations involve the use of a viewing instrument of one type or another.
Since its introduction by Kirstein in 1895, the conventional laryngoscope has been the most popular device
used for this purpose. Today, the conventional laryngoscope consists of a handle containing batteries with a
light source, and a set of interchangeable blades. Early laryngoscopes used a straight “Magill Blade”, and
this design is still the standard pattern veterinary laryngoscopes are based upon; however the blade is difficult
to control in adult humans and can cause pressure on the vagus nerve, which can cause unexpected cardiac
arrhythmias to spontaneously occur in adults. Two basic styles of laryngoscope blade are currently
commercially available: the curved blade and the straight blade. The Macintosh blade is the most widely
used of the curved laryngoscope blades, while the Miller blade is the most popular style of straight blade.
Both Miller and Macintosh laryngoscope blades are available in sizes 0 (neonatal) through 4 (large adult).
There are many other styles of curved and straight blades (e.g., Phillips, Robertshaw, Sykes, Wisconsin, Wis-
Hipple, etc.) with accessories such as mirrors for enlarging the field of view and even ports for the
administration of oxygen. These specialty blades are primarily designed for use by anesthetists, most commonly
in the operating room. Additionally, paramedics are trained to use direct laryngoscopy to assist with intubation
in the field. The Macintosh blade is positioned in the vallecula, anterior to the epiglottis, lifting it out of the
visual pathway, while the Miller blade is positioned posterior to the epiglottis, trapping it while exposing the
glottis and vocal folds. Incorrect usage can cause trauma to the front incisors; the correct technique is to
displace the chin upwards and forward at the same time, not to use the blade as a lever with the teeth serving
as the fulcrum.
Fig. Vie Scope Direct Line of Site Laryngoscope by Adroit Surgical.

The Miller, Wisconsin, Wis-Hipple, and Robertshaw blades are commonly used for infants. It is easier to
visualize the glottis using these blades than the Macintosh blade in infants, due to the larger size of the epiglottis
relative to that of the glottis.
Blade Named for Year introduced Comments

Cranwall George D. Cranton and Barry 1963 straight, no flange
L. Wall
Jackson Chevalier Jackson straight
Janeway Henry H. Janeway straight
Reduced Flange George D. Cranton 1999 curved reduced flange at heel
(RF Mac)
Macintosh Robert Reynolds Macintosh 1943 curved
Magill Ivan Magill 1921 straight
McCoy 1993 Lever-tip for anterior
displacement of the Epiglottic
vallecula and epiglottis in difficult
intubation.
Miller Robert A. Miller 1941 straight
Parrott C.M. Parrott 1951 curved
Phillips 1973 straight
Robertshaw straight
Seward straight
Siker 1956 curved, with integrated mirror
Soper R.I. Soper 1947 straight
Vie Scope N. Vasan 2016 Direct Line of Sight
Wis-Hipple straight
Wisconsin straight
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Besides the conventional laryngoscopes, many other devices have been developed as alternatives to direct
laryngoscopy. These include a number of indirect fibreoptic viewing laryngoscopes such as the flexible fibreoptic
bronchoscope. The flexible fibreoptic bronchoscope or rhinoscope can be used for office-based diagnostics or
for tracheal intubation.
The patient can remain conscious during the procedure, so that the vocal folds can be observed during
phonation. Surgical instruments passed through the scope can be used for performing procedures such as biopsies
of suspicious masses. These instruments have become indispensable within the otolaryngology, pulmonology
and anesthesia communities. Other available fibreoptic devices include the Bullard scope, UpsherScope, and
the WuScope. These devices are widely employed for tracheal intubation, especially in the setting of the difficult
intubation.
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The conventional direct laryngoscope uses a line of sight provided by a rigid viewing instrument with a light
on the blade or intra-oral portion which requires a direct view of the target larynx; this view is clearly seen in
80-90% of attempts. The frequent failure of direct laryngoscopy to provide an adequate view for tracheal
intubation led to the development of alternative devices such as the lighted stylet, and a number of indirect
fibreoptic viewing laryngoscopes, such as the fibrescope, Bullard scope, Upsher scope, and the WuScope.
Though these devices can be effective alternatives to direct laryngoscopy, they each have certain limitations,
and none of them is effective under all circumstances.
One important limitation commonly associated with these devices is fogging of the lens. In an attempt to
address some of these limitations, Dr. Jon Berall, a New York City internist and emergency medicine physician,
designed the camera screen straight video laryngoscope in 1998. The first true video laryngoscope Glidescope
was produced in 1999 and a production version with 60 degree angle, an onboard heater, and a custom screen
was first sold in dec 2000. The true video laryngoscope has a camera on the blade with no intervening fibreoptic
components. The concept is important because it is simpler to produce and handle the resultant images from
CMOS cameras. The integrated camera leads to a series of low cost variants that are not possible with the
hybrid Fibreoptic units.
Fig. Glidescope video laryngoscope, showing 60-degree angulated blade. The CMOS active pixel sensor
(CMOS APS) video camera and light source are located at the point of angulation of the blade.
An anesthesia machine is visible on the high resolution LCD monitor.
In 2001, the GlideScope (designed by vascular and general surgeon John Allen Pacey) became the first
commercially available video laryngoscope. It incorporates a high resolution digital camera, connected by a
video cable to a high resolution LCD monitor. It can be used for tracheal intubation to provide controlled
mechanical ventilation, as well as for removal of foreign bodies from the airway.
GlideScope owes its superior results to a combination of five key factors:
1. The steep 60-degree angulation of its blade improves the view of the glottis by reducing the
requirement for anterior displacement of the tongue.
2. The CMOS APS digital camera is located at the point of angulation of the blade (rather than at the
tip). This placement allows the operator to more effectively view the field in front of the camera.
3. The video camera is recessed for protection from blood and secretions which might otherwise obstruct
the view.
4. The video camera has a relatively wide viewing angle of 50 degrees.
5. The heated lens innovation helps to prevent fogging of the lens, which might otherwise obscure the
view.
Tracheal intubation with the GlideScope can be facilitated by the use of the Verathon Stylet, a rigid stylet
that is curved to follow the 60° angulation of the blade. To achieve a 99% successful rate of intubation with the
GlideScope requires the operator to acquire a new skill set with this stylet. In a 2003 study, the authors noted
that the GlideScope provided adequate vision of the glottis (Cormack and Lehane grade I-II) even when the
oral, pharyngeal and laryngeal axes could not be optimally aligned due to the presence of a cervical collar.
Despite this significant limitation, the average time to intubate the trachea with the GlideScope was only 38
seconds. In 2005, the first major clinical study comparing the Glidescope to the conventional laryngoscope was
published. In 133 patients in whom both Glidescope and conventional laryngoscopy were performed, excellent
or good laryngeal exposure was obtained in 124/133 (93%) of Glidescope laryngoscopy patients, compared
with only 98/133 (74%) of patients in whom conventional laryngoscopy was used. Intubation was successful in
128/133 (96%) of Glidescope laryngoscopy patients. These early results suggest that this device may be a
useful alternative in the management of difficult tracheal intubation.
The Verathon design team later produced the Ranger Video Laryngoscope for a United States Air Force
requirement that is now rolling forward into EMS and military use. The Cobalt series of GlideScope then
introduced a single-use variant that encompasses weights from 1000 grams to morbid obesity and is
successful in many airway syndromes as well. The GlideScope Ranger is a variant designed for use in pre-
hospital airway management including air, land, and sea applications. This device weighs 1.5 pounds, and
is waterproof as well as airworthy to 20,000 feet altitude. The GlideScope Cobalt is a variant that has a
reusable video camera with light-emitting core which has a disposable or single use external shell for
prevention of cross infection. In August 2009, the team at Verathon collaborated with Professor John
Sakles from the University of Arizona Emergency Department in achieving the world’s first tracheal
intubation conducted with the assistance of telemedicine technology. During this demonstration, Dr. Sakles
and the University of Arizona Telemedicine service guided physicians in a rural hospital as they performed
a tracheal intubation using the GlideScope. Several types of video laryngoscopes are also currently available,
such as the Truview PCD-R Manufactured by Truphatek Israel, Glidescope, McGrath laryngoscope, Daiken
Medical Coopdech C-scope VLP-100, the Storz C-Mac, Pentax-AWS(or Airway Scope), Video Macintosh
Intubating Laryngoscope System (VMS), the Berci DCI, and the Copilot VL. These laryngoscopes employ
a variety of features such as a monitor on the handle and or channels to assist in guiding the endotracheal
tube into the trachea. The superior performance of video laryngoscopes in airway management where
cervical spine injury is possible has raised the question of whether these scopes should supersede direct
laryngoscopy in routine airway management.
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Other “non-invasive” devices which can be employed to assist in tracheal intubation are the laryngeal mask
airway (Some types of which may be used as a conduit for endotracheal tube placement), the lighted stylet, and
the AirTraq. Due to the widespread availability of such devices, the technique of blind digital intubation of the
trachea is rarely practiced today, though it may still be useful in emergency situations under austere conditions
such as natural or man-made disasters.
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Cases of mild or severe injury caused by rough and inexperienced use of laryngoscopes have been reported.
These include minor damage to the soft tissues within the throat which causes a sore throat after the operation
to major injuries to the larynx and pharynx causing permanent scarring, ulceration and abscesses if left untreated.
Additionally, there is a risk of causing tooth damage.
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An intubating stylet is a malleable metal wire designed to be inserted into the endotracheal tube to make the
tube conform better to the upper airway anatomy of the specific individual. This aid is commonly used with a
difficult laryngoscopy. Just as with laryngoscope blades, there are also several types of available stylets, such
as the Verathon Stylet, which is specifically designed to follow the 60° blade angle of the GlideScope video
laryngoscope. The Eschmann tracheal tube introducer (often incorrectly referred to as a “gum elastic bougie”)
is specialized type of stylet used to facilitate difficult intubation. This flexible device is 60 cm (24 in) in length,
15 French (5 mm diameter) with a small “hockey-stick” angle at the far end. Unlike a traditional intubating
stylet, the Eschmann tracheal tube introducer is typically inserted directly into the trachea and then used as a
guide over which the endotracheal tube can be passed (in a manner analogous to the Seldinger technique). As
the Eschmann tracheal tube introducer is considerably less rigid than a conventional stylet, this technique is
considered to be a relatively atraumatic means of tracheal intubation.
The tracheal tube exchanger is a hollow catheter, 56 to 81 cm (22.0 to 31.9 in) in length, that can be used for
removal and replacement of tracheal tubes without the need for laryngoscopy. The Cook Airway Exchange
Catheter (CAEC) is another example of this type of catheter; this device has a central lumen (hollow channel)
through which oxygen can be administered. The lighted stylet is a device that employs the principle of
transillumination to facilitate blind orotracheal intubation (an intubation technique in which the laryngoscopist
does not view the glottis).
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A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and
maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.
Many different types of tracheal tubes are available, suited for different specific applications:
• An endotracheal tube is a specific type of tracheal tube that is nearly always inserted through the
mouth (orotracheal) or nose (nasotracheal).
• A tracheostomy tube is another type of tracheal tube; this 2–3-inch-long (51–76 mm) curved metal
or plastic tube may be inserted into a tracheostomy stoma (following a tracheotomy) to maintain a
patent lumen.
• A tracheal button is a rigid plastic cannula about 1 inch in length that can be placed into the
tracheostomy after removal of a tracheostomy tube to maintain patency of the lumen.
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Portex Medical (England and France) produced the first cuff-less plastic ‘Ivory’ endotracheal tubes, in
conjunction with Magill’s design later adding a cuff as manufacturing techniques became more viable, these
were glued on by hand to make the famous Blue-line tube copied by many other manufacturers. Maeterlinck
GmBH developed the disposable endotracheal tube and produced a plethora of design variations, adding the
‘Murphy Eye’ to their tubes in case of ‘accidental’ placement of the tube to avoid right bronchial occlusion.
David S. Sheridan was one of the manufacturers of the American markets “disposable” plastic tracheal
tube now used routinely in surgery. Previously, red rubber (Rusch-Germany) tubes were used, then sterilized
for re-use.
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Tracheal tubes can also be used to deliver oxygen in higher concentrations than found in air, or to administer
other gases such as helium, nitric oxide, nitrous oxide, xenon, or certain volatile anesthetic agents such as
desflurane, isoflurane, or sevoflurane. Tracheal tubes may also be used as a route for administration of certain
medications such as salbutamol, atropine, epinephrine, ipratropium, and lidocaine. Tracheal tubes are commonly
used for airway management in the settings of general anesthesia, critical care, mechanical ventilation, and
emergency medicine.
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Most endotracheal tubes today are constructed of polyvinyl chloride, but specialty tubes constructed of
silicone rubber, latex rubber, or stainless steel are also widely available. Most tubes have an inflatable cuff to
seal the trachea and bronchial tree against air leakage and aspiration of gastric contents, blood, secretions, and
other fluids. Uncuffed tubes are also available, though their use is limited mostly to pediatric patients (in small
children, the cricoid cartilage, the narrowest portion of the pediatric airway, often provides an adequate seal for
mechanical ventilation).
Fig. A typical cuffed endotracheal tube, constructed of polyvinyl chloride.

Types of endotracheal tube include oral or nasal, cuffed or uncuffed, preformed (e.g. RAE (Ring, Adair, and
Elwyn) tube), reinforced tubes, and double-lumen endobronchial tubes. For human use, tubes range in size
from 2 to 10.5 mm in internal diameter (ID). The size is chosen based on the patient’s body size, with the
smaller sizes being used for pediatric and neonatal patients. Tubes larger than 6 mm ID usually have an inflatable
cuff. Originally made from red rubber, most modern tubes are made from polyvinyl chloride. Those placed in a
laser field may be flexometallic. Robertshaw (and others) developed double-lumen endo-bronchial tubes for
thoracic surgery. These allow single-lung ventilation while the other lung is collapsed to make surgery easier.
The deflated lung is re-inflated as surgery finishes to check for fistulas (tears). Another type of endotracheal
tube has a small second lumen opening above the inflatable cuff, which can be used for suction of the
nasopharngeal area and above the cuff to aid extubation (removal). This allows suctioning of secretions which
sit above the cuff which helps reduce the risk of chest infections in long-term intubated patients.
Fig. A Carlens double-lumen endotracheal tube, commonly

used for thoracic surgical operations such as VATS lobectomy.
The “armored” endotracheal tubes are cuffed, wire-reinforced, silicone rubber tubes which are quite flexible
but yet difficult to compress or kink. This can make them useful for situations in which the trachea is anticipated
to remain intubated for a prolonged duration, or if the neck is to remain flexed during surgery. Polyvinyl
chloride tubes are relatively stiff in comparison. Preformed tubes (such as the oral and nasal RAE tubes, named
after the inventors Ring, Adair and Elwyn) are also widely available for special applications. These may also be
constructed of polyvinyl chloride or wire-reinforced silicone rubber. Other tubes (such as the Bivona Fome-Cuf
tube) are designed specifically for use in laser surgery in and around the airway. Various types of double-lumen
endotracheal (actually, endobronchial) tubes have been developed (Carlens, White, Robertshaw, etc.) for
ventilating each lung independently—this is useful during pulmonary and other thoracic operations.
Age Weight (Inner) diameter
(mm)
Preterm 3 kg 2.5–3.0
0–6 months 3.5 kg 3.0–3.5
6–12 months 7 kg 3.5–4.0
1–3 years 10–12 kg 4.0–4.5
4–7 years 16–18 kg 5.0–5.5
8–10 years 24–30 kg 5.5–6.5
Adult female 7.0-7.5
Adult male 8.0-9.0
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Several types of tracheostomy tubes are available, depending on the requirements of the patient, including
Shiley, Bivona (a silicon tube with metal rings that are good for airways with damage to the tracheal rings or
otherwise not straight), and fenestrated.
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A tracheal button is generally used in people with severe obstructive sleep apnea, who often wear this device
during waking hours and remove it while sleeping to ensure a patent airway and reduce the risk of asphyxiation.
Since the tube does not extend far into the trachea, it is easy to breathe and speak with the device in place.
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No single method for confirming tracheal tube placement has been shown to be 100% reliable. Accordingly, the
use of multiple methods for confirmation of correct tube placement is now widely considered to be the standard of
care. Such methods include direct visualization as the tip of the tube passes through the glottis, or indirect visualization
of the tracheal tube within the trachea using a device such as a bronchoscope. With a properly positioned tracheal
tube, equal bilateral breath sounds will be heard upon listening to the chest with a stethoscope, and no sound upon
listening to the area over the stomach. Equal bilateral rise and fall of the chest wall will be evident with ventilatory
excursions. A small amount of water vapor will also be evident within the lumen of the tube with each exhalation and
there will be no gastric contents in the tracheal tube at any time. Ideally, at least one of the methods utilized for
confirming tracheal tube placement will be a measuring instrument. Waveform capnography has emerged as the gold
standard for the confirmation of tube placement within the trachea. Other methods relying on instruments include the
use of a colorimetric end-tidal carbon dioxide detector, a self-inflating esophageal bulb, or an esophageal detection
device. The distal tip of a properly positioned tracheal tube will be located in the mid-trachea, roughly 2 cm (1 in)
above the bifurcation of the carina; this can be confirmed by chest x-ray. If it is inserted too far into the trachea
(beyond the carina), the tip of the tracheal tube is likely to be within the right main bronchus — a situation often
referred to as a “right mainstem intubation”. In this situation, the left lung may be unable to participate in ventilation,
which can lead to decreased oxygen content due to ventilation/perfusion mismatch.
Special Situations
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Tracheal intubation in the emergency setting can be difficult with the fibreoptic bronchoscope due to blood,
vomit, or secretions in the airway and poor patient cooperation. Because of this, patients with massive facial
injury, complete upper airway obstruction, severely diminished ventilation, or profuse upper airway bleeding
are poor candidates for fibreoptic intubation. Fibreoptic intubation under general anesthesia typically requires
two skilled individuals. Success rates of only 83–87% have been reported using fibreoptic techniques in the
emergency department, with significant nasal bleeding occurring in up to 22% of patients. These drawbacks
limit the use of fibreoptic bronchoscopy somewhat in urgent and emergency situations. Personnel experienced
in direct laryngoscopy are not always immediately available in certain settings that require emergency tracheal
intubation. For this reason, specialized devices have been designed to act as bridges to a definitive airway. Such
devices include the laryngeal mask airway, cuffed oropharyngeal airway and the esophageal-tracheal combitube
(Combitube). Other devices such as rigid stylets, the lightwand (a blind technique) and indirect fibreoptic rigid
stylets, such as the Bullard scope, Upsher scope and the WuScope can also be used as alternatives to direct
laryngoscopy. Each of these devices have its own unique set of benefits and drawbacks, and none of them is
effective under all circumstances.
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Rapid sequence induction and intubation (RSI) is a particular method of induction of general anesthesia,
commonly employed in emergency operations and other situations where patients are assumed to have a “full
stomach”. The objective of RSI is to minimize the possibility of regurgitation and pulmonary aspiration of
gastric contents during the induction of general anesthesia and subsequent tracheal intubation. RSI traditionally
involves preoxygenating the lungs with a tightly fitting oxygen mask, followed by the sequential administration
of an intravenous sleep-inducing agent and a rapidly acting neuromuscular-blocking drug, such as rocuronium,
succinylcholine, or cisatracurium besilate, before intubation of the trachea. One important difference between
RSI and routine tracheal intubation is that the practitioner does not manually assist the ventilation of the lungs
after the onset of general anesthesia and cessation of breathing, until the trachea has been intubated and the cuff
has been inflated. Another key feature of RSI is the application of manual ‘cricoid pressure’ to the cricoid
cartilage, often referred to as the “Sellick maneuver”, prior to instrumentation of the airway and intubation of
the trachea.
Since the introduction of RSI, there has been controversy regarding virtually every aspect of this technique,
including:
• Choice of induction drug, dose and method of administration.
• Avoidance of manual ventilation before tracheal intubation.
• Optimal position and whether the head-up, head-down, or horizontal supine position is the safest for
induction of anesthesia in full-stomach patients.
• Application of cricoid pressure (the Sellick maneuver).
Named for British anesthetist Brian Arthur Sellick (1918–1996) who first described the procedure in 1961,
the goal of cricoid pressure is to minimize the possibility of regurgitation and pulmonary aspiration of gastric
contents. Cricoid pressure has been widely used during RSI for nearly fifty years, despite a lack of compelling
evidence to support this practice. The initial article by Sellick was based on a small sample size at a time when
high tidal volumes, head-down positioning and barbiturate anesthesia were the rule. Beginning around 2000, a
significant body of evidence has accumulated which questions the effectiveness of cricoid pressure. The
application of cricoid pressure may in fact displace the esophagus laterally instead of compressing it as described
by Sellick. Cricoid pressure may also compress the glottis, which can obstruct the view of the laryngoscopist
and actually cause a delay in securing the airway. Cricoid pressure is often confused with the “BURP” (Backwards
Upwards Rightwards Pressure) maneuver. While both of these involve digital pressure to the anterior aspect
(front) of the laryngeal apparatus, the purpose of the latter is to improve the view of the glottis during laryngoscopy
and tracheal intubation, rather than to prevent regurgitation. Both cricoid pressure and the BURP maneuver
have the potential to worsen laryngoscopy. RSI may also be used in prehospital emergency situations when a
patient is conscious but respiratory failure is imminent (such as in extreme trauma). This procedure is commonly
performed by flight paramedics. Flight paramedics often use RSI to intubate before transport because intubation
in a moving fixed-wing or rotary-wing aircraft is extremely difficult to perform due to environmental factors.
The patient will be paralyzed and intubated on the ground before transport by aircraft.
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A cricothyrotomy (also called cric, thyrocricotomy, cricothyroidotomy, inferior laryngotomy,
intercricothyrotomy, coniotomy or emergency airway puncture) is an incision made through the skin and
cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway
obstruction by a foreign body, angioedema, or massive facial trauma. Cricothyrotomy is nearly always
performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or
contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require
manipulation of the cervical spine, and is associated with fewer complications. However, while cricothyrotomy
may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure
until a definitive airway can be established. A cricothyrotomy is often used as an airway of last resort given
the numerous other airway options available including standard tracheal intubation and rapid sequence
induction which are the common means of establishing an airway in an emergency scenario. Cricothyrotomies
account for approximately 1% of all emergency department intubations, and is used mostly in persons who
have experienced a traumatic injury.
Some general indications for this procedure include:
• Inability to intubate
• Inability to ventilate
• Inability to maintain spo2 >90%
• Severe traumatic injury that prevents oral or nasal tracheal intubation.
Contraindications:
• Inability to identify landmarks (cricothyroid membrane)
• Underlying anatomical abnormality such as a tumor or severe goiter
• Tracheal transection
• Acute laryngeal disease due to infection or trauma
• Small children under 12 years old (a 10–14 gauge catheter over the needle may be used).
The procedure was first described in 1805 by Félix Vicq-d’Azyr, a French surgeon and anatomist. A
cricothyrotomy is generally performed by making a vertical incision on the skin of the neck just below the
laryngeal prominence (Adam’s apple), then making another transverse incision in the cricothyroid membrane
which lies deep to this point. A tracheostomy tube or endotracheal tube with a 6 or 7 mm internal diameter is
then inserted, the cuff is inflated, and the tube is secured. The person performing the procedure might utilize a
bougie device, a semi-rigid, straight piece of plastic with a one-inch tip at a 30 degree angle, to provide rigidity
to the tube and assist with guiding its placement. Confirmation of placement is assessed by bilateral ausculation
of the lungs and observation of the rise and fall of the chest.
Needle cricothyrotomy:
• A needle cricothyrotomy is similar, but instead of making a scalpel incision, a large over-the-needle
catheter is inserted (10- to 14-gauge). This is considerably simpler, particularly if using specially
designed kits. This technique provides very limited airflow. The delivery of oxygen to the lungs
through an over-the-needle catheter inserted through the skin into the trachea using a high pressure
gas source is considered a form of conventional ventilation called percutaneous transtracheal ventilation
(PTV).
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Tracheotomy consists of making an incision on the front of the neck and opening a direct airway through an
incision in the trachea. The resulting opening can serve independently as an airway or as a site for a tracheostomy
tube to be inserted; this tube allows a person to breathe without the use of his nose or mouth. The opening may
be made by a scalpel or a needle (referred to as surgical and percutaneous techniques respectively) and both
techniques are widely used in current practice.
Fig. Diagram of a tracheostomy tube in the trachea.

In order to limit the risk of damage to the recurrent laryngeal nerves (the nerves that control the voicebox),
the tracheotomy is performed as high in the trachea as possible. If only one of these nerves is damaged, the
patient’s voice may be impaired (dysphonia); if both of the nerves are damaged, the patient will be unable to
speak (aphonia). In the acute setting, indications for tracheotomy are similar to those for cricothyrotomy. In the
chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and removal
of tracheal secretions (e.g., comatose patients, or extensive surgery involving the head and neck).
/03+9,5
There are significant differences in airway anatomy and respiratory physiology between children and adults,
and these are taken into careful consideration before performing tracheal intubation of any pediatric patient.
The differences, which are quite significant in infants, gradually disappear as the human body approaches a
mature age and body mass index.
Fig. A premature infant weighing 990 grams (35 ounces), intubated

and requiring mechanical ventilation in the neonatal intensive-care unit.
For infants and young children, orotracheal intubation is easier than the nasotracheal route. Nasotracheal
intubation carries a risk of dislodgement of adenoids and nasal bleeding. Despite the greater difficulty, nasotracheal
intubation route is preferable to orotracheal intubation in children undergoing intensive care and requiring
prolonged intubation because this route allows a more secure fixation of the tube. As with adults, there are a
number of devices specially designed for assistance with difficult tracheal intubation in children. Confirmation
of proper position of the tracheal tube is accomplished as with adult patients. Because the airway of a child is
narrow, a small amount of glottic or tracheal swelling can produce critical obstruction. Inserting a tube that is
too large relative to the diameter of the trachea can cause swelling. Conversely, inserting a tube that is too small
can result in inability to achieve effective positive pressure ventilation due to retrograde escape of gas through
the glottis and out the mouth and nose (often referred to as a “leak” around the tube). An excessive leak can
usually be corrected by inserting a larger tube or a cuffed tube. The tip of a correctly positioned tracheal tube
will be in the mid-trachea, between the collarbones on an anteroposterior chest radiograph. The correct diameter
of the tube is that which results in a small leak at a pressure of about 25 cm (10 in) of water. The appropriate
inner diameter for the endotracheal tube is estimated to be roughly the same diameter as the child’s little finger.
The appropriate length for the endotracheal tube can be estimated by doubling the distance from the corner of
the child’s mouth to the ear canal. For premature infants 2.5 mm (0.1 in) internal diameter is an appropriate size
for the tracheal tube. For infants of normal gestational age, 3 mm (0.12 in) internal diameter is an appropriate
size. For normally nourished children 1 year of age and older, two formulae are used to estimate the appropriate
diameter and depth for tracheal intubation. The internal diameter of the tube in mm is (patient’s age in years +
16)/ 4, while the appropriate depth of insertion cm is 12 + (patient’s age in years/ 2).
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In newborns free flow oxygen used to be recommended during intubation however as there is no evidence of
benefit the 2011 NRP guidelines no longer do.
Predicting Difficulty
Tracheal intubation is not a simple procedure and the consequences of failure are grave. Therefore, the
patient is carefully evaluated for potential difficulty or complications beforehand. This involves taking the
medical history of the patient and performing a physical examination, the results of which can be scored against
one of several classification systems. The proposed surgical procedure (e.g., surgery involving the head and
neck, or bariatric surgery) may lead one to anticipate difficulties with intubation. Many individuals have unusual
airway anatomy, such as those who have limited movement of their neck or jaw, or those who have tumors, deep
swelling due to injury or to allergy, developmental abnormalities of the jaw, or excess fatty tissue of the face
and neck. Using conventional laryngoscopic techniques, intubation of the trachea can be difficult or even
impossible in such patients. This is why all persons performing tracheal intubation must be familiar with
alternative techniques of securing the airway. Use of the flexible fibreoptic bronchoscope and similar devices
has become among the preferred techniques in the management of such cases. However, these devices require
a different skill set than that employed for conventional laryngoscopy and are expensive to purchase, maintain
and repair. When taking the patient’s medical history, the subject is questioned about any significant signs or
symptoms, such as difficulty in speaking or difficulty in breathing. These may suggest obstructing lesions in
various locations within the upper airway, larynx, or tracheobronchial tree. A history of previous surgery (e.g.,
previous cervical fusion), injury, radiation therapy, or tumors involving the head, neck and upper chest can also
provide clues to a potentially difficult intubation. Previous experiences with tracheal intubation, especially
difficult intubation, intubation for prolonged duration (e.g., intensive care unit) or prior tracheotomy are also
noted.
A detailed physical examination of the airway is important, particularly:
• The range of motion of the cervical spine: the subject should be able to tilt the head back and then
forward so that the chin touches the chest.
• The range of motion of the jaw (the temporomandibular joint): three of the subject’s fingers should
be able to fit between the upper and lower incisors.
• The size and shape of the upper jaw and lower jaw, looking especially for problems such as maxillary
hypoplasia (an underdeveloped upper jaw), micrognathia (an abnormally small jaw), or retrognathia
(misalignment of the upper and lower jaw).
• The thyromental distance: three of the subject’s fingers should be able to fit between the Adam’s
apple and the chin.
• The size and shape of the tongue and palate relative to the size of the mouth.
• The teeth, especially noting the presence of prominent maxillary incisors, any loose or damaged
teeth, or crowns.
Many classification systems have been developed in an effort to predict difficulty of tracheal intubation,
including the Cormack-Lehane classification system, the Intubation Difficulty Scale (IDS), and the Mallampati
score. The Mallampati score is drawn from the observation that the size of the base of the tongue influences the
difficulty of intubation. It is determined by looking at the anatomy of the mouth, and in particular the visibility
of the base of palatine uvula, faucial pillars and the soft palate. Although such medical scoring systems may aid
in the evaluation of patients, no single score or combination of scores can be trusted to specifically detect all
and only those patients who are difficult to intubate. Furthermore, one study of experienced anesthesiologists,
on the widely used Cormack–Lehane classification system, found they did not score the same patients consistently
over time, and that only 25% could correctly define all four grades of the widely used Cormack–Lehane
classification system. Under certain emergency circumstances (e.g., severe head trauma or suspected cervical
spine injury), it may be impossible to fully utilize these the physical examination and the various classification
systems to predict the difficulty of tracheal intubation. In such cases, alternative techniques of securing the
airway must be readily available.
Complications
Tracheal intubation is generally considered the best method for airway management under a wide variety of
circumstances, as it provides the most reliable means of oxygenation and ventilation and the greatest degree of
protection against regurgitation and pulmonary aspiration. However, tracheal intubation requires a great deal of
clinical experience to master and serious complications may result even when properly performed. Four anatomic
features must be present for orotracheal intubation to be straightforward: adequate mouth opening (full range of
motion of the temporomandibular joint), sufficient pharyngeal space (determined by examining the back of the
mouth), sufficient submandibular space (distance between the thyroid cartilage and the chin, the space into
which the tongue must be displaced in order for the larygoscopist to view the glottis), and adequate extension of
the cervical spine at the atlanto-occipital joint. If any of these variables is in any way compromised, intubation
should be expected to be difficult. Minor complications are common after laryngoscopy and insertion of an
orotracheal tube. These are typically of short duration, such as sore throat, lacerations of the lips or gums or
other structures within the upper airway, chipped, fractured or dislodged teeth, and nasal injury. Other
complications which are common but potentially more serious include accelerated or irregular heartbeat, high
blood pressure, elevated intracranial and introcular pressure, and bronchospasm. More serious complications
include laryngospasm, perforation of the trachea or esophagus, pulmonary aspiration of gastric contents or
other foreign bodies, fracture or dislocation of the cervical spine, temporomandibular joint or arytenoid cartilages,
decreased oxygen content, elevated arterial carbon dioxide, and vocal cord weakness. In addition to these
complications, tracheal intubation via the nasal route carries a risk of dislodgement of adenoids and potentially
severe nasal bleeding. Newer technologies such as flexible fibreoptic laryngoscopy have fared better in reducing
the incidence of some of these complications, though the most frequent cause of intubation trauma remains a
lack of skill on the part of the laryngoscopist.
Complications may also be severe and long-lasting or permanent, such as vocal cord damage, esophageal
perforation and retropharyngeal abscess, bronchial intubation, or nerve injury. They may even be immediately
life-threatening, such as laryngospasm and negative pressure pulmonary edema (fluid in the lungs), aspiration,
unrecognized esophageal intubation, or accidental disconnection or dislodgement of the tracheal tube. Potentially
fatal complications more often associated with prolonged intubation and/or tracheotomy include abnormal
communication between the trachea and nearby structures such as the innominate artery (tracheoinnominate
fistula) or esophagus (tracheoesophageal fistula). Other significant complications include airway obstruction
due to loss of tracheal rigidity, ventilator-associated pneumonia and narrowing of the glottis or trachea. The
cuff pressure is monitored carefully in order to avoid complications from over-inflation, many of which can be
traced to excessive cuff pressure restricting the blood supply to the tracheal mucosa. A 2000 Spanish study of
bedside percutaneous tracheotomy reported overall complication rates of 10–15% and procedural mortality of
0%, which is comparable to those of other series reported in the literature from the Netherlands and the United
States. Inability to secure the airway, with subsequent failure of oxygenation and ventilation is a life-threatening
complication which if not immediately corrected leads to decreased oxygen content, brain damage, cardiovascular
collapse, and death. When performed improperly, the associated complications (e.g., unrecognized esophageal
intubation) may be rapidly fatal. Without adequate training and experience, the incidence of such complications
is high. The case of Andrew Davis Hughes, from Emerald Isle, NC is a widely known case in which the patient
was improperly intubated and, due to the lack of oxygen, suffered severe brain damage and died. For example,
among paramedics in several United States urban communities, unrecognized esophageal or hypopharyngeal
intubation has been reported to be 6% to 25%. Although not common, where basic emergency medical technicians
are permitted to intubate, reported success rates are as low as 51%. In one study, nearly half of patients with
misplaced tracheal tubes died in the emergency room. Because of this, recent editions of the American Heart
Association’s Guidelines for Cardiopulmonary Resuscitation have de-emphasized the role of tracheal intubation
in favour of other airway management techniques such as bag-valve-mask ventilation, the laryngeal mask airway
and the Combitube. One complication—unintentional and unrecognized intubation of the esophagus—is both
common (as frequent as 25% in the hands of inexperienced personnel) and likely to result in a deleterious or
even fatal outcome. In such cases, oxygen is inadvertently administered to the stomach, from where it cannot be
taken up by the circulatory system, instead of the lungs. If this situation is not immediately identified and
corrected, death will ensue from cerebral and cardiac anoxia. Of 4,460 claims in the American Society of
Anesthesiologists (ASA) Closed Claims Project database, 266 (approximately 6%) were for airway injury. Of
these 266 cases, 87% of the injuries were temporary, 5% were permanent or disabling, and 8% resulted in
death. Difficult intubation, age older than 60 years, and female gender were associated with claims for perforation
of the esophagus or pharynx. Early signs of perforation were present in only 51% of perforation claims, whereas
late sequelae occurred in 65%.
Alternatives
Although it offers the greatest degree of protection against regurgitation and pulmonary aspiration, tracheal
intubation is not the only means to maintain a patent airway. Alternative techniques for airway management and
delivery of oxygen, volatile anesthetics or other breathing gases include the laryngeal mask airway, i-gel, cuffed
oropharyngeal airway, continuous positive airway pressure (CPAP mask), nasal BiPAP mask, simple face mask,
and nasal cannula. General anesthesia is often administered without tracheal intubation in selected cases where
the procedure is brief in duration, or procedures where the depth of anesthesia is not sufficient to cause significant
compromise in ventilatory function. Even for longer duration or more invasive procedures, a general anesthetic
may be administered without intubating the trachea, provided that patients are carefully selected, and the risk-
benefit ratio is favourable (i.e., the risks associated with an unprotected airway are believed to be less than the
risks of intubating the trachea). Airway management can be classified into closed or open techniques depending
on the system of ventilation used. Tracheal intubation is a typical example of a closed technique as ventilation
occurs using a closed circuit. Several open techniques exist, such as spontaneous ventilation, apnoeic ventilation
or jet ventilation. Each has its own specific advantages and disadvantages which determine when it should be
used. Spontaneous ventilation has been traditionally performed with an inhalational agent (i.e. gas induction or
inhalational induction using halothane or sevoflurane) however it can also be performed using intravenous
anaesthesia (e.g. propofol, ketamine or dexmedetomidine). SponTaneous Respiration using IntraVEnous
anaesthesia and High-flow nasal oxygen (STRIVE Hi) is an open airway technique that uses an upwards titration
of propofol which maintains ventilation at deep levels of anaesthesia. It has been used in airway surgery as an
alternative to tracheal intubation.
History
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The earliest known depiction of a tracheotomy is found on two Egyptian tablets dating back to around 3600
BC. The 110-page Ebers Papyrus, an Egyptian medical papyrus which dates to roughly 1550 BC, also makes
reference to the tracheotomy. Tracheotomy was described in the Rigveda, a Sanskrit text of ayurvedic medicine
written around 2000 BC in ancient India. The Sushruta Samhita from around 400 BC is another text from the
Indian subcontinent on ayurvedic medicine and surgery that mentions tracheotomy. Asclepiades of Bithynia (c.
124–40 BC) is often credited as being the first physician to perform a non-emergency tracheotomy. Galen of
Pergamon (AD 129–199) clarified the anatomy of the trachea and was the first to demonstrate that the larynx
generates the voice. In one of his experiments, Galen used bellows to inflate the lungs of a dead animal. Ibn
Sînâ (980–1037) described the use of tracheal intubation to facilitate breathing in 1025 in his 14-volume medical
encyclopaedia, The Canon of Medicine. In the 12th century medical textbook Al-Taisir, Ibn Zuhr (1092–1162)—
also known as Avenzoar—of Al-Andalus provided a correct description of the tracheotomy operation. The first
detailed descriptions of tracheal intubation and subsequent artificial respiration of animals were from Andreas
Vesalius (1514–1564) of Brussels. In his landmark book published in 1543, De humani corporis fabrica, he
described an experiment in which he passed a reed into the trachea of a dying animal whose thorax had been
opened and maintained ventilation by blowing into the reed intermittently. Antonio Musa Brassavola (1490–
1554) of Ferrara successfully treated a patient suffering from peritonsillar abscess by tracheotomy. Brassavola
published his account in 1546; this operation has been identified as the first recorded successful tracheotomy,
despite the many previous references to this operation. Towards the end of the 16th century, Hieronymus Fabricius
(1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually
performed the operation himself. In 1620 the French surgeon Nicholas Habicot (1550–1624) published a report
of four successful tracheotomies. In 1714, anatomist Georg Detharding (1671–1747) of the University of Rostock
performed a tracheotomy on a drowning victim.
Despite the many recorded instances of its use since antiquity, it was not until the early 19th century that the
tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction. In
1852, French physician Armand Trousseau (1801–1867) presented a series of 169 tracheotomies to the Académie
Impériale de Médecine. 158 of these were performed for the treatment of croup, and 11 were performed for
“chronic maladies of the larynx”. Between 1830 and 1855, more than 350 tracheotomies were performed in
Paris, most of them at the Hôpital des Enfants Malades, a public hospital, with an overall survival rate of only
20–25%. This compares with 58% of the 24 patients in Trousseau’s private practice, who fared better due to
greater postoperative care. In 1871, the German surgeon Friedrich Trendelenburg (1844–1924) published a
paper describing the first successful elective human tracheotomy to be performed for the purpose of administration
of general anesthesia. In 1888, Sir Morell Mackenzie (1837–1892) published a book discussing the indications
for tracheotomy. In the early 20th century, tracheotomy became a life-saving treatment for patients afflicted
with paralytic poliomyelitis who required mechanical ventilation. In 1909, Philadelphia laryngologist Chevalier
Jackson (1865–1958) described a technique for tracheotomy that is used to this day.
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In 1854, a Spanish singing teacher named Manuel García (1805–1906) became the first man to view the
functioning glottis in a living human. In 1858, French pediatrician Eugène Bouchut (1818–1891) developed a
new technique for non-surgical orotracheal intubation to bypass laryngeal obstruction resulting from a diphtheria-
related pseudomembrane. In 1880, Scottish surgeon William Macewen (1848–1924) reported on his use of
orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well
as in the setting of general anesthesia with chloroform. In 1895, Alfred Kirstein (1863–1922) of Berlin first
described direct visualization of the vocal cords, using an esophagoscope he had modified for this purpose; he
called this device an autoscope. In 1913, Chevalier Jackson was the first to report a high rate of success for the
use of direct laryngoscopy as a means to intubate the trachea. Jackson introduced a new laryngoscope blade that
incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or
bronchoscope. Also in 1913, New York surgeon Henry H. Janeway (1873–1921) published results he had
achieved using a laryngoscope he had recently developed. Another pioneer in this field was Sir Ivan Whiteside
Magill (1888–1986), who developed the technique of awake blind nasotracheal intubation, the Magill forceps,
the Magill laryngoscope blade, and several apparati for the administration of volatile anesthetic agents. The
Magill curve of an endotracheal tube is also named for Magill. Sir Robert Reynolds Macintosh (1897–1989)
introduced a curved laryngoscope blade in 1943; the Macintosh blade remains to this day the most widely used
laryngoscope blade for orotracheal intubation. Between 1945 and 1952, optical engineers built upon the earlier
work of Rudolph Schindler (1888–1968), developing the first gastrocamera. In 1964, optical fibre technology
was applied to one of these early gastrocameras to produce the first flexible fibreoptic endoscope. Initially used
in upper GI endoscopy, this device was first used for laryngoscopy and tracheal intubation by Peter Murphy, an
English anesthetist, in 1967. The concept of using a stylet for replacing or exchanging orotracheal tubes was
introduced by Finucane and Kupshik in 1978, using a central venous catheter. By the mid-1980s, the flexible
fibreoptic bronchoscope had become an indispensable instrument within the pulmonology and anesthesia
communities. The digital revolution of the 21st century has brought newer technology to the art and science of
tracheal intubation. Several manufacturers have developed video laryngoscopes which employ digital technology
such as the CMOS active pixel sensor (CMOS APS) to generate a view of the glottis so that the trachea may be
intubated.
LARYNGEAL TUBE
The laryngeal tube (known as the King LT in the U.S.) is an airway management device designed as an
alternative to other airway management techniques such as mask ventilation, laryngeal mask airway, and tracheal
intubation. This device can be inserted blindly through the oropharynx into the hypopharynx to create an airway
during anaesthesia and cardiopulmonary resuscitation so as to enable mechanical ventilation of the lungs.
Fig. Standard Laryngeal Tube size 5 (VBM Medizintechnik, Sulz, Germany) with the syringe for cuff inflation.
Description
In its basic (standard) version, the laryngeal tube is made up of a tube with a larger balloon cuff in the middle
(oropharyngeal cuff) and a smaller balloon cuff at the end (oesophageal cuff). The tube is kinked at an angle of
30-45° in the middle; the kink is located in the larger cuff. There are two apertures, located between the two
cuffs, through which ventilation takes place. Both cuffs are inflated through a single small lumen line and pilot
balloon. The cuffs are high-volume, low-pressure cuffs with inflating volume ranging from 10 ml (size 0) to 90
ml (size 5). A large bore syringe, which is marked with the required volume for each size, is used to inflate the
cuffs. A cuff inflator can also be used, in which case the cuffs should be inflated to a pressure of 60 cm H2O.
Three black lines on the tube indicate the depth of insertion when aligned with the teeth.
History
The laryngeal tube was developed in Germany and introduced to the European market by VBM Medizintechnik
in the autumn of 1999. Since then the design has been modified several times. Currently four different models
are used: the standard tube as single use or re-use models and the modified tube (laryngeal tube-Suction II) as
single use or re-use models. The re-usable models can be autoclaved up to 50 times, while the modified laryngeal
tube (Suction) incorporates an extra lumen for inserting a gastric tube or suction system. There are six sizes of
the laryngeal tube, ranging from newborn (size 0) to large adult (size 5). The connector of the tube is colour-
coded for each size. The different sizes are calibrated according to weight or height. The laryngeal tube was
licensed for use during cardiopulmonary resuscitation in Japan in 2002, and approved for use in the United
States by the Food and Drug Administration in 2003. The European Resuscitation Council, in its 2005 guidelines
for advanced life support (ALS), accepts its use as an alternate airway device for medical personnel who are not
experienced in tracheal intubation.
Use and Efficacy

Various studies have shown that insertion and use of the standard tracheal tube is easy, providing a clear
airway in the majority of cases. Comparative studies indicate that the standard laryngeal tube is generally as
effective as the laryngeal mask airway, while some studies indicate that the Pro-seal laryngeal mask may be
more effective than the standard laryngeal tube under controlled ventilation conditions in general anaesthesia.
The indications and contraindications for use of the laryngeal tube are similar to those of the laryngeal mask
airway and include the use in general anaesthesia for minor surgical operations. Several studies describe the
usefulness of the device in securing a difficult airway, even in cases where insertion of the laryngeal mask had
failed. The double-lumen laryngeal tube-Suction II, with the possibility of placing a gastric tube, has been
found to have distinct advantages over the standard laryngeal tube and has been recommended as a first-line
device to secure the airway in emergency situations when direct laryngoscopy fails in neonates and infants. The
laryngeal tube is also recommended for medical personnel not experienced in tracheal intubation, and as a
rescue device when intubation has failed in adults. According to the manufacturer the use of Laryngeal tubes is
contraindicated in people with an intact gag reflex, known oesophageal disease, and people who have ingested
caustic substances.
COMBITUBE
The Combitube—also known as the esophageal tracheal airway or esophageal tracheal double-lumen airway—
is a blind insertion airway device (BIAD) used in the pre-hospital and emergency setting. It is designed to
provide an airway to facilitate the mechanical ventilation of a patient in respiratory distress.
Description and Use

It consists of a cuffed, double-lumen tube that is inserted through the patient’s mouth to secure an airway and
enable ventilation. Generally, the distal tube (tube two, clear) enters the esophagus, where the cuff is inflated
and ventilation is provided through the proximal tube (tube one, blue) which opens at the level of the larynx. In
the rare instance where the distal tube intubates the trachea, ventilation is provided through the distal tube.
Inflation of the cuff in the esophagus allows a level of protection against aspiration of gastric content similar to
that found in the laryngeal mask. The simplicity of placement is the main advantage of the Combitube over
endotracheal intubation. When intubating with a traditional endotracheal tube, care must be taken to visually
ensure that the tube has been placed in the trachea while the dual-lumen design of the Combitube allows for
ventilation to proceed regardless of esophageal or tracheal placement. A device called the Positube, which
allows for esophageal intubation detection, can be used on tube number two to rule out the intubation of the
Combitube in the trachea. The Positube checks for air flow resistance on tube number two and is very helpful in
checking proper Combitube placement when intubation is performed in noisy environments. The Combitube’s
ease of use makes it an option for use in the pre-hospital, emergency setting when advanced level providers
capable of placing an endotracheal tube are not immediately available. The drawbacks of Combitubes are
evidenced by reports of serious complications such as aspiration, esophagus perforation and cranial nerve
dysfunction associated with their use. While it has been suggested as an option by the American Heart Association
and European Resuscitation Council for situations where intubation attempts are unsuccessful since the year
2000, it is seldom used outside of the pre-hospital, emergency setting, as it does not allow for long term airway
control. Alternatives to the Combitube include the laryngeal mask airway, the endotracheal tube, and the laryngeal
tube.
NASOPHARYNGEAL AIRWAY
In medicine, a nasopharyngeal airway, also known as an NPA, nasal trumpet (because of its flared end), or
nose hose, is a type of airway adjunct, is a tube that is designed to be inserted into the nasal passageway to
secure an open airway. When a patient becomes unconscious, the muscles in the jaw commonly relax and can
allow the tongue to slide back and obstruct the airway. This makes airway management necessary, and an NPA
is one of the available tools. The purpose of the flared end is to prevent the device from becoming lost inside the
patient’s nose.
Fig. Nasopharyngeal airway.
Sizes
As with other catheters, NPAs are measured using the French catheter scale, but sizes are usually also quoted
in millimeters. Typical sizes include: 6.5 mm/28FR, 7.0 mm/30FR, 7.5 mm/32FR, 8.0 mm/34FR, and 8.5 mm/
36FR.
Indications and Contraindications

These devices are used by emergency care professionals such as EMTs and paramedics in situations where
an artificial form of airway maintenance is necessary, but tracheal intubation is impossible, inadvisable, or
outside the practitioner’s scope of practice. An NPA is often used in conscious patients where an oropharyngeal
airway would trigger the gag reflex.
Insertion
The correct size airway is chosen by measuring the device on the patient: the device should reach from the
patient’s nostril to the earlobe or the angle of the jaw. The outside of the tube is lubricated with a water-based
lubricant so that it enters the nose more easily. The device is inserted until the flared end rests against the
nostril.
POCKET MASK
A pocket mask, or pocket face mask or CPR mask, is a device used to safely deliver rescue breaths during a
cardiac arrest or respiratory arrest. The specific term “Pocket Mask” is the registered trade marked name for the
product manufactured by Laerdal Medical AS.
Fig. A pocket mask with carrying case and detached one-way valve.
Design
The pocket mask is a small device that can be carried on one’s person. Air is administered to the patient
when the emergency responder exhales through a one-way filter valve. Modern pocket masks have either a built
in one-way valve or an attachable, disposable filter to protect the emergency responder from the patient’s
potentially infectious bodily substances, such as vomit or blood. Many masks also have a built-in oxygen intake
tube, allowing for administration of 50-60% oxygen. Without being hooked up to an external line, exhaled air
from the provider can still provide sufficient oxygen to live, up to 16%. Earth’s atmosphere consists of
approximately 21% oxygen.
Usage
While a pocket mask is not as efficient as a bag valve mask, it does have its advantages when only one
rescuer is available. As suggested by its name, the pocket mask benefits from a somewhat easier portability
when compared to the bag valve mask. Also, in contrast to the bag valve mask, which requires two hands to
operate (one to form a seal and the other to squeeze the bag), the pocket mask allows for both of the rescuer’s
hands to be on the patients head. This hand placement provides a superior seal on the patient’s face, and allows
the responder to perform a jaw thrust on patients suspected of a spinal injury.
BAG VALVE MASK

A bag valve mask, abbreviated to BVM and sometimes known by the proprietary name Ambu bag or generically
as a manual resuscitator or “self-inflating bag”, is a hand-held device commonly used to provide positive
pressure ventilation to patients who are not breathing or not breathing adequately. The device is a required part
of resuscitation kits for trained professionals in out-of-hospital settings (such as ambulance crews) and is also
frequently used in hospitals as part of standard equipment found on a crash cart, in emergency rooms or other
critical care settings. Underscoring the frequency and prominence of BVM use in the United States, the American
Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care
recommend that “all health care providers should be familiar with the use of the bag-mask device.” Manual
resuscitators are also used within the hospital for temporary ventilation of patients dependent on mechanical
ventilators when the mechanical ventilator needs to be examined for possible malfunction, or when ventilator-
dependent patients are transported within the hospital. Two principal types of manual resuscitators exist; one
version is self-filling with air, although additional oxygen (O2) can be added but is not necessary for the device
to function. The other principal type of manual resuscitator (flow-inflation) is heavily used in non-emergency
applications in the operating room to ventilate patients during anesthesia induction and recovery. Use of manual
resuscitators to ventilate a patient is frequently called “bagging” the patient and is regularly necessary in medical
emergencies when the patient’s breathing is insufficient (respiratory failure) or has ceased completely (respiratory
arrest). Use of the manual resuscitator force-feeds air or oxygen into the lungs in order to inflate them under
pressure, thus constituting a means to manually provide positive-pressure ventilation. It is used by professional
rescuers in preference to mouth-to-mouth ventilation, either directly or through an adjunct such as a pocket
mask.
Fig. A disposable BVM Resuscitator.
History
The bag-valve mask concept was developed in 1953 by the German engineer Holger Hesse and his partner,
Danish anaesthetist Henning Ruben, following their initial work on a suction pump. Later Hesse’s company
was renamed to Ambu, which has manufactured and market the device since the late 1950s. The full-form of
AMBU is Artificial Manual Breathing Unit. An Ambu® bag is a self-inflating bag resuscitator from the company
Ambu, who still manufactures and markets self-inflating bag resuscitators. Today there are several manufacturers
of self-inflating bag resuscitators. Some, like the original Ambu bag, are durable and intended for reuse (after
thorough cleaning). Others are inexpensive and intended for a single use. Initially produced in one size, now
BVMs are available in sizes for use with infants, children or adults.
Standard Components
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The BVM consists of a flexible air chamber (the “bag”, roughly a foot in length), attached to a face mask via
a shutter valve. When the face mask is properly applied and the “bag” is squeezed, the device forces air through
into the patient’s lungs; when the bag is released, it self-inflates from its other end, drawing in either ambient air
or a low pressure oxygen flow supplied by a regulated cylinder, while also allowing the patient’s lungs to
deflate to the ambient environment (not the bag) past the one way valve.
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Bag and valve combinations can also be attached to an alternate airway adjunct, instead of to the mask. For
example, it can be attached to an endotracheal tube or laryngeal mask airway. Small heat and moisture exchangers,
or humidifying/ bacterial filters, can be used. A bag-valve mask can be used without being attached to an
oxygen tank to provide “room air” (21% oxygen) to the patient, however manual resuscitator devices also can
be connected to a separate bag reservoir which can be filled with pure oxygen from a compressed oxygen
source – this can increase the amount of oxygen delivered to the patient to nearly 100%. Bag-valve masks come
in different sizes to fit infants, children, and adults.
The face mask size may be independent of the bag size; for example, a single pediatric-sized bag might be
used with different masks for multiple face sizes, or a pediatric mask might be used with an adult bag for
patients with small faces. Most types of the device are disposable and therefore single use, while others are
designed to be cleaned and reused.
Method of Operation
Manual resuscitators cause the gas inside the inflatable bag portion to be force-fed to the patient via a one-
way valve when compressed by the rescuer; the gas is then ideally delivered through a mask and into the
patient’s trachea, bronchus and into the lungs. In order to be effective, a bag valve mask must deliver between
500 and 800 milliliters of air to a normal male adult patient’s lungs, but if supplemental oxygen is provided 400
ml may still be adequate. Squeezing the bag once every 5 to 6 seconds for an adult or once every 3 seconds for
an infant or child provides an adequate respiratory rate (10–12 respirations per minute in an adult and 20 per
minute in a child or infant). Professional rescuers are taught to ensure that the mask portion of the BVM is
properly sealed around the patient’s face (that is, to ensure proper “mask seal”); otherwise, pressure needed to
force-inflate the lungs is released to the environment. This is difficult when a single rescuer attempts to maintain
a face mask seal with one hand while squeezing the bag with other. Therefore, common protocol uses two
rescuers: one rescuer to hold the mask to the patient’s face with both hands and focus entirely on maintaining a
leak-proof mask seal, while the other rescuer squeezes the bag and focuses on breath (or tidal volume) and
timing.
An endotracheal tube (ET) can be inserted by an advanced practitioner and can substitute for the mask
portion of the manual resuscitator. This provides more secure air passage between the resuscitator and the
patient, since the ET tube is sealed with an inflatable cuff within the trachea (or windpipe), so any regurgitation
is less likely to enter the lungs, and so that forced inflation pressure can only go into the lungs and not inadvertently
go to the stomach. The ET tube also maintains an open and secure airway at all times, even during CPR
compressions; as opposed to when a manual resuscitator is used with a mask when a face mask seal can be
difficult to maintain during compressions.
Complications
Under normal breathing, the lungs inflate under a slight vacuum when the chest wall muscles and diaphragm
expand; this “pulls” the lungs open, causing air to enter the lungs to inflate under a gentle vacuum. However,
when using a manual resuscitator, as with other methods of positive-pressure ventilation, the lungs are force-
inflated with pressurized air or oxygen. This inherently leads to risk of various complications, many of which
depend on whether the manual resuscitator is being used with a face mask or ET tube. Complications are related
to over-inflating or over-pressurizing the patient, which can cause: (1) air to inflate the stomach (called gastric
insufflation); (2) lung injury from over-stretching (called volutrauma); and/or (3) lung injury from over-
pressurization (called barotrauma).
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When a face mask is used in conjunction with a manual resuscitator, the intent is for the force-delivered air
or oxygen to inflate the lungs. However air entering the patient also has access to the stomach via the esophagus,
which can inflate if the resuscitator is squeezed too hard (causing air flow that is too rapid for the lungs to
absorb alone) or too much (causing excess air to divert to the stomach).” Gastric inflation can lead to vomiting
and subsequent aspiration of stomach contents into the lungs, which has been cited as a major hazard of bag-
valve-mask ventilation, with one study suggesting this effect is difficult to avoid even for the most skilled and
experienced users, stating “When using a self-inflatable bag, even experienced anesthesiologists in our study
may have performed ventilation with too short inspiratory times and/or too large tidal volumes, which resulted
in stomach inflation in some cases.” The study goes on to state that “Stomach inflation is a complex problem
that may cause regurgitation, [gastric acid] aspiration, and, possibly, death.” When stomach inflation leads to
vomiting of highly acidic stomach acids, delivery of subsequent breaths can force these caustic acids down into
the lungs where they cause life-threatening or fatal lung injuries including Mendelson’s syndrome, aspiration
pneumonia, adult respiratory distress syndrome and “pulmonary injuries similar to that seen in victims of
chlorine gas exposure”. Apart from the risks of gastric inflation causing vomiting and regurgitation, at least two
reports have been found indicating that gastric insufflation itself remains clinically problematic even when
vomiting does not occur. In one case of failed resuscitation (leading to death), gastric insufflation in a 3-month-
old boy put sufficient pressure against the lungs that “precluded effective ventilation”. Another reported
complication was a case of stomach rupture caused by stomach over-inflation from a manual resuscitator. The
causative factors and degree of risk of inadvertent stomach inflation have been examined, with one published
study revealing that during prolonged resuscitation up to 75% of air delivered to the patient may inadvertently
be delivered to the stomach instead of the lungs.
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When an endotracheal (ET) tube is placed, one of the key advantages is that a direct air-tight passageway is
provided from the output of the manual resuscitator to the lungs, thus eliminating the possibilities of inadvertent
stomach inflation or lung injuries from gastric acid aspiration. However this places the lungs at increased risk
from separate lung injury patterns caused by accidental forced over-inflation (called volutrauma and/or
barotrauma). Sponge-like lung tissue is delicate, and over-stretching can lead to adult respiratory distress
syndrome – a condition that requires prolonged mechanical ventilator support in the ICU and is associated with
poor survival (e.g., 50%), and significantly increased care costs of up to $30,000 per day. Lung volutrauma,
which can still be achieved through “careful” delivery of large, slow breaths, can also lead to a “popped” or
collapsed lung (called a pneumothorax), with at least one published report describing “a patient in whom a
sudden tension pneumothorax developed during ventilation with a bag-valve device.” Additionally, there is at
least one report of manual resuscitator use where the lungs were accidentally over-inflated to the point where
“the heart contained a large volume of air,” and the “aorta and pulmonary arteries were filled with air” – a
condition called an air embolism which “is almost uniformly fatal”.
Public Health Risk from Manual Resuscitator Complications

Two factors appear to make the public particularly at risk from complications from manual resuscitators: (1)
their prevalence of use (leading to high probability of exposure), and (2) apparent inability for providers to
protect patients from uncontrolled, inadvertent, forced over-inflation.
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Manual resuscitators are commonly used for temporary ventilation support, especially flow-inflation versions
that are used during anesthesia induction/recovery during routine surgery. Accordingly, most citizens are likely
to be “bagged” at least once during their lifetime as they undergo procedures involving general anesthesia.
Additionally, a significant number of newborns are ventilated with infant-sized manual resuscitators to help
stimulate normal breathing, making manual resuscitators among the very first therapeutic medical devices
encountered upon birth. As previously stated, manual resuscitators are the first-line device recommended for
emergency artificial ventilation of critical care patients, and are thus used not only throughout hospitals but also
in out-of-hospital care venues by firefighters, paramedics and outpatient clinic personnel.
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Manual resuscitators have no built-in tidal volume control – the amount of air used to force-inflate the lungs
during each breath depends entirely on how much the operator squeezes the bag. In response to the dangers
associated with use of manual resuscitators, specific guidelines from the American Heart Association and
European Resuscitation Council were issued that specify recommended maximal tidal volumes (or breath sizes)
and ventilation rates safe for patients. While no studies are known that have assessed the frequency of
complications and/or deaths due to uncontrolled manual resuscitator use, numerous peer-reviewed studies have
found that, despite established safety guidelines, the incidence of provider over-inflation with manual resuscitators
continues to be “endemic” and unrelated to provider training or skill level. Another clinical study found “the
tidal volume delivered by a manual resuscitator shows large variations”, concluding that “the manual resuscitator
is not a suitable device for accurate ventilation.” A separate assessment of another high-skilled group with
frequent emergency use of manual resuscitators (ambulance paramedics) found that “Despite seemingly adequate
training, EMS personnel consistently hyperventilated patients during out-of-hospital CPR”, with the same research
group concluding that “Unrecognized and inadvertent hyperventilation may be contributing to the currently
dismal survival rates from cardiac arrest.” A peer-reviewed study published in 2012 assessed the possible
incidence of uncontrolled over-inflation in newborn neonates, finding that “a large discrepancy between the
delivered and the current guideline values was observed for all parameters,” and that “regardless of profession
or handling technique... 88.4% delivered excessive pressures, whereas... 73.8% exceeded the recommended
range of volume”, concluding that “the great majority of participants from all professional groups delivered
excessive pressures and volumes.” A further examination has recently been made to assess whether a solution
to the over-ventilation problem may lie with use of pediatric-sized manual resuscitators in adults or use of more
advanced flow-inflation (or “Mapleson C”) versions of manual resuscitators: while “the paediatric self-inflating
bag delivered the most guideline-consistent ventilation”, it did not lead to full guideline compliance as
“participants hyperventilated patients’ lungs in simulated cardiac arrest with all three devices.”
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“Hyperventilation” can be achieved through delivery of (1) too many breaths per minute; (2) breaths that are
too large and exceed the patient’s natural lung capacity; or (3) a combination of both. With use of manual
resuscitators, neither rate nor inflating volumes can be physically controlled through built-in safety adjustments
within the device itself, and as highlighted above, studies show providers frequently exceed designated safety
guidelines for both ventilation rate (10 breaths per minute) and volume (5–7 mL/ kg body weight) as outlined
by the American Heart Association and European Resuscitation Council. Numerous studies have concluded
that ventilation at rates in excess of current guidelines are capable of interfering with blood flow during
cardiopulmonary resuscitation, however the pre-clinical experiments associated with these findings involved
delivery of inspiratory volumes in excess of current guidelines (e.g., they assessed the effects of hyperventilation
via both excessive rate and excessive volumes simultaneously). A more recent study published in 2012 expanded
knowledge on this topic by evaluating the separate effects of (1) isolated excessive rate with guideline-compliant
inspiratory volumes; (2) guideline-compliant rate with excessive inspiratory volumes; and (3) combined guideline
non-compliance with both excessive rate and volume. This study found that excessive rate more than triple the
current guideline (e.g., 33 breaths per minute) may not interfere with CPR when inspiratory volumes are delivered
within guideline-compliant levels, suggesting that ability to keep breath sizes within guideline limits may
individually mitigate clinical dangers of excessive rate. It was also found that when guideline-excessive tidal
volumes were delivered, changes in blood flow were observed that were transient at low ventilation rates but
sustained when both tidal volumes and rates were simultaneously excessive, suggesting that guideline-excessive
tidal volume is the principal mechanism of side effects, with ventilation rate acting as a multiplier of these
effects. Consistent with previous studies where both excessive rate and volumes were found to produce side
effects of blood flow interference during CPR, a complicating factor may be inadequate time to permit full
expiration of oversized breaths in between closely spaced high-rate breaths, leading to the lungs never being
permitted to fully exhale between ventilations (also called “stacking” of breaths). A recent advancement in the
safety of manual ventilation may be the growing use of time-assist devices that emit an audible and/or visual
metronome tone or flashing light at the proper guideline-designated rate interval for breath frequency; one
study found these devices may lead to near 100% guideline compliance for ventilation rate. While this
advancement appears to provide a solution to the “rate problem” associated with guideline-excessive manual
resuscitator use, it may not address the “volume problem” which may continue to make manual resuscitators a
patient hazard (as complications can still occur from over-inflation even when rate is delivered within guidelines).
Currently the only devices that can deliver pre-set, physician-prescribed inflation volumes reliably within
safety guidelines are mechanical ventilators that require an electrical power source and/or a source of compressed
oxygen, a higher level of training to operate, and typically cost hundreds to thousands of dollars more than a
disposable manual resuscitator.
Additional Components/Features
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A filter is sometimes placed between the mask and the bag (before or after the valve) to prevent contamination
of the bag.
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Some devices have PEEP valve connectors, for better positive airway pressure maintenance.
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A covered port may be incorporated into the valve assembly to allow inhalatory medicines to be injected into
the airflow, which may be particularly effective in treating patients in respiratory arrest from severe asthma.
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A separate covered port may be included into the valve assembly to enable a pressure-monitoring device to
be attached, enabling rescuers to continuously monitor the amount of positive-pressure being generated during
forced lung inflation.
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A pressure relief valve (often known as a “pop-up valve”) is typically included in pediatric versions and
some adult versions, the purpose of which is to prevent accidental over-pressurization of the lungs. A bypass
clip is usually incorporated into this valve assembly in case medical needs call for inflation at a pressure beyond
the normal cutoff of the pop-up valve.
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Some bags are designed to collapse for storage. A bag not designed to store collapsed may lose elasticity
when stored compressed for long periods, reducing its effectiveness. The collapsible design has longitudinal
scoring so that the bag collapses on the scoring “pivot point,” opposite to the direction of normal bag compression.
Manual Resuscitator Alternatives

In a hospital, long-term mechanical ventilation is provided by using a more complex, automated ventilator.
However a frequent use of a manual resuscitator is to temporarily provide manual ventilation whenever
troubleshooting of the mechanical ventilator is needed, if the ventilator circuit needs to be changed, or if there
is a loss of electrical power or source of compressed air and/or oxygen. A rudimentary type of mechanical
ventilator device that has the advantage of not needing electricity is a flow-restricted, oxygen-powered ventilation
device (FROPVD). These are similar to manual resuscitators in that oxygen is pushed through a mask to force-
inflate the patient’s lungs, but unlike a manual resuscitator where the pressure used to force-inflate the patient’s
lungs comes from a person manually squeezing a bag, with the FROPVD the pressure needed to force-inflate
the lungs comes directly from a pressurized oxygen cylinder. These devices will stop functioning when the
compressed oxygen tank becomes depleted.
Types of Manual Resuscitators

• Self-inflating bags: This type of manual resuscitator is the standard design most often used in both
in-hospital and out-of-hospital settings. The material used for the bag-portion of a self-inflating manual
resuscitator has a “memory”, meaning after it is manually compressed it will automatically re-expand
on its own in between breaths (drawing in air for the next breath). These devices can be used alone
(thus delivering room-air) or can be used in connection with an oxygen source to deliver nearly
100% oxygen. As a result of these features, this type of manual resuscitator is appropriate for in-
hospital use and in out-of-hospital settings (e.g., ambulances).
• Flow-inflating bags: Also termed “anesthesia bags”, these are a specialized form of manual resuscitator
with a bag-portion that is flaccid and does not re-inflate on its own. This necessitates an external
flow source of pressurized inflation gas for the bag to inflate; once inflated the provider can manually
squeeze the bag or, if the patient is breathing on his/her own, the patient can inhale directly through
the bag itself. These types of manual resuscitators are used extensively during anesthesia induction
and recovery, and are often attached to anesthesia consoles so anesthesia gases can be used to ventilate
the patient. They are primarily utilized by anesthesiologists administering general anesthesia, but
also during some in-hospital emergencies which may involve anesthesiologists or respiratory therapists.
They are not typically used outside hospital settings. As per a recent Indian study, these flow inflation
bags can also be used to provide CPAP in spontaneously breathing children. The study quotes that
this mode of CPAP is cost effective in limited resource settings.
CHEST TUBE
A chest tube (chest drain, thoracic catheter, tube thoracostomy, or intercostal drain) is a flexible plastic tube
that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air
(pneumothorax), fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space. It is also
known as a Bülau drain or an intercostal catheter. The concept of chest drainage was first advocated by Hippocrates
when he described the treatment of empyema by means of incision, cautery, and insertion of metal tubes.
However, the technique was not widely used until the influenza epidemic of 1917 to drain post-pneumonic
empyema, which was first documented by Dr. C. Pope, on “Joel”, a 22-month-old infant. The use of chest tubes
in postoperative thoracic care was reported in 1922, and they were regularly used post-thoracotomy in World
War II, though they were not routinely used for emergency tube thoracostomy following acute trauma until the
Korean War.
Fig. The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of the chest.
This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest.
Medical Uses
• Pneumothorax: accumulation of air or gas in the pleural space
• Pleural effusion: accumulation of fluid in the pleural space
– Chylothorax: a collection of lymphatic fluid in the pleural space
– Empyema: a pyogenic infection of the pleural space
– Hemothorax: accumulation of blood in the pleural space
– Hydrothorax: accumulation of serous fluid in the pleural space.
Contraindications
Contraindications to chest tube placement include refractory coagulopathy and presence of a diaphragmatic
hernia, as well as hepatic hydrothorax. Additional contraindications include scarring in the pleural space
(adhesions).
Complications
A common complication after thoracic surgery that arises within 30–50% of patients are air leaks. Here,
digital chest drainage systems can provide a remedy as they monitor intra-pleural pressure and air leak flow,
constantly. Major insertion complications include hemorrhage, infection, and reexpansion pulmonary edema.
Injury to the liver, spleen or diaphragm is possible if the tube is placed inferior to the pleural cavity. Injuries to
the thoracic aorta and heart can also occur. Minor complications include a subcutaneous hematoma or seroma,
anxiety, shortness of breath (dyspnea), and cough (after removing large volume of fluid). In most cases, the
chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube
induced scarring of the intercostal space is not uncommon. Subcutaneous emphysema indicates backpressure
created by undrained air, often caused by a clogged drain or insufficient negative pressure.
Device
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Chest tubes are commonly made from clear plastics like PVC and soft silicone. Chest tubes are made in a
range of sizes measured by their external diameter from 6 Fr to 40 Fr. Chest tubes, like most catheters, are
measured in French catheter scale. For adults, 20 Fr to 40 Fr (6.7 to 13.3mm external diameter) are commonly
used, and 6 Fr to 26 Fr for children. Conventional chest tubes feature multiple drainage fenestrations in the
section of the tube which resides inside the patient, as well as distance markers along the length of the tube,
and a radiopaque stripe which outlines the first drainage hole. Chest tubes are also provided in right angle,
trocar, flared, and tapered configurations for different drainage needs. As well, some chest tubes are coated
with heparin to help prevent thrombus formation, though the effect of this is disputed. Chest tube have an
end hole (proximal, towards the patient) and a series of side holes. The number of side holes is generally 6 on
most chest tubes. The length of tube that has side holes is the effective drainage length (EDL). In chest tubes
designed for pediatric heart surgery, the EDL is shorter, generally by only having 4 side holes. Channel style
chest drains, also called Blake drains, are so-called silastic drains made of silicone and feature open flutes
that reside inside the patient. Drainage is thought to be achieved by capillary action, allowing the fluids to
travel through the open grooves into a closed cross section, which contains the fluid and allows it to be
suctioned through the tube. Though these chest tubes are more expensive than conventional ones, they are
theoretically less painful.
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A chest drainage system is typically used to collect chest drainage (air, blood, effusions). Most commonly,
drainage systems use three chambers which are based on the three-bottle system. The first chamber allows fluid
that is drained from the chest to be collected. The second chamber functions as a “water seal”, which acts as a
one way valve allowing gas to escape, but not reenter the chest. Air bubbling through the water seal chamber is
usual when the patient coughs or exhales but may indicate, if continual, a pleural or system leak that should be
evaluated critically. It can also indicate a leak of air from the lung. The third chamber is the suction control
chamber. The height of the water in this chamber regulates the negative pressure applied to the system. A gentle
bubbling through the water column minimizes evaporation of the fluid and indicates that the suction is being
regulated to the height of the water column. In this way, increased wall suction does not increase the negative
pressure of the system.
Newer drainage systems eliminate the water seal using a mechanical check-valve, and some also use a
mechanical regulator to regulate the suction pressure. Systems which employ both these are dubbed “dry”
systems, whereas systems that retain the water seal but use a mechanical regulator are called “wet-dry” systems.
Systems which use a water seal and water column regulator are called “wet” systems. Dry systems are
advantageous as tip-overs of wet systems can spill and mix with blood, mandating the replacement of the
system. Even newer systems are smaller and more ambulatory so the patient can be sent home for drainage if
indicated. More recently digital or electronic chest drainage systems have been introduced. An onboard motor
is used as vacuum source along with an integrated suction control canister and water seal. These systems
monitor the patient and will alert if the measured data are out of range. Due to the digital control of the negative
pressure, the system is able to objectively quantify the presence of a pleural or system leak. Digital drainage
systems allow clinicians to mobilize patients early, even for those on continuous suction, which is difficult to
accomplish with the traditional water-seal system under suction. Recently published clinical data indicates, that
application of such systems can also lead to a reduction in complications.
Technique
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The insertion technique for emergency pleural drainage is described in detail in an article of the NEJM. The
free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or
fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can
be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile. British Thoracic
Society recommends the tube is inserted in an area described as the “safe zone”, a region bordered by: the
lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi
and a horizontal line superior to the nipple. More specifically, the tube is inserted into the 5th intercostal space
slightly anterior to the mid axillary line. Chest tubes are usually inserted under local anesthesia. The skin over
the area of insertion is first cleansed with antiseptic solution, such as iodine, before sterile drapes are placed
around the area.
The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small
incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed
through this passage. If necessary, patients may be given additional analgesics for the procedure. Once the tube
is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is
in place, a chest radiograph will be taken to check the location of the drain. The tube stays in for as long as there
is air or fluid to be removed, or risk of air gathering. Chest tubes can also be placed using a trocar, which is a
pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an
increased risk of iatrogenic lung injury. Placement using the Seldinger technique, in which a blunt guidewire is
passed through a needle (over which the chest tube is then inserted) has been described.
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The placement technique for postoperative drainage (e.g. cardiac surgery) differs from the technique
used for emergency situations. At the completion of open cardiac procedures, chest tubes are placed through
separate stab incisions, typically near the inferior aspect of the sternotomy incision. In some instances
multiple drains may be used to evacuate the mediastinal, pericardial, and pleural spaces. The drainage
holes are placed inside the patient and the chest tube is passed out through the incision. Once the tube is in
place, it is sutured to the skin to prevent movement. The chest tube is then connected to the drainage
canister using additional tubing and connectors and connected to a suction source, typically regulated to -
20 cm of water.
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After suturing, dressings are applied for hygienical reasons covering the wound. First, a y-slit compress is
used around the tube. Second, a compress (10 x 10 cm) is placed on top and finally an adhesive plaster is added
in a way that tension is avoided. A bridle rein is recommended to fix the tube to the skin. This tape bridge will
prevent the tube from moving backwards and the possibility to cause clogging. It also prevents pain as it
reduces tension on the fixation stitch. Alternatively, a large adhesive plaster that functions like a tape bridge
may be used.
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Chest tubes should be kept free of dependent loops, kinks, and obstructions which may prevent drainage. In
general, chest tubes are not clamped except during insertion, removal, or when diagnosing air leaks. Manual
manipulation, often called milking, stripping, fan folding, or tapping, of chest tubes is commonly performed to
clear chest tube obstructions. No conclusive evidence has demonstrated that any of these techniques are more
effective than the others, and no method has shown to improve chest tube drainage. Furthermore, chest tube
manipulation has proved to increase negative pressure, which may be detrimental, and painful to the patient.
For these reasons, many hospitals do not allow these types of manual tube manipulations. Internal chest tube
clearing can be performed to clear chest tube obstructions using an open or closed technique. Open chest tube
clearing involves breaking the sterile environment separating the chest tube from the drainage canister tubing.
The internal lumen may then be flushed with saline, or a second catheter may be inserted inside the chest tube
and suction used to clear the obstructions.
AUTOMATED EXTERNAL DEFIBRILLATOR

An automated external defibrillator (AED) is a portable electronic device that automatically diagnoses the
life-threatening cardiac arrhythmias of ventricular fibrillation and pulseless ventricular tachycardia, and is able
to treat them through defibrillation, the application of electricity which stops the arrhythmia, allowing the heart
to reestablish an effective rhythm. With simple audio and visual commands, AEDs are designed to be simple to
use for the layperson, and the use of AEDs is taught in many first aid, certified first responder, and basic life
support (BLS) level cardiopulmonary resuscitation (CPR) classes. The portable version of the defibrillator was
invented in the mid-1960s by Frank Pantridge in Belfast, Northern Ireland.
Indications
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An automated external defibrillator is used in cases of life-threatening cardiac arrhythmias which lead to
sudden cardiac arrest, which is not the same as a heart attack.
The rhythms that the device will treat are usually limited to:
1. Pulseless Ventricular tachycardia (shortened to VT or V-Tach)
2. Ventricular fibrillation (shortened to VF or V-Fib).
In each of these two types of shockable cardiac arrhythmia, the heart is electrically active, but in a dysfunctional
pattern that does not allow it to pump and circulate blood. In ventricular tachycardia, the heart beats too fast to
effectively pump blood. Ultimately, ventricular tachycardia leads to ventricular fibrillation. In ventricular fibrillation,
the electrical activity of the heart becomes chaotic, preventing the ventricle from effectively pumping blood. The
fibrillation in the heart decreases over time, and will eventually reach asystole. AEDs, like all defibrillators, are not
designed to shock asystole (‘flat line’ patterns) as this will not have a positive clinical outcome. The asystolic patient
only has a chance of survival if, through a combination of CPR and cardiac stimulant drugs, one of the shockable
rhythms can be established, which makes it imperative for CPR to be carried out prior to the arrival of a defibrillator.
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Uncorrected, these cardiac conditions (ventricular tachycardia, ventricular fibrillation, asystole) rapidly lead
to irreversible brain damage and death, once cardiac arrest takes place. After approximately three to five minutes
in cardiac arrest, irreversible brain/tissue damage may begin to occur. For every minute that a person in cardiac
arrest goes without being successfully treated (by defibrillation), the chance of survival decreases by 7 percent
per minute in the first 3 minutes, and decreases by 10 percent per minute as time advances beyond ~3 minutes.
,8<09,4,5;:-69:,
AEDs are designed to be used by laypersons who ideally should have received AED training. However,
sixth-grade students have been reported to begin defibrillation within 90 seconds, as opposed to a trained
operator beginning within 67 seconds. This is in contrast to more sophisticated manual and semi-automatic
defibrillators used by health professionals, which can act as a pacemaker if the heart rate is too slow (bradycardia)
and perform other functions which require a skilled operator able to read electrocardiograms. Bras with a metal
underwire and piercings on the torso must be removed before using the AED on someone to avoid interference.
American television show Mythbusters found evidence that use of a defibrillator on a woman wearing an
underwire bra can lead to arcing or fire but only in unusual and unlikely circumstances. In a study analyzing the
effects of having AEDs immediately present during Chicago’s Heart Start programme over a two-year period,
of 22 individuals, 18 were in a cardiac arrhythmia which AEDs can treat. Of these 18, 11 survived. Of these 11
patients, 6 were treated by bystanders with absolutely no previous training in AED use.
Implementation
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Automated external defibrillators are generally either kept with trained personnel who will attend events or are
public access units which can be found in places including corporate and government offices, shopping centres,
airports, airplanes, restaurants, casinos, hotels, sports stadiums, schools and universities, community centers,
fitness centers, health clubs, theme parks, workplaces and any other location where people may congregate. The
location of a public access AED should take into account where large groups of people gather, regardless of age or
activity. Children as well as adults may fall victim to sudden cardiac arrest (SCA). In many areas, emergency
vehicles are likely to carry AEDs, with some ambulances carrying an AED in addition to manual defibrillators.
Police or fire vehicles often carry an AED for use by first responders. Some areas have dedicated community first
responders, who are volunteers tasked with keeping an AED and taking it to any victims in their area. AEDs are
also increasingly common on commercial airliners, cruise ships, and other transportation facilities. High-rise
buildings are densely populated, but are more difficult to access by emergency crews facing heavy traffic and
security barriers. It has been suggested that AEDs carried on elevators could save critical minutes for cardiac arrest
victims, and reduce their deployment cost. In order to make them highly visible, public access AEDs are often
brightly colored, and are mounted in protective cases near the entrance of a building. When these protective cases
are opened or the defibrillator is removed, some will sound a buzzer to alert nearby staff to their removal, though
this does not necessarily summon emergency services; trained AED operators should know to phone for an ambulance
when sending for or using an AED. In September 2008, the International Liaison Committee on Resuscitation
issued a ‘universal AED sign’ to be adopted throughout the world to indicate the presence of an AED, and this is
shown on the right. A trend that is developing is the purchase of AEDs to be used in the home, particularly by those
with known existing heart conditions. The number of devices in the community has grown as prices have fallen to
affordable levels. There has been some concern among medical professionals that these home users do not necessarily
have appropriate training, and many advocate the more widespread use of community responders, who can be
appropriately trained and managed. Typically, an AED kit will contain a face shield for providing a barrier between
patient and first aider during rescue breathing; a pair of nitrile rubber gloves; a pair of trauma shears for cutting
through a patient’s clothing to expose the chest; a small towel for wiping away any moisture on the chest, and a
razor for shaving those with very hairy chests.
9,7(9(;065-697,9(;065
Most manufacturers recommend checking the AED before every period of duty or on a regular basis for fixed
units. Some units need to be switched on in order to perform a self check; other models have a self check system
built in with a visible indicator. All manufacturers mark their electrode pads with an expiration date, and it is
important to ensure that the pads are in date. This is usually marked on the outside of the pads. Some models are
designed to make this date visible through a ‘window’, although others will require the opening of the case to find
the date stamp. It is also important to ensure that the AED unit’s batteries have not expired. The AED manufacturer
will specify how often the batteries should be replaced. Each AED has a different recommended maintenance
schedule outlined in the user manual. Common checkpoints on every checklist, however, also include a monthly
check of the battery power by checking the green indicator light when powered on, condition and cleanliness of all
cables and the unit, and check for the adequate supplies To ensure that AED is working properly at all times, the D-
Box telemetry device can be used. It connects to an AED device, recognizes the particular device’s beeps and
knows that it beeps in just this particular way when it’s broken. In a situation when an AED has stopped working,
the D-Box sends notifications and lets you discover problems before it’s too late.
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An AED is “automatic” because of the unit’s ability to autonomously analyse the patient’s condition. To
assist this, the vast majority of units have spoken prompts, and some may also have visual displays to instruct
the user. “External” refers to the fact that the operator applies the electrode pads to the bare chest of the
victim (as opposed to internal defibrillators, which have electrodes surgically implanted inside the body of a
patient). When turned on or opened, the AED will instruct the user to connect the electrodes (pads) to the
patient. Once the pads are attached, everyone should avoid touching the patient so as to avoid false readings
by the unit. The pads allow the AED to examine the electrical output from the heart and determine if the
patient is in a shockable rhythm (either ventricular fibrillation or ventricular tachycardia). If the device
determines that a shock is warranted, it will use the battery to charge its internal capacitor in preparation to
deliver the shock. This system is not only safer (charging only when required), but also allows for a faster
delivery of the electric current.
When charged, the device instructs the user to ensure no one is touching the patient and then to press a
button to deliver the shock; human intervention is usually required to deliver the shock to the patient in order
to avoid the possibility of accidental injury to another person (which can result from a responder or bystander
touching the patient at the time of the shock). Depending on the manufacturer and particular model, after the
shock is delivered most devices will analyze the patient and either instruct CPR to be performed, or prepare
to administer another shock. Many AED units have an ‘event memory’ which store the ECG of the patient
along with details of the time the unit was activated and the number and strength of any shocks delivered.
Some units also have voice recording abilities to monitor the actions taken by the personnel in order to
ascertain if these had any impact on the survival outcome. All this recorded data can be either downloaded to
a computer or printed out so that the providing organisation or responsible body is able to see the effectiveness
of both CPR and defibrillation. Some AED units even provide feedback on the quality of the compressions
provided by the rescuer. The first commercially available AEDs were all of a monophasic type, which gave
a high-energy shock, up to 360 to 400 joules depending on the model. This caused increased cardiac injury
and in some cases second and third-degree burns around the shock pad sites. Newer AEDs (manufactured
after late 2003) have tended to utilise biphasic algorithms which give two sequential lower-energy shocks of
120–200 joules, with each shock moving in an opposite polarity between the pads. This lower-energy waveform
has proven more effective in clinical tests, as well as offering a reduced rate of complications and reduced
recovery time.
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A standard logo is clearly advertised. The location is indicated in OpenStreetMap by the
emergency=defibrillator tag.
Usage
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Unlike regular defibrillators, an automated external defibrillator requires minimal training to use. It
automatically diagnoses the heart rhythm and determines if a shock is needed. Automatic models will administer
the shock without the user’s command. Semi-automatic models will tell the user that a shock is needed, but the
user must tell the machine to do so, usually by pressing a button. In most circumstances, the user cannot
override a “no shock” advisory by an AED. Some AEDs may be used on children – those under 55 lbs (25 kg)
in weight or under age 8. If a particular model of AED is approved for pediatric use, all that is required is the use
of more appropriate pads. All AEDs approved for use in the United States use an electronic voice to prompt
users through each step. Because the user of an AED may be hearing impaired, many AEDs now include visual
prompts as well. Most units are designed for use by non-medical operators. Their ease of use has given rise to
the notion of public access defibrillation (PAD), which experts agree has the potential to be the single greatest
advance in the treatment of out-of-hospital cardiac arrest since the invention of CPR. Some advances include a
CPR feedback device by Zoll and Cardiac Science, non-polarized pads (they can be placed in either location)
by Cardiac Science, a status indicator most AEDS, and simple voice and text prompts with an adjustable skill
level, on most AEDs.
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Observational studies have shown that in out of hospital cardiac arrest, public access defibrillators when
used were associated with 40% median survival. When operated by non-dispatched lay first responders they
have the highest likelihood of leading to survival.
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Automated external defibrillators are now easy enough to use that most states in the United States include
the “good faith” use of an AED by any person under Good Samaritan laws. “Good faith” protection under a
Good Samaritan law means that a volunteer responder (not acting as a part of one’s occupation) cannot be held
civilly liable for the harm or death of a victim by providing improper or inadequate care, given that the harm or
death was not intentional and the responder was acting within the limits of their training and in good faith. In
the United States, Good Samaritan laws provide some protection for the use of AEDs by trained and untrained
responders. AEDs create little liability if used correctly; NREMT-B and many state Emergency Medical
Technician (EMT) training and many CPR classes incorporate or offer AED education as a part of their
programme. In addition to Good Samaritan laws, Ontario, Canada also has the “Chase McEachern Act (Heart
Defibrillator Civil Liability), 2007 (Bill 171 – Subsection N)”, passed in June, 2007, which protects individuals
from liability for damages that may occur from their use of an AED to save someone’s life at the immediate
scene of an emergency unless damages are caused by gross negligence.
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In 2012, automated external defibrillators were under scrutiny by the U.S. Food and Drug Administration
(FDA) which considered reclassifying AEDs as class III premarket approval devices. Technical malfunctions
likely contributed to more than 750 deaths in the 5-year period between 2004 and 2009, in most cases by
component failures or design errors. During the same period, up to 70 types of AEDs were recalled, including
recalls from every AED manufacturer in the world. In January and February 2015, the FDA issued this news
release: “The FDA issued a final order that will require AED manufacturers to submit premarket approval
applications (PMAs), which undergo a more rigorous review than what was required to market these devices in
the past. The agency’s strengthened review will focus on the critical requirements needed to ensure the safety
and reliability of AEDs and their necessary accessories, including batteries, pad electrodes, adapters and hardware
keys for pediatric use.” In the United Kingdom there is concern that poor maintenance may make public
defibrillators unreliable. The Henley Standard reported on 21 July 2017 that more than half the defibrillators in
Henley-on-Thames and the surrounding area were at risk of failing, either because of low battery power or
because adhesive pads had deteriorated.
History
The first use of an external defibrillator on a human was in 1947 by Claude Beck. The portable version of the
defibrillator was invented in the mid-1960s by Frank Pantridge in Belfast, Northern Ireland, a pioneer in
emergency medical treatment.
IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR
An implantable cardioverter-defibrillator (ICD) or automated implantable cardioverter defibrillator (AICD)
is a device implantable inside the body, able to perform cardioversion, defibrillation, and (in modern versions)
pacing of the heart. The device is therefore capable of correcting most life-threatening cardiac arrhythmias. The
ICD is the first-line treatment and prophylactic therapy for patients at risk for sudden cardiac death due to
ventricular fibrillation and ventricular tachycardia. Current devices can be programmed to detect abnormal
heart rhythms and deliver therapy via programmable antitachycardia pacing in addition to low-energy and high-
energy shocks. “AICD” was trademarked by the Boston Scientific corporation, so the more generic “ICD” is
preferred terminology.
Fig. A single chamber ICD with its right ventricular lead connected into the header; note, starting from the end of the
lead, the tip and adjacent first ring, used to sense the cardiac electrical activity and stimulate the right ventricle,
the coil and the two rings for atrial sensing.
Current device batteries last about 6–10 years, With advances in the technology (batteries with more capacity
or, potentially in the future with rechargeable batteries ) it may be possible to increase this well past 10 years.
The lead (the electrical cable connecting the device to the heart) has a much longer average longevity but can
incur various types of malfunction, specifically insulation failure or fracture of the conductor and require
replacement. The process of implantation of an ICD system is similar to implantation of a pacemaker. In fact,
ICDs are composed of an ICD generator and of wires. The first component or generator, contains a computer
chip or circuitry with RAM (memory), programmable software, a capacitor and a battery; this is implanted
typically under the skin in the left upper chest. The second part of the system is an electrode wire or wires that,
similar to pacemakers, are connected to the generator and passed through a vein to the right chambers of the
heart.
The lead usually lodges in the apex or septum of the right ventricle. Just like pacemakers, ICDs can have a
single wire or lead in the heart (in the right ventricle, single chamber ICD), two leads (in the right atrium and
right ventricle, dual chamber ICD) or three leads (biventricular ICD, one in the right atrium, one in the right
ventricle and one on the outer wall of the left ventricle). The difference between pacemakers and ICDs is that
pacemakers are also available as temporary units and are generally designed to correct slow heart rates, i.e.
bradycardia, while ICDs are often permanent safeguards against sudden life-threatening arrhythmias. Recent
developments include the subcutaneous ICD (S-ICD), and the ability to pace the left ventricle from multiple
sites near-simultaneously with Multipoint Pacing (Abbott).
Indications
Implantation of ICD is meant to prevent sudden cardiac death and is indicated under various conditions. Two
broad but distinct categories are primary and secondary prevention. Primary prevention refers to patients who
have not suffered a life-threatening arrhythmia episode. Secondary prevention has the strongest evidence for
benefit and it refers to survivors of cardiac arrest secondary to ventricular fibrillation or hemodynamically
unstable sustained ventricular tachycardia after reversible causes are excluded. Similarly, ICD use in primary
prevention is to prevent cardiac death in patients who are at risk for sustained ventricular tachycardia or ventricular
fibrillation. This population accounts for the bulk of all ICD implants. There are a multitude of guideline
indications for ICD use in primary preventions with varying degree of supporting evidence. Periodically, both
the American College of Cardiology (ACC)/American Heart Association (AHA) and European Society of
Cardiology provide an update to this guideline.
Some of the Class I indications are as follows:
• With LVEF ≤ 35% due to prior Myocardial Infarction (MI) who are at least 40 days post-MI and are
in NYHA Functional Class II or III
• With LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF ≤ 30%, and
are in NYHA Functional Class I
• With non-ischemic DCM who have an LVEF ≤ 35% and who are in NYHA Functional Class II or
III
• With non-sustained VT due to prior MI, LVEF < 40%, and inducible VF or sustained VT at
electrophysiological study
• With structural heart disease and spontaneous sustained VT, whether hemodynamically stable or
unstable
• With syncope of undetermined origin with clinically relevant, hemodynamically significant sustained
VT or VF induced at electrophysiological study
Clinical Trials
A number of clinical trials have demonstrated the superiority of the ICD over AAD (antiarrhythmic drugs) in
the prevention of death from malignant arrhythmias. The SCD-HeFT trial (published in 2005) showed a significant
all-cause mortality benefit for patients with ICD. Congestive heart failure patients that were implanted with an
ICD had an all-cause death risk 23% lower than placebo and an absolute decrease in mortality of 7.2 percentage
points after five years in the overall population. Reporting in 1999, the Antiarrhythmics Versus Implantable
Defibrillators (AVID) trial consisted of 1,016 patients, and deaths in those treated with AAD were more frequent
(n = 122) compared with deaths in the ICD groups (n = 80, p< 0.001). In 2002 the MADITII trial showed benefit
of ICD treatment in patients after myocardial infarction with reduced left ventricular function (EF<30). Initially
ICDs were implanted via thoracotomy with defibrillator patches applied to the epicardium or pericardium. The
device was attached via subcutaneous and transvenous leads to the device contained in a subcutaneous abdominal
wall pocket.
The device itself acts as an electrode. Most ICDs nowadays are implanted transvenously with the devices
placed in the left pectoral region similar to pacemakers. Intravascular spring or coil electrodes are used to
defibrillate. The devices have become smaller and less invasive as the technology advances. Current ICDs
weigh only 70 grams and are about 12.9 mm thick. A recent study by Birnie and colleagues at the University of
Ottawa Heart Institute has demonstrated that ICDs are underused in both the United States and Canada. An
accompanying editorial by Dr. Chris Simpson of Queen’s University explores some of the economic, geographic,
social and political reasons for this.
History
The development of the ICD was pioneered at Sinai Hospital in Baltimore by a team including Michel Mirowski,
Morton Mower, and William Staewen. Mirowski teamed up with Mower and Staewen and together they commenced
their research in 1969 but it was 11 years before they treated their first patient. Similar developmental work was
carried out almost coincidentally by Schuder and colleagues at the University of Missouri. More than a decade of
research went into the development of an implantable defibrillator that would automatically sense the onset of
ventricular fibrillation and deliver an electric countershock within 15–20 seconds, converting the rhythm to sinus
rhythm. Improved versions were programmed to be able to detect ventricular tachycardia, often a forerunner of
ventricular fibrillation. These were then called implantable cardioverters. The work was commenced against much
skepticism even by leading experts in the field of arrhythmias and sudden death. There was doubt that their ideas
would ever become a clinical reality. In 1972 Bernard Lown, the inventor of the external defibrillator, stated in the
journal Circulation – “The very rare patient who has frequent bouts of ventricular fibrillation is best treated in a
coronary care unit and is better served by an effective anti-arrhythmic programme or surgical correction of inadequate
coronary blood flow or ventricular malfunction. In fact, the implanted defibrillator system represents an imperfect
solution in search of a plausible and practical application.” The problems to be overcome were the design of a
system which would allow detection of ventricular fibrillation or ventricular tachycardia. Despite the lack of
financial backing and grants, they persisted and the first device was implanted in February 1980 at Johns Hopkins
Hospital by Dr. Levi Watkins, Jr. Modern ICDs do not require a thoracotomy and possess pacing, cardioversion,
and defibrillation capabilities.
Working Mechanism
ICDs constantly monitor the rate and rhythm of the heart and can deliver therapies, by way of an electrical
shock, when the heart rate exceeds a preset number. More modern devices have software designed to attempt a
discrimination between ventricular fibrillation and ventricular tachycardia (VT), and may try to pace the heart
faster than its intrinsic rate in the case of VT, to try to break the tachycardia before it progresses to ventricular
fibrillation. This is known as overdrive pacing, or anti-tachycardia pacing (ATP). ATP is only effective if the
underlying rhythm is ventricular tachycardia, and is never effective if the rhythm is ventricular fibrillation.
Many modern ICDs use a combination of various methods to determine if a fast rhythm is normal,
supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation.
Rate discrimination evaluates the rate of the lower chambers of the heart (the ventricles) and compares it to
the rate in the upper chambers of the heart (the atria). If the rate in the atria is faster than or equal to the rate in
the ventricles, then the rhythm is most likely not ventricular in origin, and is usually more benign. If this is the
case, the ICD does not provide any therapy, or withholds it for a programmable length of time.
Rhythm discrimination will see how regular a ventricular tachycardia is. Generally, ventricular tachycardia
is regular. If the rhythm is irregular, it is usually due to conduction of an irregular rhythm that originates in the
atria, such as atrial fibrillation. In the picture, an example of torsades de pointes can be seen; this represents a
form of irregular ventricular tachycardia. In this case, the ICD will rely on rate, not regularity, to make the
correct diagnosis.
Morphology discrimination checks the morphology of every ventricular beat and compares it to what the ICD
knows is the morphology of normally conducted ventricular impulse for the patient. This normal ventricular
impulse is often an average of a multiple of normal beats of the patient acquired in the recent past and known as a
template.
The integration of these various parameters is very complex, and clinically, the occurrence of inappropriate
therapy is still occasionally seen and a challenge for future software advancements.
Fig. Lead II electrocardiogram (known as “rhythm strip”) showing torsades de pointes being
shocked by an implantable cardioverter-defibrillator back to the patient’s baseline cardiac rhythm.
Living with an ICD

People who have an implanted cardioverter-defibrillator can live full lives. Usually the ICD may not improve
the quality of life of the patient, although it may provide a strong degree of reassurance. As with a pacemaker,
however, living with an ICD does impose some restrictions on the person’s lifestyle, outlined below.
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Almost all forms of physical activities can be performed by patients with an ICD. All forms of sports that do
not pose a risk of damaging the ICD or because of the underlying cardiomyopathy can be undertaken by the
patient. Special care should be taken not to put excessive strain on the shoulder, arm and torso area where the
ICD is implanted. Doing so may damage the ICD or the leads going from the ICD generator to the patient’s
heart. Particularly to be avoided are exercises that cause the clavicle to be pulled down towards the ribs, such as
lifting weights with the arm, on the ICD site, while standing.
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Equipment using large magnets or generating magnetic fields, or any similar environment, must be avoided
by patients with an ICD. As with other metallic objects, an ICD is normally a contraindication to the use of
magnetic resonance imaging (MRI). However, several ICD manufacturers have recently introduced MR-
Conditional ICDs, which allow the use of MRI under specified safe operating conditions.
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Implantable cardioverter defibrillators have demonstrated clear life-saving benefits, but concerns about patient
acceptance and psychological adjustment to the ICD have been the focus of much research. Researchers including
those from the field of cardiac psychology have concluded that the quality of life (QoL) of ICD patients is at
least equal to, or better than, that of those taking anti-arrhythmic medications. The largest study of examined
2,521 patients with stable heart failure in the SCD-HeFT trial. Results indicated that there were no differences
between ICD-treated and medication-treated groups at 30 months in patient-reported QoL. Psychological
adjustment following ICD implantation has also been well studied. In rare cases, the ICD can become infected
and is usually bacterial in origin but other organisms such as certain fungi have occasionally been implicated.
This is more likely to occur in people with diabetes, heart failure, kidney failure, or a suppressed immune
system. Anxiety is a common psychological side effect, with approximately 13–38% of ICD patients reporting
clinically significant anxiety. The primary etiological factors contributing to anxiety in ICD patients have not
been determined, however. Depressive symptoms are also common, but the incidence of these problems has
been shown to be similar to those observed in other cardiac patient groups, with approximately 24–41% of
patients with ICDs experiencing depressive symptoms. Problems in psychosocial adjustment to ICDs, including
the experience of anxiety, among spouses or other romantic partners are also prevalent. This phenomenon may
be related, at least in part, to shared shock anxiety and avoidance of physical and sexual contact.
Managing Initial Mechanical Ventilation in the Emergency Department 177
Chapter 6
Managing Initial Mechanical

Ventilation in the Emergency
Department

A medical emergency is an acuteinjury or illness that poses an immediate risk to a person’s life or long-term
health. These emergencies may require assistance from another person, who should ideally be suitably qualified
to do so, although some of these emergencies such as cardiovascular (heart), respiratory, and gastrointestinal
cannot be dealt with by the victim themselves. Dependent on the severity of the emergency, and the quality of
any treatment given, it may require the involvement of multiple levels of care, from first aiders to Emergency
Medical Technicians and emergency physicians. Any response to an emergency medical situation will depend
strongly on the situation, the patient involved and availability of resources to help them. It will also vary
depending on whether the emergency occurs whilst in hospital under medical care, or outside medical care (for
instance, in the street or alone at home).
RESPONSE
Summoning Emergency Services

For emergencies starting outside medical care, a key component of providing proper care is to summon the
emergency medical services (usually an ambulance), by calling for help using the appropriate local emergency
telephone number, such as 999, 911, 111, 112 or 000. After determining that the incident is a medical emergency
(as opposed to, for example, a police call), the emergency dispatchers will generally run through a questioning
system such as AMPDS in order to assess the priority level of the call, along with the caller’s name and location.
First Aid and Assisting Emergency Services

Those who are trained to perform first aid can act within the bounds of the knowledge they have, whilst
awaiting the next level of definitive care. Those who are not able to perform first aid can also assist by remaining
calm and staying with the injured or ill person. A common complaint of emergency service personnel is the
propensity of people to crowd around the scene of victim, as it is generally unhelpful, making the patient more
stressed, and obstructing the smooth working of the emergency services. If possible, first responders should
designate a specific person to ensure that the emergency services are called. Another bystander should be sent
to wait for their arrival and direct them to the proper location. Additional bystanders can be helpful in ensuring
that crowds are moved away from the ill or injured patient, allowing the responder adequate space to work.
Legal Protections for Responders

To prevent the delay of life-saving aid from bystanders, many states of the USA have “Good Samaritan
laws” which protect civilian responders who choose to assist in an emergency. In many situations, the general
public may delay giving care due to fear of liability should they accidentally cause harm. Good Samaritan laws
often protect responders who act within the scope of their knowledge and training, as a “reasonable person” in
the same situation would act. The concept of implied consent can protect first responders in emergency situations.
A first responder may not legally touch a patient without the patient’s consent.
However, consent may be either expressed or implied:
• If a patient is able to make decisions, they must give expressed, informed consent before aid is
given.
• However, if a patient is too injured or ill to make decisions – for example, if they are unconscious,
have an altered mental status, or cannot communicate - implied consent applies. Implied consent
means that treatment can be given, because it is assumed that the patient would want that care.
Usually, once care has begun, a first responder or first aid provider may not leave the patient or terminate
care until a responder of equal or higher training (such as an emergency medical technician) assumes care. This
can constitute abandonment of the patient, and may subject the responder to legal liability. Care must be continued
until the patient is transferred to a higher level of care; the situation becomes too unsafe to continue; or the
responder is physically unable to continue due to exhaustion or hazards. Unless the situation is particularly
hazardous, and is likely to further endanger the patient, evacuating an injured victim requires special skills, and
should be left to the professionals of the emergency medical and fire service.
The Chain of Survival

The principles of the chain of survival apply to medical emergencies where the patient is not breathing and
has no pulse.
This involves four stages:
1. Early access
2. Early cardiopulmonary resuscitation (CPR)
3. Early defibrillation
4. Early advanced life support (ALS).
CLINICAL RESPONSE
Within hospital settings, an adequate staff is generally present to deal with the average emergency situation.
Emergency medicine physicians have training to deal with most medical emergencies, and maintain CPR and
Advanced Cardiac Life Support (ACLS) certifications. In disasters or complex emergencies, most hospitals
have protocols to summon on-site and off-site staff rapidly. Both emergency department and inpatient medical
emergencies follow the basic protocol of Advanced Cardiac Life Support. Irrespective of the nature of the
emergency, adequate blood pressure and oxygenation are required before the cause of the emergency can be
eliminated. Possible exceptions include the clamping of arteries in severe hemorrhage.
NON-TRAUMA EMERGENCIES
While the golden hour is a trauma treatment concept, two emergency medical conditions have well-documented
time-critical treatment considerations: stroke and myocardial infarction (heart attack). In the case of stroke,
there is a window of three hours within which the benefit of thrombolytic drugs outweighs the risk of major
bleeding. In the case of a heart attack, rapid stabilization of fatal arrhythmias can prevent sudden cardiac arrest.
In addition, there is a direct relationship between time-to-treatment and the success of reperfusion (restoration
of blood flow to the heart), including a time-dependent reduction in the mortality and morbidity.

An emergency department (ED), also known as an accident and emergency department (A&E), emergency
room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in
emergency medicine, the acute care of patients who present without prior appointment; either by their own
means or by that of an ambulance. The emergency department is usually found in a hospital or other primary
care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for
a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention.
In some countries, emergency departments have become important entry points for those without other means
of access to medical care. The emergency departments of most hospitals operate 24 hours a day, although
staffing levels may be varied in an attempt to reflect patient volume.
HISTORY
Accident services were already provided by workmen’s compensation plans, railway companies, and
municipalities in Europe and the United States by the late mid-nineteenth century, but the first specialized
trauma care center in the world was opened in 1911 in the United States at the University of Louisville Hospital
in Louisville, Kentucky, and was developed by surgeon Arnold Griswold during the 1930s. Griswold also
equipped police and fire vehicles with medical supplies and trained officers to give emergency care while en
route to the hospital. Today, a typical hospital has its emergency department in its own section of the ground
floor of the grounds, with its own dedicated entrance. As patients can present at any time and with any complaint,
a key part of the operation of an emergency department is the prioritization of cases based on clinical need. This
process is called triage. Triage is normally the first stage the patient passes through, and consists of a brief
assessment, including a set of vital signs, and the assignment of a “chief complaint” (e.g. chest pain, abdominal
pain, difficulty breathing, etc.). Most emergency departments have a dedicated area for this process to take
place, and may have staff dedicated to performing nothing but a triage role. In most departments, this role is
fulfilled by a triage nurse, although dependent on training levels in the country and area, other health care
professionals may perform the triage sorting, including paramedics or physicians. Triage is typically conducted
face-to-face when the patient presents, or a form of triage may be conducted via radio with an ambulance crew;
in this method, the paramedics will call the hospital’s triage center with a short update about an incoming
patient, who will then be triaged to the appropriate level of care.
Most patients will be initially assessed at triage and then passed to another area of the department, or another
area of the hospital, with their waiting time determined by their clinical need. However, some patients may
complete their treatment at the triage stage, for instance if the condition is very minor and can be treated
quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient.
Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and
move straight to the appropriate part of the department. The resuscitation area, commonly referred to as “Trauma”
or “Resus”, is a key area in most departments. The most seriously ill or injured patients will be dealt with in this
area, as it contains the equipment and staff required for dealing with immediately life-threatening illnesses and
injuries. Typical resuscitation staffing involves at least one attending physician, and at least one and usually
two nurses with trauma and Advanced Cardiac Life Support training. These personnel may be assigned to the
resuscitation area for the entirety of the shift, or may be “on call” for resuscitation coverage (i.e. if a critical
case presents via walk-in triage or ambulance, the team will be paged to the resuscitation area to deal with the
case immediately). Resuscitation cases may also be attended by residents, radiographers, ambulance personnel,
respiratory therapists, hospital pharmacists and/or students of any of these professions depending upon the skill
mix needed for any given case and whether or not the hospital provides teaching services. Patients who exhibit
signs of being seriously ill but are not in immediate danger of life or limb will be triaged to “acute care” or
“majors,” where they will be seen by a physician and receive a more thorough assessment and treatment.
Examples of “majors” include chest pain, difficulty breathing, abdominal pain and neurological complaints.
Advanced diagnostic testing may be conducted at this stage, including laboratory testing of blood and/or urine,
ultrasonography, CT or MRI scanning. Medications appropriate to manage the patient’s condition will also be
given. Depending on underlying causes of the patient’s chief complaint, he or she may be discharged home
from this area or admitted to the hospital for further treatment.
Patients whose condition is not immediately life-threatening will be sent to an area suitable to deal with
them, and these areas might typically be termed as a prompt care or minors area. Such patients may still have
been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing.
Children can present particular challenges in treatment. Some departments have dedicated pediatrics areas, and
some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by
visiting the emergency department, as well as provide distraction therapy for simple procedures. Many hospitals
have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and mental
health nurses and social workers. There is typically at least one room for people who are actively a risk to
themselves or others (e.g. suicidal). Fast decisions on life-and-death cases are critical in hospital emergency
departments. As a result, doctors face great pressures to overtest and overtreat. The fear of missing something
often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head
bumps, and non-threatening stomach aches, with a high cost on the health care system.
NOMENCLATURE IN ENGLISH
Emergency department became commonly used when emergency medicine was recognised as a medical
specialty, and hospitals and medical centres developed departments of emergency medicine to provide services.
Other common variations include ‘emergency ward,’ ‘emergency centre’ or ‘emergency unit’. ‘Accident and
Emergency’ or ‘A&E’ is still the accepted term in the United Kingdom, Commonwealth countries, and the
Republic of Ireland, as are earlier terms such as ‘Casualty’ or ‘casualty ward’, which continue to be used
informally. The same applies to ‘emergency room’ or ‘ER’ in North America, originating when emergency
facilities were provided in a single room of the hospital by the department of surgery.
SIGNAGE
Regardless of naming convention, there is a widespread usage of directional signage in white text on a red
background across the world, which indicates the location of the emergency department, or a hospital with such
facilities. Signs on emergency departments may contain additional information. In some American states there
is close regulation of the design and content of such signs. For example, California requires wording such as
“Comprehensive Emergency Medical Service” and “Physician On Duty”, to prevent persons in need of critical
care from presenting to facilities that are not fully equipped and staffed.
In some countries, including the United States and Canada, a smaller facility that may provide assistance
in medical emergencies is known as a clinic. Larger communities often have walk-in clinics where people
with medical problems that would not be considered serious enough to warrant an emergency department
visit can be seen. These clinics often do not operate on a 24-hour basis. Very large clinics may operate as
“free-standing emergency centres,” which are open 24 hours and can manage a very large number of conditions.
However, if a patient presents to a free-standing clinic with a condition requiring hospital admission, he or
she must be transferred to an actual hospital, as these facilities do not have the capability to provide inpatient
care.
UNITED STATES
The Centers for Medicare and Medicaid Services (CMS) classified emergency departments into two types:
Type A, the majority, which are open 24 hours a day, 7 days a week, 365 days a year; and those who are not,
Type B. Many US emergency departments are exceedingly busy. A study found that in 2009, there were an
estimated 128,885,040 ED encounters in US hospitals. Approximately one-fifth of ED visits in 2010 were for
patients under the age of 18 years. In 2009–2010, a total of 19.6 million emergency department visits in the
United States were made by persons aged 65 and over. Most encounters (82.8 percent) resulted in treatment and
release; 17.2 percent were admitted to inpatient care. The 1986 Emergency Medical Treatment and Active
Labour Act is an act of the United States Congress, that requires Emergency Departments, if the associated
hospital receives payments from Medicare, to provide appropriate medical examination and emergency treatment
to all individuals seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to
pay. Like an unfunded mandate, there are no reimbursement provisions. Rates of ED visits rose between 2006
and 2011 for almost every patient characteristic and location. The total rate of ED visits increased 4.5% in that
time. However, the rate of visits for patients under one year of age declined 8.3%.
A survey of New York area doctors in February 2007 found that injuries and even deaths have been caused
by excessive waits for hospital beds by ED patients. A 2005 patient survey found an average ED wait time from
2.3 hours in Iowa to 5.0 hours in Arizona. One inspection of Los Angeles area hospitals by Congressional staff
found the EDs operating at an average of 116% of capacity (meaning there were more patients than available
treatment spaces) with insufficient beds to accommodate victims of a terrorist attack the size of the 2004
Madrid train bombings. Three of the five Level I trauma centres were on “diversion”, meaning ambulances
with all but the most severely injured patients were being directed elsewhere because the ED could not safely
accommodate any more patients. This controversial practice was banned in Massachusetts (except for major
incidents, such as a fire in the ED), effective 1 January 2009; in response, hospitals have devoted more staff to
the ED at peak times and moved some elective procedures to non-peak times. In 2009, there were 1,800 EDs in
the country. In 2011, about 421 out of every 1,000 people in the United States visited the emergency department;
five times as many were discharged as were admitted. Rural areas are the highest rate of ED visits (502 per
1,000 population) and large metro counties had the lowest (319 visits per 1,000 population). By region, the
Midwest had the highest rate of ED visits (460 per 1,000 population) and Western States had the lowest (321
visits per 1,000 population).
Most Common Reasons for Discharged Emergency Department Visits in the United States, 2011
Age (in years) Reason for Visit Visits
<1 Fever of unknown origin 270,000
1–17 Superficial injury, contusion 1.6 million
18–44 Sprains and Strains 3.2 million
45–64 Non-specific chest pain 1.5 million
65–84 Non-specific chest pain 643,000
85+ Superficial injury, contusion 213,000
In addition to the normal hospital based emergency departments a trend has developed in some states (including
Texas and Colorado) of emergency departments not attached to hospitals. These new emergency departments
are referred to as free standing emergency departments. The rationale for these operations is the ability to
operate outside of hospital policies that may lead to increased wait times and reduced patient satisfaction.
UNITED KINGDOM
All A&E departments throughout the United Kingdom are financed and managed publicly by the NHS of
each constituent country (England, Scotland, Wales and Northern Ireland). As with most other NHS services,
emergency care is provided to all, both resident citizens and those not ordinarily resident in the UK, free at the
point of need and regardless of any ability to pay.
In England departments are divided into three categories:
• Type 1 A&E department – major A&E, providing a consultant-led 24 hour service with full
resuscitation facilities
• Type 2 A&E department – single specialty A&E service (e.g. ophthalmology, dentistry)
• Type 3 A&E department – other A&E/ minor injury unit/ walk-in centre, treating minor injuries and illnesses
Historically, waits for assessment in A&E were very long in some areas of the UK. In October 2002, the
Department of Health introduced a four-hour target in emergency departments that required departments in
England to assess and treat patients within four hours of arrival, with referral and assessment by other departments
if deemed necessary. It was expected that the patients would have physically left the department within the four
hours. Present policy is that 95% of all patient cases do not “breach” this four-hour wait. The busiest departments
in the UK outside London include University Hospital of Wales in Cardiff, The North Wales Regional Hospital
in Wrexham, the Royal Infirmary of Edinburgh and Queen Alexandra Hospital in Portsmouth. In July 2014, the
QualityWatch research programme published in-depth analysis which tracked 41 million A&E attendances
from 2010 to 2013. This showed that the number of patients in a department at any one time was closely linked
to waiting times, and that crowding in A&E had increased as a result of a growing and ageing population,
compounded by the freezing or reduction of A&E capacity. Between 2010/11 and 2012/13 crowding increased
by 8%, despite a rise of just 3% in A&E visits, and this trend looks set to continue. Other influential factors
identified by the report included temperature (with both hotter and colder weather pushing up A&E visits),
staffing and inpatient bed numbers. A&E services in the UK are often the focus of a great deal of media and
political interest, and data on A&E performance is published weekly. However, this is only one part of a complex
urgent and emergency care system. Reducing A&E waiting times therefore requires a comprehensive, coordinated
strategy across a range of related services. Many A&E departments are crowded and confusing. Many of those
attending are understandably anxious, and some are mentally ill, and especially at night are under the influence
of alcohol or other substances. Pearson Lloyd’s redesign – ‘A Better A&E’ – is claimed to have reduced aggression
against hospital staff in the departments by 50 per cent. A system of environmental signage provides location-
specific information for patients. Screens provide live information about how many cases are being handled
and the current status of the A&E department. Waiting times for patients to be seen at A&E have been rising.
CRITICAL CONDITIONS HANDLED
Cardiac Arrest
Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency
department already in this state. Treatment is basic life support and advanced life support as taught in advanced
life support and advanced cardiac life support courses.
Heart Attack
Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be
triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will
be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine
will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl
trinitrate (nitroglycerin) (GTN or NTG) will be given, unless contraindicated by the presence of other drugs,
such as drugs that treat erectile dysfunction. An ECG that reveals ST segment elevation or new left bundle
branch block suggests complete blockage of one of the main coronary arteries. These patients require immediate
reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting
medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing
significantly the mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is
somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a
nearby facility with facilities for angioplasty.
Trauma
Major trauma, the term for patients with multiple injuries, often from a motor vehicle crash or a major fall, is
initially handled in the Emergency Department. However, trauma is a separate (surgical) specialty from emergency
medicine (which is itself a medical specialty, and has certifications in the United States from the American Board
of Emergency Medicine). Trauma is treated by a trauma team who have been trained using the principles taught in
the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons.
Some other international training bodies have started to run similar courses based on the same principles. The
services that are provided in an emergency department can range from x-rays and the setting of broken bones to
those of a full-scale trauma centre. A patient’s chance of survival is greatly improved if the patient receives
definitive treatment (i.e. surgery or reperfusion) within one hour of an accident (such as a car accident) or onset of
acute illness (such as a heart attack). This critical time frame is commonly known as the “golden hour”. Some
emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a
patient to a trauma centre. This inter-hospital transfer is often done when a patient requires advanced medical care
unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.
Mental Illness
Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions
(including many US states), patients who appear to be mentally ill and to present a danger to themselves or
others may be brought against their will to an emergency department by law enforcement officers for psychiatric
examination. The emergency department conducts medical clearance rather than treats acute behavioural
disorders. From the emergency department, patients with significant mental illness may be transferred to a
psychiatric unit (in many cases involuntarily).
Asthma and COPD

Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease
(COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline,
have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Non-
invasive ventilation in the ED has reduced the requirement for tracheal intubation in many cases of severe
exacerbations of COPD.
SPECIAL FACILITIES, TRAINING, AND EQUIPMENT

An ED requires different equipment and different approaches than most other hospital divisions. Patients
frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and
information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to
work quickly and effectively even with minimal information. ED staff must also interact efficiently with pre-
hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-
hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in
using (and safely removing) specialized equipment, since devices such as military anti-shock trousers (“MAST”)
and traction splints require special procedures. Among other reasons, given that they must be able to handle
specialized equipment, physicians can now specialize in emergency medicine, and EDs employ many such
specialists. ED staff have much in common with ambulance and fire crews, combat medics, search and rescue
teams, and disaster response teams.
Often, joint training and practice drills are organized to improve the coordination of this complex response
system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing,
returning, or reimbursing for costly items. Cardiac arrest and major trauma are relatively common in EDs, so
defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival
in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this
specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which
spread first to ambulances, then in an automatic version to police cars and fire apparatus, and most recently to
public spaces such as airports, office buildings, hotels, and even shopping malls. Because time is such an
essential factor in emergency treatment, EDs typically have their own diagnostic equipment to avoid waiting
for equipment installed elsewhere in the hospital. Nearly all have radiographic examination rooms staffed by
dedicated Radiographer, and many now have full radiology facilities including CT scanners and ultrasonography
equipment. Laboratory services may be handled on a priority basis by the hospital lab, or the ED may have its
own “STAT Lab” for basic labs (blood counts, blood typing, toxicology screens, etc.) that must be returned very
rapidly.
NON-EMERGENCY USE
Metrics applicable to the ED can be grouped into three main categories, volume, cycle time, and patient
satisfaction. Volume metrics including arrivals per hour, percentage of ED beds occupied and age of patients
are understood at a basic level at all hospitals as an indication for staffing requirements. Cycle time metrics are
the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort
is needed to collect and analyze this data. Patient satisfaction metrics, already commonly collected by nursing
groups, physician groups and hospitals, are useful in demonstrating the impact of changes in patient perception
of care over time. Since patient satisfaction metrics are derivative and subjective, they are less useful in primary
process improvement.
Health information exchanges can reduce non-urgent ED visits by supplying current data about admissions,
discharges, and transfers to health plans and accountable care organizations, allowing them to shift ED use to
primary care settings. In all Primary Care Trusts there are out of hours medical consultations provided by
general practitioners or nurse practitioners. In the United States, and many other countries, hospitals are beginning
to create areas in their emergency rooms for people with minor injuries. These are commonly referred as Fast
Track or Minor Care units. These units are for people with non-life-threatening injuries. The use of these units
within a department have been shown to significantly improve the flow of patients through a department and to
reduce waiting times. Urgent care clinics are another alternative, where patients can go to receive immediate
care for non-life-threatening conditions. To reduce the strain on limited ED resources, American Medical
Response created a checklist that allows EMTs to identify intoxicated individuals who can be safely sent to
detoxification facilities instead.
OVERCROWDING
Emergency department overcrowding is when function of a department is hindered by an inability to treat all
patients in an adequate manner. This is a common occurrence in emergency departments worldwide.
Overcrowding causes inadequate patient care which leads to poorer patient outcomes. To address this problem,
escalation policies are used by emergency departments when responding to an increase in demand (e.g., a
sudden inflow of patients) or a reduction in capacity (e.g., a lack of beds to admit patients). The policies aim to
maintain the ability to deliver patient care, without compromising safety, by modifying ‘normal’ processes.
Emergency Department Waiting Times

Emergency department (ED) waiting times have a serious impact on patient mortality, morbidity with
readmission in less than 30 days, length of stay, and patient satisfaction. A review of the literature bears out the
logical premise that since the outcome of treatment for all diseases and injuries is time-sensitive, the sooner
treatment is rendered, the better the outcome. Various studies reported significant associations between waiting
times and higher mortality and morbidity among those who survived. It is clear from the literature that untimely
hospital deaths and morbidity can be reduced by reductions in ED waiting times.
Exit Block
While a significant proportion of people attending emergency departments are discharged home after treatment,
many require admission for ongoing observation or treatment, or to ensure adequate social care before discharge
is possible. If people requiring admission are not able to be moved to inpatient beds swiftly, “exit block” or
“access block” occurs. This often leads to crowding and impairs flow to the point that it can lead to delays in
appropriate treatment for newly presenting cases (“arrival access block”). This phenomenon is more common
in densely populated areas, and affects pediatric departments less than adults ones. Exit block can lead to delays
in care both in the people awaiting inpatient beds (“boarding”) and those who newly present to an exit blocked
department. Various solutions have been proposed, such as changes in staffing or increasing inpatient capacity.
Frequent Presenters
Frequent presenters are persons who will present themselves at a hospital multiple times, usually those with
complex medical requirements or with psychological issues complicating medical management. These persons
contribute to overcrowding and typically require more hospital resources although they do not account for a
significant amount of visits. To help prevent inappropriate emergency department use and return visits, some
hospitals offer care coordination and support services such as at-home and in-shelter transitional primary care
for frequent presenters and short-term housing for homeless patients recovering after discharge.
EMERGENCY DEPARTMENTS IN THE MILITARY

Emergency departments in the military benefit from the added support of enlisted personnel who are capable
of performing a wide variety of tasks they have been trained for through specialized military schooling. For
example, in United States Military Hospitals, Air Force Aerospace Medical Technicians and Navy Hospital
Corpsmen perform tasks that fall under the scope of practice of both doctors (i.e. sutures, staples and incision
and drainages) and nurses (i.e. medication administration, foley catheter insertion, and obtaining intravenous
access) and also perform splinting of injured extremities, nasogastric tube insertion, intubation, wound cauterizing,
eye irrigation, and much more. Often, some civilian education and/or certification will be required such as an
EMT certification, in case of the need to provide care outside the base where the member is stationed. The
presence of highly trained enlisted personnel in an Emergency Departments drastically reduces the workload
on nurses and doctors.
VIOLENCE AGAINST HEALTH CARE WORKERS

According to a survey at an urban inner-city tertiary care centre in Vancouver, 57% of health care workers
were physically assaulted in 1996. 73% were afraid of patients as a result of violence, almost half, 49%, hid
their identities from patients, 74% had reduced job satisfaction. Over one-quarter of the respondents took days
off because of violence. Of respondents no longer working in the emergency department, 67% reported that
they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence
prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the
company of family and friends were the most frequent coping strategies cited by those surveyed.
MEDICATION ERRORS
Medication errors are issues that lead to incorrect medication distribution or potential for patient harm. As of
2014, around 3% of all hospital-related adverse effects were due to medication errors in the emergency department
(ED); between 4% and 14% of medications given to patients in the ED were incorrect and children were
particularly at risk. Errors can arise if the doctor prescribes the wrong medication, if the prescription intended
by the doctor is not the one actually communicated to the pharmacy due to an illegibly-written prescription or
misheard verbal order, if the pharmacy dispenses the wrong medication, or if the medication is then given to the
wrong person. The ED is a riskier environment than other areas of the hospital due to medical practitioners not
knowing the patient as well as they know longer term hospital patients, due to time pressure caused by
overcrowding, and due to the emergency-driven nature of the medicine that is practiced there.

Emergency medical services, also known as ambulance services or paramedic services (abbreviated to the
initialism EMS, EMAS, EMARS or SAMU in some countries), are a type of emergency service dedicated to
providing out-of-hospital acute medical care, transport to definitive care, and other medical transport to patients
with illnesses and injuries which prevent the patient from transporting themselves. Emergency medical services
may also be locally known as a paramedic service, a first aid squad, FAST squad, emergency squad, rescue
squad, ambulance squad, ambulance service, ambulance corps, or life squad. The goal of most emergency
medical services is to either provide treatment to those in need of urgent medical care, with the goal of
satisfactorily treating the presenting conditions, or arranging for timely removal of the patient to the next point
of definitive care. This is most likely an emergency department at a hospital. The term emergency medical
service evolved to reflect a change from a simple system of ambulances providing only transport, to a system in
which preliminary medical care is given on scene and during transport. In some developing regions, the term is
not used, or may be used inaccurately, since the service in question does not provide treatment to the patients,
but only the provision of transport to the point of care. In most places in the world, the EMS is summoned by
members of the public (or other emergency services, businesses, or authorities) via an emergency telephone
number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal
with the situation. In some parts of the world, the emergency medical service also encompasses the role of
moving patients from one medical facility to an alternative one; usually to facilitate the provision of a higher
level or more specialized field of care but also to transfer patients from a specialized facility to a local hospital
or nursing home when they no longer require the services of that specialized hospital, such as following successful
cardiac catheterization due to a heart attack. In such services, the EMS is not summoned by members of the
public but by clinical professionals (e.g. physicians or nurses) in the referring facility. Specialized hospitals
that provide higher levels of care may include services such as neonatal intensive care (NICU), pediatric intensive
care (PICU), state regional burn centres, specialized care for spinal injury and/or neurosurgery, regional stroke
centers, specialized cardiac care (Cardiac catheterization), and specialized/regional trauma care. In some
jurisdictions, EMS units may handle technical rescue operations such as extrication, water rescue, and search
and rescue. Training and qualification levels for members and employees of emergency medical services vary
widely throughout the world. In some systems, members may be present who are qualified only to drive
ambulances, with no medical training. In contrast, most systems have personnel who retain at least basic first
aid certifications, such as Basic Life Support (BLS).
HISTORY
Emergency care in the field has been rendered in different forms since the beginning of recorded history.
The New Testament contains the parable of the Good Samaritan, where a man who was beaten is cared for by
a Samaritan. Luke 10:34 (NIV) – “He went to him and bandaged his wounds, pouring on oil and wine. Then he
put the man on his own donkey, took him to an inn and took care of him.” Also during the Middle Ages, the
Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield. The first use of
the ambulance as a specialized vehicle, in battle came about with the ambulances volantes designed by Dominique
Jean Larrey (1766–1842), Napoleon Bonaparte’s chief surgeon. Larrey was present at the battle of Spires,
between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by
the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of
battle) until after hostilities had ceased, and set about developing a new ambulance system. Having decided
against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons,
which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment
in the field. Larrey’s projects for ‘flying ambulances’ were first approved by the Committee of Public Safety in
1794. Larrey subsequently entered Napoleon’s service during the Italian campaigns in 1796, where his ambulances
were used for the first time at Udine, Padua and Milan, and he adapted his ambulances to the conditions, even
developing a litter which could be carried by a camel for a campaign in Egypt. In civilian ambulances, a major
advance was made (which in future years would come to shape policy on hospitals and ambulances) with the
introduction of a transport carriage for cholera patients in London during 1832. The statement on the carriage,
as printed in The Times, said “The curative process commences the instant the patient is put in to the carriage;
time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily
that the hospitals may be less numerous and located at greater distances from each other”. This tenet of ambulances
providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical
planning.
The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati, Ohio
(now the Cincinnati General) by 1865. This was soon followed by other services, notably the New York service
provided out of Bellevue Hospital which started in 1869 with ambulances carrying medical equipment, such as
splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine. In June 1887 the St John
Ambulance Brigade was established to provide first aid and ambulance services at public events in London. It
was modelled on a military-style command and discipline structure. The earliest emergency medical service
was reportedly the rescue society founded by Jaromir V. Mundy, Count J. N. Wilczek, and Eduard Lamezan-
Salins in Vienna after the disastrous fire at the Vienna Ringtheater in 1881. Named the “Vienna Voluntary
Rescue Society,” it served as a model for similar societies worldwide. Also in the late 19th century, the automobile
was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by
steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However,
the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael
Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local
businessmen, in February 1899. This was followed in 1900 by New York City, who extolled its virtues of
greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile
ambulances were electrically powered with 2 hp motors on the rear axle. American historians claim that the
world’s first component of civilian pre-hospital care on scene began in 1928, when “Julien Stanley Wise started
the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, which was the first land-based rescue squad
in the nation.” Canadian historians dispute this with the city of Toronto claiming “The first formal training for
ambulance attendants was conducted in 1892.”
During World War One, further advances were made in providing care before and during transport –
traction splints were introduced during World War I, and were found to have a positive effect on the morbidity
and mortality of patients with leg fractures. Two-way radios became available shortly after World War I,
enabling for more efficient radio dispatch of ambulances in some areas. Prior to World War II, there were
some areas where a modern ambulance carried advanced medical equipment, was staffed by a physician, and
was dispatched by radio. In many locations, however, ambulances were hearses – the only available vehicle
that could carry a recumbent patient – and were thus frequently run by funeral homes. These vehicles, which
could serve either purpose, were known as combination cars. Prior to World War II, hospitals provided
ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it
became difficult for many hospitals to maintain their ambulance operations. City governments in many cases
turned ambulance services over to the police or fire department. No laws required minimal training for
ambulance personnel and no training programmes existed beyond basic first aid. In many fire departments,
assignment to ambulance duty became an unofficial form of punishment. Advances in the 1960s, especially
the development of CPR and defibrillation as the standard form of care for out-of-hospital cardiac arrest,
along with new pharmaceuticals, led to changes in the tasks of the ambulances. In Belfast, Northern Ireland
the first experimental mobile coronary care ambulance successfully resuscitated patients using these
technologies. One well-known report in the US during that time was Accidental Death and Disability: The
Neglected Disease of Modern Society. This report is commonly known as The White Paper. These studies,
along with the White Paper report, placed pressure on governments to improve emergency care in general,
including the care provided by ambulance services. In the US prior to the 1970s, ambulance service was
largely unregulated. While some areas ambulances were staffed by advanced first-aid-level responders, in
other areas, it was common for the local undertaker, having the only transport in town in which one could lie
down, to operate both the local furniture store (where he would make coffins as a sideline) and the local
ambulance service. The government reports resulted in the creation of standards in ambulance construction
concerning the internal height of the patient care area (to allow for an attendant to continue to care for the
patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several
other factors. In 1971 a progress report was published at the annual meeting, by the then president of American
Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study was a “superb white paper”
that “jolted and wakened the entire structure of organized medicine. This report is created as a “prime mover”
and made the “single greatest contribution of its kind to the improvement of emergency medical services”.
Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital
setting. Such advancements included Dr. R Adams Cowley creating the country’s first statewide EMS
programme, in Maryland.
SERVICE PROVIDERS
Some countries closely regulate the industry (and may require anyone working on an ambulance to be
qualified to a set level), whereas others allow quite wide differences between types of operator.
• Government Ambulance Service: Operating separately from (although alongside) the fire and police
services of the area, these ambulances are funded by local, provincial or national governments. In
some countries, these only tend to be found in big cities, whereas in countries such as the United
Kingdom, almost all emergency ambulances are part of a national health system. In the United States,
ambulance services provided by a local government are often referred to as “third service” EMS (the
Fire Department, Police Department, and separate EMS forming an emergency services trio) by the
employees of said service, as well as other city officials and residents. Government Ambulance
Services also have to take Civil service exams just like government fire departments and police. In
the United States, certain federal government agencies employ Emergency Medical Technicians at
the Basic and Advanced Life Support levels, such as the National Park Service and the Federal
Bureau of Prisons.
• Fire or Police Linked Service: In countries such as the United States, Japan, France, and parts of
India; ambulances can be operated by the local fire or police services. Fire-based EMS is the most
common model in the United States, where nearly all urban fire departments provide EMS and a
majority of emergency transport ambulance services in large cities are part of fire departments. It is
somewhat rare for a police department in the United States to provide EMS or ambulance services,
although many police officers have basic medical training.
• Volunteer Ambulance Service: Charities or non-profit companies operate ambulances, both in an
emergency and patient transport function. This may be along similar lines to volunteer fire companies,
as they provide the main service for an area, and are either community or privately owned. They
may be linked to a volunteer fire service, with volunteers providing both services. There are charities
who focus on providing ambulances for the community, or for cover at private events (sports etc.).
The Red Cross provides this service in some parts of the world on a volunteer basis (and in others as
a Private Ambulance Service), as do other smaller organisations such as St John Ambulance and the
Order of Malta Ambulance Corps. These volunteer ambulances may be seen providing support to
the full time ambulance crews during times of emergency. In some cases the volunteer charity may
employ paid members of staff alongside volunteers to operate a full time ambulance service, such in
some parts of Australia, Ireland and most importantly Germany and Austria. First Aid Squads are
common names for establishments of volunteer Emergency Medical Services. First Aid Squads receive
support from the town and rely on fundraisers to stay in operation. Ambulance crews in First Aid
Squads range from 2-5 people all of whom need to be state-certified EMTs. Shifts range from 6-12
hours with some members pulling 24-hour shifts when needed. Some towns rely solely on volunteer
ambulance services while others have township-run services or paid, private companies. In the United
States, volunteer ambulances are more rare, but can still be seen in both metropolitan and rural
areas. One example of a volunteer ambulance service which operates in a major city is the New
York City-based Hatzalah organisation.
• Private Ambulance Service: Normal commercial companies with paid employees, but often on contract
to the local or national government. Private companies may provide only the patient transport elements
of ambulance care (i.e. non-urgent), but in some places, they are contracted to provide emergency
care, or to form a ‘second tier’ response, where they only respond to emergencies when all of the
full-time emergency ambulance crews are busy. This may mean that a government or other service
provide the ‘emergency’ cover, whilst a private firm may be charged with ‘minor injuries’ such as
cuts, bruises or even helping the mobility-impaired if they have for example fallen and simply need
help to get up again, but do not need treatment. This system has the benefit of keeping emergency
crews available at all times for genuine emergencies. These organisations may also provide services
known as ‘Stand-by’ cover at industrial sites or at special events. In Latin America, private ambulance
companies are often the only readily available EMS service
• Combined Emergency Service: These are full service emergency service agencies, which may be
found in places such as airports or large colleges and universities. Their key feature is that all
personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer
(police function). They may be found in smaller towns and cities, where size or budget does not
warrant separate services. This multi-functionality allows to make the most of limited resource or
budget, but having a single team respond to any emergency.
• Hospital-based Service: Hospitals may provide their own ambulance service as a service to the
community, or where ambulance care is unreliable or chargeable. Their use would be dependent on
using the services of the providing hospital. Most Advanced Life Support (Paramedic) services in
the United States are this type of service.
• Charity Ambulance: This special type of ambulance is provided by a charity for the purpose of
taking sick children or adults on trips or vacations away from hospitals, hospices or care homes
where they are in long term care. Examples include the UK’s ‘Jumbulance’ project.
• Company Ambulance: Many large factories and other industrial centres, such as chemical plants, oil
refineries, breweries and distilleries have ambulance services provided by employers as a means of
protecting their interests and the welfare of their staff. These are often used as first response vehicles
in the event of a fire or explosion.
PURPOSE
Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life,
Prevent Further Injury, and Promote Recovery. This common theme in medicine is demonstrated by the “star of
life”. The Star of Life shown here, where each of the ‘arms’ to the star represent one of the six points, are used
to represent the six stages of high quality pre-hospital care, which are:
1. Early detection – members of the public, or another agency, find the incident and understand the problem
2. Early reporting – the first persons on scene make a call to the emergency medical services (911) and
provide details to enable a response to be mounted
3. Early response – the first professional (EMS) rescuers are dispatched and arrive on scene as quickly
as possible, enabling care to begin
4. Good on-scene/ field care – the emergency medical service provides appropriate and timely
interventions to treat the patient at the scene of the incident without doing further harm.
5. Care in transit -– the emergency medical service load the patient in to suitable transport and continue
to provide appropriate medical care throughout the journey
6. Transfer to definitive care – the patient is handed over to an appropriate care setting, such as the
emergency department at a hospital, in to the care of physicians.
LEVELS OF CARE
Emergency Medical Service is provided by a variety of individuals, using a variety of methods. To some
extent, these will be determined by country and locale, with each individual country having its own ‘approach’
to how EMS should be provided, and by whom. In some parts of Europe, for example, legislation insists that
efforts at providing advanced life support (ALS) Mobile Intensive Care Units (MICU) services must be physician-
staffed, while other permit some elements of that skill set to specially trained nurses, but have no paramedics.
Elsewhere, as in North America, the UK and Australasia, ALS services are performed by paramedics, but rarely
with the type of direct “hands-on” physician leadership seen in Europe. Increasingly, particularly in the UK and
in South Africa, the role is being provided by specially trained paramedics who are independent practitioners in
their own right. Beyond the national model of care, the type Emergency Medical Service will be determined by
local jurisdictions and medical authorities, based upon the needs of the community, and the economic resources
to support it. A category of emergency medical service which is known as ‘medical retrieval’ or rendez vous
MICU protocol in some countries (Australia, NZ, Great Britain, and Francophone Canada) refers to critical
care transport of patients between hospitals (as opposed to pre-hospital). Such services are a key element in
regionalized systems of hospital care where intensive care services are centralized to a few specialist hospitals.
An example of this is the Emergency Medical Retrieval Service in Scotland.
In the United States, this is referred to as “Critical Care Transport” and qualifications for this role vary by
state and can include a nurse, paramedic and/or an EMT. Generally speaking, the levels of service available will
fall into one of three categories; Basic Life Support (BLS), Advanced Life Support (ALS), and Critical Care
Transport (CCT) by traditional health care professionals, meaning nurses and/or physicians working in the pre-
hospital setting and even on ambulances. In some jurisdictions, a fourth level, Intermediate Life Support (ILS),
which is essentially a BLS provider with a moderately expanded skill set, may be present, but this level rarely
functions independently, and where it is present may replace BLS in the emergency part of the service. When
this occurs, any remaining staff at the BLS level is usually relegated to the non-emergency transportation
function. Job titles typically include Emergency Medical Technician, Ambulance Technician, or Paramedic.
These ambulance care givers are generally professionals or paraprofessionals and in some countries their use is
controlled through training and registration. While these job titles are protected by legislation in some countries,
this protection is by no means universal, and anyone might, for example, call themselves an ‘EMT’ or a
‘paramedic’, regardless of their training, or the lack of it. In some jurisdictions, both technicians and paramedics
may be further defined by the environment in which they operate, including such designations as ‘Wilderness’,
‘Tactical’, and so on.
Basic Life Support (BLS)
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An emergency worker (Police Officer, Firefighter, Ambulance Volunteer) whose duties include provision of
immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen
administration, cardio-pulmonary resuscitation (CPR), and automated external defibrillator (AED) usage. The
first responder training is considered a bare minimum for emergency service workers who may be sent out in
response to an emergency call. First responders are commonly dispatched by the ambulance service to arrive
quickly and stabilize the patient before an ambulance can arrive and to then assist the ambulance crew.
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Most jurisdictions require two licensed pre-hospital providers to operate a licensed ambulance. Some
jurisdictions separate the ‘driver’ and ‘attendant’ functions, employing ambulance driving staff with no medical
qualification (or just a first aid certificate), whose job is to drive ambulances. While this approach persists in
some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in
radio communications, ambulance operations and emergency response driving skills.
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Ambulance Care Assistants (ACAs) have varying levels of training across the world. In many countries,
such staff are usually only required to perform patient transport duties (which can include stretcher or wheelchair
cases), rather than acute care. However, there remain both countries and individual jurisdictions in which
economics will not support ALS service, and the efforts of such individuals may represent the only EMS
available. Dependent on the provider (and resources available), they may be trained in first aid or extended
skills such as use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some
services, they may also provide emergency cover when other units are not available, or when accompanied by
a fully qualified technician or paramedic.
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Emergency medical technicians, also known as Ambulance Technicians in the UK and EMT in the United
States. In the United States, EMT is usually made up of 3 levels. EMT-B, EMT-I (EMT-A in some states) and
EMT-Paramedic. The National Registry of EMT New Educational Standards for EMS renamed the provider
levels as follows: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced
EMT (AEMT), and Paramedic. EMTs are usually able to perform a wide range of emergency care skills,
such as Automated defibrillation, care of spinal injuries and oxygen therapy. In few jurisdictions, some
EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs, more
advanced airway procedures, CPAP, and limited cardiac monitoring. Most advanced procedures and skills
are not within the national scope of practice for an EMT. As such most states require additional training and
certifications to perform above the national curriculum standards. In the US, an EMT certification requires
intense courses and training in field skills. A certification expires after two years and holds a requirement of
taking 48 CEUs (continuing education credits). 24 of these credits must be in refresher courses while the
other 24 can be taken in a variety ways such as emergency driving training, pediatric, geriatric, or bariatric
care, specific traumas, etc.
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Some emergency medical technicians, known as Wilderness Emergency Medical Technicians (WEMTs),
are trained with protocols adapted for the non-urban, backcountry environments (remote, austere, or resource-
deficient areas). Not formally referred to as such, wilderness EMS-like systems (WEMS) have been developed
to deliver standardization and professionalism to medical responses and education in the wilderness arena.
Examples include the international safety organization, the National Ski Patrol or the regional-responding
Appalachian Search and Rescue Conference (USA based). Like traditional EMS providers, all wilderness
emergency medical (WEM) providers must still operate under on-line or off-line medical oversight. To assist
physicians in the skills necessary to provide this oversight, the Wilderness Medical Society and the National
Association of EMS Physicians jointly supported the development in 2011 of a unique “Wilderness EMS
Medical Director” certification course, which was cited by the Journal of EMS as one of the Top 10 EMS
Innovations of 2011. Skills taught in WEMT courses exceeding the EMT-Basic scope of practice include
catheterization, antibiotic administration, use of intermediate Blind Insertion Airway Devices (i.e. King
Laryngeal Tube), Nasogastric Intubation, and simple suturing; however, the scope of practice for the WEMT
still falls under BLS level care. A multitude of organizations provide WEM training, including private schools,
non-profit organizations such as the Appalachian Center for Wilderness Medicine and the Wilderness EMS
Institute, military branches, community colleges and universities, EMS-college-hospital collaborations, and
others.
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An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS
system is the use of highly trained dispatch personnel who can provide “pre-arrival” instructions to callers
reporting medical emergencies. They use carefully structured questioning techniques and provide scripted
instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions,
bleeding, childbirth, and cardiac arrest. Even with a fast response time by a first responder measured in minutes,
some medical emergencies evolve in seconds. Such a system provides, in essence, a “zero response time,” and
can have an enormous impact on positive patient outcomes.
Advanced Life Support (ALS)
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A paramedic has a high level of pre-hospital medical training and usually involves key skills not
performed by technicians, often including cannulation (and with it the ability to use a range of drugs to
relieve pain, correct cardiac problems, and perform endotracheal intubation), cardiac monitoring, tracheal
intubation, pericardiocentesis, cardioversion, needle decompression and other skills such as performing a
cricothyrotomy. The most important function of the paramedic is to identify and treat any life-threatening
conditions and then to assess the patient carefully for other complaints or findings that may require
emergency treatment. In many countries, this is a protected title, and use of it without the relevant
qualification may result in criminal prosecution. In the United States, paramedics represent the highest
licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such
as Wilderness ALS Care, Flight Paramedic Certification (FP-C), and Critical Care Emergency Medical
Transport Programme certification.
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Recently studies have looked at new level of pre-hospital care. What has developed is the critical care
paramedic, also called an advanced practice Paramedic in some parts of United States and Canada. These
providers represent a higher level of licensure above that of the DOT or respective paramedic level curriculum.
The training, permitted skills, and certification requirements vary from one jurisdiction to the next. These
providers transport critically ill or injured patients from one hospital to a receiving hospital with higher level
of care (ie.. cardiac catheterization, trauma services or specialized ICU services) not available at referring
facility. These paramedics receive additional training beyond normal EMS medicine. The Board for Critical
Care Transport Certification (BCCTPC®) has developed a certification exam for flight and ground critical
care paramedics Some educational facilities that provide this training are UMBC Critical Care Emergency
Medical Transport Programme or “Cleveland Clinic CICP programme”..Individual services such as “Wake
County EMS”.and”MedStar EMS”. Have developed ‘in-house’ advanced practice paramedic providers. These
providers have a vast array of and medications to handle complex medical and trauma patients. Examples of
medication are Dopamine, Dobutamine, Propofol, blood and blood products to name just a few. Some examples
of skills include, but not limited to, life support systems normally restricted to the ICU or critical care
hospital setting such as mechanical ventilators, Intra-aortic balloon pump (IABP) and external pacemaker
monitoring. Depending on the service medical direction, these providers are trained on placement and use of
UVCs (Umbilical Venous Catheter), UACs (Umbilical Arterial Catheter), surgical airways, central lines,
arterial lines and chest tubes.
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In the United Kingdom and South Africa, some serving paramedics receive additional university education
to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement,
including the ability to autonomously prescribe medications, including drugs usually reserved for doctors, such
as courses of antibiotics. An emergency care practitioner is a position sometimes referred to as a ‘super paramedic’
and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are
university graduates in Emergency Medical Care or qualified paramedics who have undergone further training,
and are authorized to perform specialized techniques. Additionally some may prescribe medicines (from a
limited list) for longer term care, such as antibiotics. With respect to a Primary Health Care setting, they are also
educated in a range of Diagnostic techniques.
Traditional Health care Professions
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The use of registered nurses (RNs) in the pre-hospital setting is common in many countries. In some regions
of the world nurses are the primary health care worker that provides emergency medical services. In European
countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work
under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably
Norway, paramedics do exist, but the role of the ‘ambulance nurse’ continues to be developed, as it is felt that
nurses may bring unique skills to some situations encountered by ambulance crews. In North America, and to a
lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical
transport work. These are mostly air-medical personnel or critical care transport providers, often working in
conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United
States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive
Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to
seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive
Care or Prehospital Nurse licensure that is above the Paramedic. Many states allow registered nurses to also
become registered paramedics according to their role in the emergency medical services team. In Estonia 60%
of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer
medicines pre-hospital such as physicians in Estonia. In the Netherlands, all ambulances are staffed by a registered
nurse with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT. In Sweden,
since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are
allowed to administer drugs. And all Advanced Life Support Ambulances are staffed at least by a registered
nurse in Spain. In France, since 1986, fire department-based rescue ambulances have had the option of providing
resuscitation service (reanimation) using specially trained nurses, operating on protocols, while SAMU-SMUR
units are staffed by physicians and nurses
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There are many places in Europe, most notably in France, Italy, the German-speaking countries (Germany,
Switzerland, Austria), and Spain where the model of EMS is different, and physicians take a more direct,
‘hands-on’ approach to pre-hospital care. In France, Italy, and Spain, response to high-acuity emergency calls is
physician-led, as with the French SMUR teams. Paramedics do not exist within those systems, and most ALS is
performed by physicians. In the German-speaking countries, paramedics do exist, but special physicians (called
Notarzt) respond directly to high-acuity calls, supervising the paramedics ALS procedures directly. In these
countries, paramedics may perform many procedures under their “Notfallkompetenz” (“emergency competence”),
meaning that they may autonomously perform treatments, such as defibrillation or administering drugs, if there
is no physician on scene, and a life-threatening condition is present, otherwise they may only act on the physician’s
instructions. Some systems - most notably air ambulances in the UK.will employ physicians to take the clinical
lead in the ambulance; bringing a full range of additional skills such as use of medications that are beyond the
paramedic skill set. The response of physicians to emergency calls is routine in many parts of Europe, but is
uncommon in the UK, where physicians are generally tasked to high priority calls on a voluntary basis. Within
the UK a sub-speciality of Pre-Hospital Care is being developed for Doctors, which would allow training
programmes and consultant posts to be developed in this one area of practice. This ‘hands-on’ approach is less
common in the United States. While one will occasionally see a physician with an ambulance crew on an
emergency call, this is much more likely to be the Medical Director or an associate, inducting newly trained
paramedics, or performing routine medical quality assurance. In some jurisdictions adult or pediatric critical
care transports sometimes use physicians, but generally only when it appears likely that the patient may require
surgical or advanced pharmacologic intervention beyond the skills of an EMT, paramedic or nurse during
transport. Physicians are leaders of medical retrieval teams in many western countries, where they may assist
with the transport of a critically ill, injured, or special needs patient to a tertiary care hospital, particularly when
longer transport times are involved. In these cases the physician’s role is extended to ensure the highest level of
care is provided throughout the transport and diagnosis of serious medical conditions.
PREHOSPITAL DELIVERY OF CARE

Depending on country, area within country, or clinical need, emergency medical services may be provided
by one or more different types of organization. This variation may lead to large differences in levels of care and
expected scope of practice. The most basic emergency medical services are provided as a transport operation
only, simply to take patients from their location to the nearest medical treatment. This was often the case in a
historical context, and is still true in the developing world, where operators as diverse as taxi drivers and
undertakers may operate this service. Most developed countries now provide a government funded emergency
medical service, which can be run on a national level, as is the case in the United Kingdom, where a national
network of ambulance trusts operate an emergency service, paid for through central taxation, and available to
anyone in need, or can be run on a more regional model, as is the case in the United States, where individual
authorities have the responsibility for providing these services. Ambulance services can be stand alone
organisations, but in some cases, the emergency medical service is operated by the local fire or police service.
This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective.
This can lead, in some instances, to an illness or injury being attended by a vehicle other than an ambulance,
such as fire truck. In some locales, firefighters are the first responders to calls for emergency medical aid, with
separate ambulance services providing transportation to hospitals when necessary.
Some charities or non-profit companies also operate emergency medical services, often alongside a patient
transport function. These often focus on providing ambulances for the community, or for cover at private
events, such as sports matches. The Red Cross provides this service in many countries across the world on a
volunteer basis (and in others as a Private Ambulance Service), as do some other smaller organizations such as
St John Ambulance. and the Order of Malta Ambulance Corps. In some countries, these volunteer ambulances
may be seen providing support to the full-time ambulance crews during times of emergency, or simply to help
cover busy periods. There are also private ambulance companies, with paid employees, but often on contract to
the local or national government. Many private companies provide only the patient transport elements of
ambulance care (i.e. non-urgent), although in some places these private services are contracted to provide
emergency care, or to form a ‘second tier’ response, where they only respond to emergencies when all of the
full-time emergency ambulance crews are busy or to respond to non-emergency home calls. Private companies
are often contracted by private clients to provide event specific cover, as is the case with voluntary EMS crews.
Many colleges and universities, especially in the United States, maintain their own EMS organizations. These
organizations operate at capacities ranging from first response to ALS transport. Campus EMS in the United
States is overseen by the National Collegiate Emergency Medical Services Foundation.
Strategies for Delivering Care

The essential decision in prehospital care is whether the patient should be immediately taken to the hospital,
or advanced care resources are taken to the patient where they lie. The “scoop and run” approach is exemplified
by the MEDEVAC aeromedical evacuation helicopter, whereas the “stay and play” is exemplified by the French
and Belgian SMUR emergency mobile resuscitation unit or the German “Notarzt”-System (preclinical emergency
physician). The use of helicopters was pioneered in the Korean war, when time to reach a medical facility was
reduced from 8 hours to 3 hours in World War II, and again to 2 hours by the Vietnam war. The strategy
developed for prehospital trauma care in North America is based on the Golden Hour theory, i.e., that a trauma
victim’s best chance for survival is in an operating room, with the goal of having the patient in surgery within an
hour of the traumatic event. This appears to be true in cases of internal bleeding, especially penetrating trauma
such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization;
“ABCs”, i.e. ensure airway, breathing and circulation; external bleeding control; endotracheal intubation) and
the victim is transported as fast as possible to a trauma centre. The aim in “Scoop and Run” treatment is
generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, “the platinum ten
minutes” (in addition to the “golden hour”), now commonly used in EMT training programmes. The “Scoop
and Run” is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or
respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T
segment elevation myocardial infarctions (STEMI) occurring outside of the hospital, or even inside community
hospitals without their own PCI labs, suggests that time to treatment is a clinically significant factor in heart
attacks, and that trauma patients may not be the only patients for whom ‘load and go’ is clinically appropriate.
In such conditions, the gold standard is the door to balloon time. The longer the time interval, the greater the
damage to the myocardium, and the poorer the long-term prognosis for the patient. Current research in Canada
has suggested that door to balloon times are significantly lower when appropriate patients are identified by
paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab. The
STEMI programme has reduced STEMI deaths in the Ottawa region by 50 per cent. In a related programme in
Toronto, EMS has begun to use a procedure of ‘rescuing’ STEMI patients from the Emergency Rooms of
hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals.
Models of Care
Although a variety of differing philosophical approaches are used in the provision of EMS care around the
world, they can generally be placed into one of two categories; one physician-led and the other led by pre-
hospital allied health staff such as emergency medical technicians or paramedics (which may, or may not have
accompanying physician oversight). These models are typically identified by their locations of origin. The
Franco-German model is physician-led, with doctors responding directly to all major emergencies requiring
more than simple first aid. In some cases in this model, such as France, paramedics, as they exist in the Anglo-
American model, are not used, although the term ‘paramedic’ is sometimes used generically, and those with that
designation have training that is similar to a U.S. EMT-B. The team’s physicians and in some cases, nurses,
provide all medical interventions for the patient, and non-medical members of the team simply provide the
driving and heavy lifting services. In other applications of this model, as in Germany, a paramedic equivalent
does exist, but is sharply restricted in terms of scope of practice; often not permitted to perform Advanced Life
Support (ALS) procedures unless the physician is physically present, or in cases of immediate life-threatening
conditions. Ambulances in this model tend to be better equipped with more advanced medical devices, in
essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in
most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient
until they are medically stable, and then accomplish transport. In this model, the physician and nurse may
actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance,
providing medical support to multiple ambulances. The second care structure, termed the Anglo-American
model, utilizes pre-hospital allied health staff, such as emergency medical technicians and paramedics, to staff
ambulances, which may be classified according to the varying skill levels of the crews. In this model it is rare
to find a physician actually working routinely in the pre-hospital setting, although they may be utilised on
complex or major injuries or illnesses. In this system, a physicians involvement is most likely to be the provision
of medical oversight for the work of the ambulance crews, which may be accomplished in terms of off-line
medical control, with protocols or ‘standing orders’ for certain types of medical procedures or care, or on-line
medical control, in which the technician must establish contact with the physician, usually at the hospital, and
receive direct orders for various types of medical interventions. In some cases, such as in the UK, South Africa
and Australia, a paramedic may be an autonomous health care professional, and does not require the permission
of a physician to administer interventions or medications from an agreed list, and can perform roles such as
suturing or prescribing medication to the patient. In this model, patients may still be treated at the scene up to
the skill level of the attending crew, and subsequently transported to definitive care, but in many cases the
reduced skill set of the ambulance crew and the needs of the patient indicate a shorter interval for transport of
the patient than is the case in the Franco-German model.
Clinical Governance
Paramedics in countries that follow the Anglo-American model normally function under the authority (medical
direction) of one or more physicians charged with legally establishing the emergency medical directives for a
particular region. Paramedics are credentialed and authorized by these physicians to use their own clinical
judgement and diagnostic tools to identify medical emergencies and to administer the appropriate treatment,
including drugs that would normally require a physician order. Credentialing may occur as the result of a State
Medical Board examination (U.S.) or the National Registry of Emergency Medical Technicians (U.S.). In England,
and in some parts of Canada, credentialing may occur by means of a College of Paramedicine. In these cases,
paramedics are regarded as a self-regulating health profession. The final common method of credentialing is
through certification by a Medical Director and permission to practice as an extension of the Medical Director’s
license to practice some medical acts. The authority to practice in this semi-autonomous manner is granted in
the form of standing order protocols (off-line medical control) and in some cases direct physician consultation
via phone or radio (on-line medical control). Under this paradigm, paramedics effectively assume the role of
out-of-hospital field agents to regional emergency physicians, with clinical decision-making authority using
standing orders or protocols. Recently “Telemedicine” has been making an appearance in ambulances. Similar
to online medical control, this practice allows paramedics to remotely transmit data such as vital signs and 12
and 15 lead ECGs to the hospital from the field. This allows the emergency department to prepare to treat
patients prior to their arrival. This is allowing lower level providers (Such as EMT-B) in the United States to
utilize these advanced technologies and have the doctor interpret them, thus bringing rapid identification of
rhythms to areas where paramedics are stretched thin.
In some parts of the world, those in the paramedical professional role are only permitted to practice many of
their advanced skills while assisting a physician who is physically present, or they face cases of immediately
life-threatening emergencies. In many other parts in the world, most notably in France, Belgium, Luxembourg,
Italy, and Spain, but also in Brazil and Chile, all MICU skills in the pre-hospital setting are performed by
physicians and nurses and an on-line permanent medical supervision is done by the SAMU. In certain other
jurisdictions, such as the United Kingdom and South Africa, paramedics may be entirely autonomous practitioners
capable of prescribing medications. In other jurisdictions, such as Australia and Canada, this expanded scope of
practice is under active consideration and discussion.

Emergency nursing is a specialty within the field of professional nursing focusing on the care of patients
with medical emergencies, that is, those who require prompt medical attention to avoid long-term disability or
death. Emergency nurses are most frequently employed in hospital emergency departments (EDs), although
they may also work in urgent care centers, sports arenas, and on medical transport helicopters and ambulances.
ED NURSE ROLE
In addition to addressing these “true emergencies,” emergency nurses increasingly care for people who are
unwilling or unable to get primary medical care elsewhere and come to emergency departments for help. Besides
heart attacks, strokes, gunshot wounds and car accidents, emergency nurses also tend to patients with acute
alcohol and/or drug intoxication, psychiatric and behavioural problems and those who have been raped. They
must be adept at working with patients of many different backgrounds, cultures, religions, ages and types of
disabilities. Emergency nurses must also have a good working knowledge of the many legal issues impacting
health care such as consent, handling of evidence, mandatory reporting of child and elder abuse and involuntary
psychiatric holds. In their role as patient educators, they must have a thorough knowledge of anatomy, physiology,
pharmacology and psychology and be able to communicate effectively with patients and their families. An
emergency nurse is typically assigned to triage patients as they arrive in the emergency department and as such
are the first professional patients see. Therefore, the emergency nurse must be skilled at rapid, accurate physical
examination, early recognition of life-threatening conditions. In some cases, emergency nurses may order certain
tests and medications following “collaborative practice guidelines” or “standing orders” set out by the hospital’s
emergency physician staff.
BOARD CERTIFICATION IN EMERGENCY NURSING
CEN
The Certified Emergency Nurse (CEN) designation is granted to a registered nurse who has demonstrated
expertise in emergency nursing by passing a computer-administered examination given by the Board of
Certification for Emergency Nursing (BCEN). The certification exam first became available in July 1980, was
accredited by ABSNC in February 2002, and was reaccredited in 2007 and 2012. The certification is valid for
four years, and can be renewed either by passing another examination, by completing 100 continuing education
units (CEUs) in the specialty, or by completing an online 150 question “open book exam.” As of 2015, the
BCEN has designated over 30,500 active CENs in the United States and Canada. The CEN exam has 175
questions; 150 are used for testing purposes (25 are sample questions). The passing score is 70% and the
candidate has three hours to take the exam. The test is administered internationally in Pearson Vue testing
centers.
CPEN
The Certified Pediatric Emergency Nurse (CPEN) designation is applied to a registered nurse who has
demonstrated expertise in pediatric emergency nursing by passing a computer-administered examination
given jointly by the Board of Certification for Emergency Nursing (BCEN) and the Pediatric Nursing
Certification Board (PNCB). The certification exam first became available on January 21, 2009, and was
accredited by ABSNC in May 2015.
The certification is valid for four years, and can be renewed either by passing another examination, by
completing 100 contact hours (continuing education) in the specialty, or by completing 1,000 clinical
practice hours and 40 contact hours in the specialty. The CPEN exam has 175 questions; 25 are unscored
sample questions. As of 2015, the BCEN and the PNCB have designated over 3,900 active CPENs. The
CPEN exam has 175 questions; 150 are used for testing purposes (25 are sample questions). The passing
score is 87% and the candidate has three hours to take the exam. The test is administered in AMP testing
centers internationally.
EMERGENCY NURSE PRACTITIONER (ENP)
In the United Kingdom

A specialist nurse will independently assess, diagnose, investigate, and treat a wide range of common
accidents and injuries working autonomously without reference to medical staff. They primarily treat a wide
range of musculoskeletal problems, skin problems and minor illnesses. They are trained in advanced nursing
skills.
Under the National Health Service grading system, ENPs are typically graded Band 6 or 7. Additionally,
some specialized nurses perform as [emergency care practitioner]s. They generally work in the pre-hospital
setting dealing with a wide range of medical or emergency problems. Their primary function is to assess,
diagnose and treat a patient in the home in an emergency setting.
In the United States

An advanced practice nurse assesses, diagnoses, and treats a variety of common illnesses, injuries and
disease processes in emergency care settings. ENPs are trained in advanced nursing and medical skills such as
x-ray interpretation, ophthalmic slit lamp examination, suturing, local and regional anesthesia, abscess incision
and drainage, advanced airway techniques, fracture reduction, and casting and splinting.
In Australia
Australian nurse practitioners follow the clinical practice guidelines developed by the Victorian Emergency
Nurse Practitioner Collaborative (VENPC), who have supported nurse practitioner development in Victoria.
This includes attending to minor head injuries, burns, open wounds, joint pain (Haemophilia), blood and fluid
exposure, PV bleeding, suspected UTI, abdominal pain, cellulitis and more.
CHALLENGES OF EMERGENCY NURSING

Emergency nursing is a demanding job and can be unpredictable. Emergency nurses need to have basic
knowledge of most specialty areas, to be able to work under pressure, communicate effectively with many types
of patients, collaborate with a variety of health care providers and prioritize the tasks that must be performed. It
can be quite draining both physically and mentally for many nurses. Australian emergency department treat
over 7 million patients each year. They spend much of their time on their feet and ready for unexpected changes
in patients’ conditions as well as sudden influxes of patients to the emergency department. ED (emergency
department) nurses may be exposed to traumatic situations such as heavy bleeding, dismemberment and even
death. Violence is a growing challenge for many nurses in the ED. Emergency nurses too often receive both
physical and verbal abuse from patients and visitors.
EMERGENCY NURSES IN AFRICA

Emergency nurses work in various places, many of which are understaffed as there are nursing shortages
across Africa. There is also a shortage of doctors, leaving many tasks for nurses with limited guidelines or
standards to deal with, and for many emergency nurses the scope of practice is quite undefined. Nurses may be
forced to work outside their scope causing frustration and increasing the opportunities for occupational health
hazards.
It can be speculated that triage protocols are either lacking or not being followed. The limited basic knowledge
and skill of emergency nursing included in undergraduate nurse training programmes, and the limited number
of nurse trainers, provide difficulty for many pending nurses to acquire the skills needed to work in emergency
settings.
THE HISTORY OF EMERGENCY NURSING

Around the 1800s hospitals became more popular and there was a growth in emergency care. The first
development of an emergency room was originally called “The First Aid Room”. Originally, nurses only dressed
wounds, applied eye ointments, treated minor burns with salves and bandages, and attended patients with minor
illnesses like colds and sore throats. The rule of thumb was first in, first served, but there were many cases
where some people were in more need of emergency care than others and as the situation became more intolerable,
one of the greatest medical developments came into perspective: triage. For centuries triage had been used in
war but was not yet established in the emergency department. The first time triage was referred to during a non-
disaster issue was at Yale, Newhaven Hospital, United States, in 1963, and since then has become developed
and more defined.
ADDITIONAL EMERGENCY NURSING EDUCATION/CERTIFICATION

• Advanced Burn Life Support (ABLS)
• Advanced Cardiac Life Support (ACLS)
• Advanced Medical Life Support (AMLS)
• Advanced Trauma Care for Nurses (ATCN)
• Basic Life Support (BLS)
• Course in Advanced Trauma (CATN)
• Emergency Nursing Pediatric Course (ENPC)
• Geriatric Emergency Nursing Education (GENE)
• Mobile Intensive Care Nurse (MICN)
• National Institutes of Health Stroke Scale Certification (NIHSS)
• Neonatal Resuscitation Programme (NRP)
• Pediatric Advanced Life Support (PALS)
• Pre-Hospital Emergency Care (PHEC)
• Trauma Nursing Core Course (TNCC)

Emergency psychiatry is the clinical application of psychiatry in emergency settings. Conditions requiring
psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or
other rapid changes in behaviour. Psychiatric emergency services are rendered by professionals in the fields of
medicine, nursing, psychology and social work. The demand for emergency psychiatric services has rapidly
increased throughout the world since the 1960s, especially in urban areas. Care for patients in situations involving
emergency psychiatry is complex. Individuals may arrive in psychiatric emergency service settings through
their own voluntary request, a referral from another health professional, or through involuntary commitment.
Care of patients requiring psychiatric intervention usually encompasses crisis stabilization of many serious and
potentially life-threatening conditions which could include acute or chronic mental disorders or symptoms
similar to those conditions.
DEFINITION
Symptoms and conditions behind psychiatric emergencies may include attempted suicide, substance
dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant,
rapid changes in behaviour. Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric
conditions. In addition, several rapidly lethal medical conditions present themselves with common psychiatric
symptoms. A physician’s or a nurse’s ability to identify and intervene with these and other medical conditions
is critical.
DELIVERY OF SERVICES
The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric
Emergency Services, Psychiatric Emergency Care Centers, or Comprehensive Psychiatric Emergency
Programmes. Mental health professionals from a wide area of disciplines, including medicine, nursing,
psychology, and social work in these settings alongside psychiatrists and emergency physicians. The facilities,
sometimes housed in a psychiatric hospital, psychiatric ward, or emergency department, provide immediate
treatment to both voluntary and involuntary patients 24 hours a day, 7 days a week. Within a protected
environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic
clarity, find appropriate alternatives to psychiatric hospitalization for the patient, and to treat those patients
whose symptoms can be improved within that brief period of time. Even precise psychiatric diagnoses are a
secondary priority compared with interventions in a crisis setting. The functions of psychiatric emergency
services are to assess patients’ problems, implement a short-term treatment consisting of no more than ten
meetings with the patient, procure a 24-hour holding area, mobilize teams to carry out interventions at patients’
residences, utilize emergency management services to prevent further crises, be aware of inpatient and outpatient
psychiatric resources, and provide 24/7 telephone counseling.
HISTORY
Since the 1960s the demand for emergency psychiatric services has endured a rapid growth due to
deinstitutionalization both in Europe and the United States. Deinstitutionalization, in some locations, has resulted
in a larger number of severely mentally ill people living in the community. There have been increases in the
number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric
medication. The actual number of psychiatric emergencies has also increased significantly, especially in
psychiatric emergency service settings located in urban areas.
Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless and other
disenfranchised populations. Emergency psychiatry services sometimes can be accessibility, convenience, and
anonymous. While many of the patients who used psychiatric emergency services shared common sociological
and demographic characteristics, the symptoms and needs expressed did not conform to any single psychiatric
profile. The individualized care needed for patients utilizing psychiatric emergency services is evolving, requiring
an always changing and sometimes complex treatment approach.
SCOPE
Suicide Attempts and Suicidal Thoughts

As of 2000, the World Health Organization estimated one million suicides in the world each year. There
are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders
associated with an increased risk of completed suicide or suicide attempts. Mental health professionals in
these settings are expected to predict acts of violence patients may commit against themselves (or others),
even though the complex factors leading to a suicide stem from so many sources, including psychosocial,
biological, interpersonal, anthropological and religious. These mental health professionals will use any
resources available to them to determine risk factors, make an overall assessment, and decide on any necessary
treatment.
Violent Behaviour
Aggression can be the result of both internal and external factors that create a measurable activation in the
autonomic nervous system. This activation can become evident through symptoms such as the clenching of fists
or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled. It is estimated that
17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve
both suicide and homicide. Violence is also associated with many conditions such as acute intoxication, acute
psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder and
borderline personality disorder. Additional risk factors have also been identified which may lead to violent
behaviour. Such risk factors may include prior arrests, presence of hallucinations, delusions or other neurological
impairment, being uneducated, unmarried, etc. Mental health professionals complete violence risk assessments
to determine both security measures and treatments for the patient.
Psychosis
Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination
of the source of the psychosis can be difficult. Sometimes patients brought into the setting in a psychotic
state have been disconnected from their previous treatment plan. While the psychiatric emergency service
setting will not be able to provide long term care for these types of patients, it can exist to provide a brief
respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication.
A visit to a crisis unit by a patient suffering from a chronic mental disorder may also indicate the existence of
an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition.
These considerations can play a part in an improvement to an existing treatment plan. An individual could
also be suffering from an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining
a medical or psychopathological history of a patient, performing a mental status examination, conducting
psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following
this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment.
As with other patient care considerations, the origins of acute psychosis can be difficult to determine because
of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring
immediate and complete attention. The lack of identification and treatment can result in suicide, homicide,
or other violence.
Substance Dependence, Abuse and Intoxication

Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve
after a period of observation or limited psychopharmacological treatment. However the underlying issues, such
as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition.
Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions.
Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and
characterized by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations
of impaired concentration, verbal and motor performance, insight, judgement and short term memory loss
which could result in behavioural change causing injury or death, levels of alcohol below 60 milligrams per
deciliter of blood are usually considered non-lethal. However, individuals at 200 milligrams per deciliter of
blood are considered grossly intoxicated and concentration levels at 400 milligrams per deciliter of blood are
lethal, causing complete anesthesia of the respiratory system. Beyond the dangerous behavioural changes that
occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some
individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment
usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage,
agitation and violence.
Chronic alcoholics may also suffer from alcoholic hallucinosis, wherein the cessation of prolonged drinking
may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics
are often used to treat these symptoms. Patients may also be treated for substance abuse following the
administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine,
phencyclidines, or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and
deliriants. Clinicians assessing and treating substance abusers must establish therapeutic rapport to counter
denial and other negative attitudes directed towards treatment. In addition, the clinician must determine substances
used, the route of administration, dosage, and time of last use to determine the necessary short and long term
treatments. An appropriate choice of treatment setting must also be determined. These settings may include
outpatient facilities, partial hospitals, residential treatment centers, or hospitals. Both the immediate and long
term treatment and setting is determined by the severity of dependency and seriousness of physiological
complications arising from the abuse.
Hazardous Drug Reactions and Interactions

Overdoses, drug interactions, and dangerous reactions from psychiatric medications, especially antipsychotics,
are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially lethal complication of
first or second generation antipsychotics. If untreated, neuroleptic malignant syndrome can result in fever,
muscle rigidity, confusion, unstable vital signs, or even death. Serotonin syndrome can result when selective
serotonin reuptake inhibitors or monoamine oxidase inhibitors mix with buspirone. Severe symptoms of serotonin
syndrome include hyperthermia, delirium, and tachycardia that may lead to shock. Often patients with severe
general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency
department or medicine service for increased monitoring.
Personality Disorders
Disorders manifesting dysfunction in areas related to cognition, affectivity, interpersonal functioning and
impulse control can be considered personality disorders. Patients suffering from a personality disorder will
usually not complain about symptoms resulting from their disorder. Patients suffering an emergency phase of a
personality disorder may showcase combative or suspicious behaviour, suffer from brief psychotic episodes, or
be delusional. Compared with outpatient settings and the general population, the prevalence of individuals
suffering from personality disorders in inpatient psychiatric settings is usually 7–25% higher. Clinicians working
with such patients attempt to stabilize the individual to their baseline level of function.
Anxiety
Patients suffering from an extreme case of anxiety may seek treatment when all support systems have been
exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an
underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric
disorder, from a primary psychiatric disorder such as panic disorder or generalized anxiety disorder, or as a
result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Clinicians usually
attempt to first provide a “safe harbour” for the patient so that assessment processes and treatments can be
adequately facilitated. The initiation of treatments for mood and anxiety disorders are important as patients
suffering from anxiety disorders have a higher risk of premature death.
Disasters
Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the
event. Emergency management often includes psychiatric emergency services designed to help victims cope
with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized,
panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience
tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite,
insomnia, depression, irritability, panic attacks, or dysphoria. Due to the typically disorganized and hazardous
environment following a disaster, mental health professionals typically assess and treat patients as rapidly as
possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and
basic survival considerations are managed first. Soon after a disaster clinicians may make themselves available
to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent
upon the scale of the disaster, many victims may suffer from both chronic or acute post-traumatic stress
disorder. Patients suffering severely from this disorder often are admitted to psychiatric hospitals to stabilize
the individual.
Abuse
Incidents of physical abuse, sexual abuse or rape can result in dangerous outcomes to the victim of the
criminal act. Victims may suffer from extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders,
hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical
and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be
required to report criminal activity to a police force. Mental health professionals will usually gather identifying
data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical
treatment may include a physical examination, collection of medicolegal evidence, and determination of the
risk of pregnancy, if applicable.
TREATMENT
Treatments in psychiatric emergency service settings are typically transitory in nature and only exist to
provide dispositional solutions and/or to stabilize life-threatening conditions. Once stabilized, patients suffering
chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation.
Prescribed treatments within the emergency service setting vary dependent upon the patient’s condition. Different
forms of psychiatric medication, psychotherapy, or electroconvulsive therapy may be used in the emergency
setting. The introduction and efficacy of psychiatric medication as a treatment option in psychiatry has reduced
the utilization of physical restraints in emergency settings, by reducing dangerous symptoms resulting from
acute exacerbation of mental illness or substance intoxication.
Medications
With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration.
Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the
route of administration, absorption, distribution and metabolism of the medication. A common route of
administration is oral administration, however if this method is to work the drug must be able to get to the
stomach and stay there. In cases of vomiting and nausea this method of administration is not an option.
Suppositories can, in some situations, be administered instead. Medication can also be administered through
intramuscular injection, or through intravenous injection. The amount of time required for absorption varies
dependent upon many factors including drug solubility, gastrointestinal motility and pH. If a medication is
administered orally the amount of food in the stomach may also affect the rate of absorption. Once absorbed
medications must be distributed throughout the body, or usually with the case of psychiatric medication, past
the blood–brain barrier to the brain. With all of these factors affecting the rapidity of effect, the time until the
effects are evident varies. Generally, though, the timing with medications is relatively fast and can occur within
several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after
haloperidol, an antipsychotic, is administered intramuscularly. Antipsychotics, especially Haloperidol, as well
as assorted benzodiazepines are the most frequently used drugs in emergency psychiatry, especially agitation.
Psychotherapy
Other treatment methods may be used in psychiatric emergency service settings. Brief psychotherapy can be used
to treat acute conditions or immediate problems as long as the patient understands his or her issues are psychological,
the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change,
the physician is aware of the psychopathological history of the patient, and the patient understands that their
confidentiality will be respected. The process of brief therapy under emergency psychiatric conditions includes the
establishment of a primary complaint from the patient, realizing psychosocial factors, formulating an accurate
representation of the problem, coming up with ways to solve the problem, and setting specific goals. The information
gathering aspect of brief psychotherapy is therapeutic because it helps the patient place his or her problem in the
proper perspective. If the physician determines that deeper psychotherapy sessions are required, he or she can transition
the patient out of the emergency setting and into an appropriate clinic or center.
ECT
Electroconvulsive therapy is a controversial form of treatment which cannot be involuntarily applied in
psychiatric emergency service settings. Instances wherein a patient is depressed to such a severe degree that the
patient cannot be stopped from hurting himself or herself or when a patient refuses to swallow, eat or drink
medication, electroconvulsive therapy could be suggested as a therapeutic alternative. While preliminary research
suggests that electroconvulsive therapy may be an effective treatment for depression, it usually requires a
course of six to twelve sessions of convulsions lasting at least 20 seconds for those antidepressant effects to
occur.
OBSERVATION AND COLLATERAL INFORMATION

There are other essential aspects of emergency psychiatry: observation and collateral information. The observation
of the patient’s behaviour is an important aspect of emergency psychiatry inasmuch as it allows the clinicians
working with the patient to estimate prognosis and improvements/declines in condition. Many jurisdictions base
involuntary commitment on dangerousness or the inability to care for one’s basic needs. Observation for a period
of time may help determine this. For example, if a patient who is committed for violent behaviour in the community,
continues to behave in an erratic manner without clear purpose, this will help the staff decide that hospital admission
may be needed. Collateral information or parallel information is information obtained from family, friends or
treatment providers of the patient. Some jurisdictions require consent from the patient to obtain this information
while others do not. For example, with a patient who is thought to be paranoid about people following him or
spying on him, this information can be helpful discern if these thoughts are more or less likely to be based in
reality. Past episodes of suicide attempts or violent behaviour can be confirmed or disproven.
DISPOSITION
Patient receive emergency services often on a time limited basis such as 24 or 72 hours. After this time, and
sometimes earlier, the staff must decide the next place for the patient to receive services. This is referred to as
disposition. This is one of the essential features of emergency psychiatry.
Hospital Admission
The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they
can be safely discharged to the community after a period of observation and/or brief treatment. Initial emergency
psychiatric evaluations usually involve patients who are acutely agitated, paranoid, or who are suicidal. Initial
evaluations to determine admission and interventions are designed to be as therapeutic as possible.
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Involuntary commitment, or sectioning, refers to situations where police officers, health officers, or health
professionals classify an individual as dangerous to themselves, others, gravely disabled, or mentally ill according
to the applicable government law for the region. After an individual is transported to a psychiatric emergency
service setting, a preliminary professional assessment is completed which may or may not result in involuntary
treatment. Some patients may be discharged shortly after being brought to psychiatric emergency services
while others will require longer observation and the need for continued involuntary commitment will exist.
While some patients may initially come voluntarily, it may be realized that they pose a risk to themselves or
others and involuntary commitment may be initiated at that point.
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In some locations, such as the United States, voluntary hospitalizations are outnumbered by involuntary
commitments partly due to the fact that insurance tends not to pay for hospitalization unless an imminent
danger exists to the individual or community. In addition, psychiatric emergency service settings admit
approximately one third of patients from assertive community treatment centers. Therefore, patients who are
not admitted will be referred to services in the community.
Ç
È
The golden hour, also known as golden time, refers to the period of time following a traumatic injury during
which there is the highest likelihood that prompt medical and surgical treatment will prevent death. While
initially defined as an hour the exact time period depends on the nature of the injury and can be more than or
less than this duration. It is well established that the person’s chances of survival are greatest if they receive
care within a short period of time after a severe injury; however, there is no evidence to suggest that survival
rates drop off after 60 minutes. Some have come to use the term to refer to the core principle of rapid intervention
in trauma cases, rather than the narrow meaning of a critical one-hour time period.
GENERAL CONCEPT
Cases of severe trauma, especially internal bleeding, require surgical intervention. Complications such as shock
may occur if the person is not managed appropriately and expeditiously. It therefore becomes a priority to transport
people severe trauma as fast as possible to specialists, most often found at a hospital trauma center, for treatment.
Because some injuries can cause people to deteriorate extremely rapidly, the lag time between injury and treatment
should ideally be kept to a bare minimum; this has come to be specified as no more than 60 minutes, after which
time the survival rate for people who have sustained trauma is alleged to fall off dramatically. Recommendations
for emergency medical services is less than 10 minutes at the location of the trauma before transporting,
ORIGINS OF THE TERM

Dr. R Adams Cowley is credited with promoting this concept, first in his capacity as a military surgeon and
later as head of the University of Maryland Shock Trauma Center. The concept of the “Golden Hour” may have
been derived from French military World War I data. The R Adams Cowley Shock Trauma Center section of the
University of Maryland Medical Center’s web site quotes Cowley as saying, “There is a golden hour between
life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right
then; it may be three days or two weeks later — but something has happened in your body that is irreparable.”
CONTROVERSY
While most medical professionals agree that delays in definitive care are undesirable, recent peer reviewed
literature casts doubt on the validity of the ‘golden hour’ as it appears to lack a scientific basis. The physician
Bryan Bledsoe, an outspoken critic of the golden hour and other EMS “myths” like critical incident stress
management, has indicated that the peer reviewed medical literature does not demonstrate any “magical time”
for saving critical patients.

International emergency medicine is a subspecialty of emergency medicine that focuses not only on the
global practice of emergency medicine but also on efforts to promote the growth of emergency care as a branch
of medicine throughout the world. The term international emergency medicine generally refers to the transfer
of skills and knowledge—including knowledge of ambulance operations and other aspects of prehospital care—
from developed emergency medical systems (EMSs) to those systems which are less developed. However, this
definition has been criticized as oxymoronic, given the international nature of medicine and the number of
physicians working internationally. From this point of view, international emergency medicine is better described
as the training required for and the reality of practicing the specialty outside of one’s native country. Emergency
medicine has been a recognized medical specialty in the United States and other developed countries for nearly
forty years, although these countries’ EMSs did not become fully mature until the early 1990s. At that point,
some of its practitioners turned their attention from developing the specialty at home to developing it abroad,
leading to the birth of international emergency medicine. They began to support the growth of emergency
medicine worldwide, doing so through conferences, national and regional emergency medicine organizations,
relief and development organizations, international emergency medicine fellowships, physician exchanges,
information transfer, and curriculum development.
Most developing countries are taking steps to develop emergency medicine as a specialty, to develop
accreditation mechanisms, and to promote the development of emergency medicine training programmes. Their
interest is a result of improved health care, increasing urbanization, aging populations, the rising number of
traffic fatalities, and heightened awareness of emergency medicine among their citizens. In addition, emergency
medicine is useful in dealing with time-sensitive illnesses, as well as improving public health through vaccinations,
interventions, training, and data collection. Countries that lack mature EMSs are developing emergency medicine
as a specialty so that they will be able to set up training programmes and encourage medical students to pursue
residencies in emergency medicine. Some challenges faced in international emergency medicine include immature
or non-existent training programmes, a lack of adequate emergency transport, a shortage of resources to fund
emergency medicine development, and an absence of research that could inform developing countries how to
best spend the resources they devote to emergency medicine. Additionally, the standards and methods used in
countries with mature EMSs are not always suited for use in developing countries due to a lack of infrastructure,
shortage of funds, or local demographics. Ambulances, the developed country standard, are costly and not
practical for the road conditions present in many countries; instead, a variety of modes of transportation are
used. Furthermore, in place of expensive medication and equipment, developing countries often opt for cheaper
if slightly less effective alternatives. Although it may seem that increasing availability to emergency medicine
must improve health, there is little empirical evidence to directly support that claim or to point out which
methods are most effective in improving patient health. Evidence-based medicine seeks to address this issue by
rigorously studying the effects of different interventions instead of relying on logic or tradition.
BACKGROUND
Definition
The most commonly accepted definition of international emergency medicine is that it is “the area of
emergency medicine concerned with the development of emergency medicine in other countries.” In that
definition, “other countries” refers to nations that do not have a mature emergency care system (exemplified by
board-certified emergency physicians and academic emergency medicine, among other things). Included in
those nations are some that are otherwise quite developed but lack a complete emergency medical system, such
as Armenia, China, Israel, Nicaragua, and the Philippines. Work in international emergency medicine can be
broken down into two main categories: 1) the promotion of emergency medicine as a recognized and established
specialty in other countries, and 2) the provision of humanitarian assistance. William Burdick, Mark Hauswald,
and Kenneth Iserson have criticized the above definition as oxymoronic, given the international nature of
medicine and the number of physicians working internationally. From that point of view, international emergency
medicine is not solely about development of emergency medical systems but is instead better described as the
training required for and the reality of practicing the specialty outside of one’s native country.
History
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Emergency medicine is a specialty that was first developed in the United States in the 1960s. For the United
States, the high number of traffic and other accident fatalities in the 1960s spurred a white paper from the
National Academy of Sciences; it exposed the inadequacy of the current emergency medical system and led to
the establishment of modern emergency medical services. The United Kingdom, Australia, Canada, Hong Kong,
and Singapore followed shortly thereafter, developing their respective emergency medicine systems in the
1970s and 1980s.
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By the early 1990s, the emergency medicine systems (EMSs) in the United States, the United Kingdom,
Australia, Canada, Hong Kong, and Singapore were largely mature, leading some practitioners to focus on
developing the specialty in other countries. Thus, international emergency medicine as a subspecialty began in
the 1990s, although some isolated efforts to achieve some of its goals had taken place in the late 1980s. There
were several reasons for the heightened interest these practitioners had in developing emergency medicine
abroad. One was the contrast between the EMSs of their countries and the EMSs of other countries. Another
was the revolutions of 1989, overthrowing authoritarian regimes, which facilitated spread of new ideas, such as
emergency medicine. Two international emergency medicine conferences were launched in the 1980s, the
International Conference on Emergency Medicine (ICEM) and the World Association for Disaster and Emergency
Medicine Conference (WADEM). ICEM was founded by the International Federation of Emergency Medicine,
while WADEM was started by an organization of the same name. Additionally, in the 1990s various national
and regional emergency medicine organizations began supporting the development of the specialty in other
countries, including the American College of Emergency Physicians, the European Society for Emergency
Medicine, and the Asian Society of Emergency Medicine. Furthermore, countries without mature EMSs began
taking more interest in developing them. One reason for this interest was the overall improvement in health care
in these countries. Another was the increasing urbanization taking place worldwide and the corresponding shift
of focus from infectious diseases to trauma and cardiorespiratory diseases, which are better managed by
emergency medicine than prevention. In addition to these developments, the aging population in many countries
has led to an increased need for emergency medical services. Also, American popular culture, particularly
television shows, and “the demonstrated success of emergency medicine” in countries with mature EMSs both
led the public in many countries to expect better emergency medical care. International emergency medicine
organizations, whether focused on relief or development, have also contributed to the growth of the subspecialty.
Relief organizations, such as Doctors Without Borders or AmeriCares, serve countries that do not have mature
EMSs when health catastrophes occur. These organizations also serve to “enhance [the specialty’s] image in the
international public eye”. Some development organizations, such as Emergency International or the International
Federation for Emergency Medicine, help establish and develop emergency care systems in other countries by
providing “ongoing educational and organizational assistance.”
Emergency Medicine in the Developing World

Motor vehicle crashes were a major factor that led to the development of emergency medicine in the United
States, the United Kingdom, Australia, Canada, Hong Kong, and Singapore, and they are a major factor leading
countries to develop their own emergency medical systems today. Such crashes represent a leading cause of
death for adolescents and young adults, with the majority of deaths occurring in the developing world. In recent
decades, while traffic fatalities have declined in industrialized nations, they have been on the rise in developing
ones. Furthermore, developing nations tend to have a higher proportion of fatalities per number of vehicles for
various reasons, including lower safety standards for vehicles. The lack of available emergency care in many
developing countries only serves to exacerbate this problem. This higher rate of accident mortality per vehicle
exists despite the fact that there are fewer cars in Asia and Africa than in the West. Odero et al. argue that this
shows a need to improve emergency medical care. Emergency medical care applies to other acute health problems
as well. Many illnesses with time-sensitive elements are common in developing countries, including severe
infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and
unintentional injuries, postpartum bleeding, and acute myocardial infarction. These are potentially life-threatening
conditions, yet effective treatment is often unavailable for much of the world’s population. For instance, a 2008
study of medical systems in Zambia published by the International Anesthesia Research Society found that only
50 percent of hospitals had an emergency medical system that transported patients. Just 24 percent of ambulances
carried oxygen, with only 40 percent carrying drugs of any kind. Furthermore, only 29 intensive care beds were
available in all of the hospitals surveyed, and these were only found in major hospitals. This implies that the
majority of critically ill patients are receiving care in general hospital wards. Anderson et al. argue that, aside
from acute care, emergency medicine can also play a significant role in public health. Vaccinations for many
diseases such as diphtheria, tetanus and pertussis can be administered by emergency departments, patients can
be targeted for specific interventions such as counseling for substance abuse, and conditions like hypertension
can be detected and treated. Emergency departments are excellent locations to train health care providers and to
collect data, because of the high number of patients. Emergency medicine also improves public health by
preventing secondary disease developing from an initial presentation (initial symptoms), and it serves as the
first line of defence in disaster scenarios.
Models of Emergency Care

There are two primary models of emergency medicine: the Anglo-American model, which relies on “bringing
the patient to the hospital”, and the Franco-German model, which operates through “bringing the hospital to the
patient”. Thus, in the Anglo-American model, the patient is rapidly transported by non-physician providers to
definitive care such as an emergency department in a hospital. Conversely, the Franco-German approach has a
physician, often an anesthesiologist, come to the patient and provide stabilizing care in the field. The patient is
then triaged directly to the appropriate department of a hospital. The Anglo-American model is seen in nations
such as Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States, while the Franco-
German model is found in European countries such as Austria, France, Germany, Poland, Portugal, and Russia.
Most developing emergency medical systems, including those of China, Japan, the Philippines, South Korea,
and Taiwan, have been established along Anglo-American lines, but little work exists to establish the advantage
of either system. Jeffrey Arnold and James Holliman have criticized the use of these descriptors for emergency
medical systems as an oversimplification and a needless source of controversy. Instead, Arnold and Holliman
have proposed that other groupings be used, such as classifying emergency medical systems as following a
specialty or multidisciplinary model. Specialty systems would include those with physicians dedicated to
emergency medicine, whereas multidisciplinary systems would encompass those that rely on physicians from
other disciplines to provide emergency care. Such an approach would seek to categorize pre-hospital care
separately from in-hospital systems. Within Arnold and Holliman’s understanding of emergency care models,
there is also an acknowledgement that current Western models may be inadequate in the context of developing
nations. For instance, a cost-benefit analysis found that creating an EMS system in Kuala Lumpur that met U.S.
standards for cardiac arrest response (85 percent of patients receive defibrillation within 6 minutes) would cost
US$2.5 million and only save four neurologically intact lives per year. The primary variable responsible for
that result is the relatively young demography of Kuala Lumpur, meaning that comparatively few cardiac-
related deaths occur. An example of a developing nation establishing its own model of emergency medicine
may be seen in southern Brazil. Elements of both of the major conventional models have been incorporated,
with the EMS system following French influences and the ambulances being staffed by physicians, while an
American approach to emergency medical residency training is also present.
ROLE IN OVERALL HEALTH SYSTEM
Developed Countries
In developed counties, training programmes specifically relating to the international practice of emergency
medicine are now available within many emergency medicine residencies. The curriculum that should be covered
by such programmes has been the subject of much discussion. Patient care, medical knowledge, practice-based
learning, communication skills, professionalism, and system-based practice are the basic six competencies
required of programmes approved by the Accreditation Council for Graduate Medical Education, but the
application of these goals can take many forms. The breadth of skills needed in international emergency medicine
make it unlikely that one standardized programme could fulfill the training needs for every scenario. One
Australian study found that the primary topics covered by U.S. fellowship programmes were emergency medicine
systems development, humanitarian relief, disaster management, public health, travel and field medicine,
programme administration, and academic skills. Its authors argue that attempting to cover all of those areas may
be unrealistic and that a more targeted focus on acquiring necessary skills might be more productive. After such
training is completed, or even without any EMS training, working in or visiting other nations is one way
physicians can participate in international emergency medicine. Some physicians choose to pursue their careers
overseas, while others opt for shorter trips. For example, a team of U.S. physicians spent seven months helping
establish a new emergency department and emergency residency programme in Hangzhou, China. Such exchanges
can be mutually beneficial. For instance, 23 to 28 percent of all physicians in Australia, the United States, the
United Kingdom and Canada received their training at medical schools outside of the country in which they
currently practice.
Developing Countries
The experience of international emergency medicine in developing countries is in some ways the opposite of
that of developed ones. As of the 2000s, developing countries are attempting to establish effective systems of
care and recognized specialty programmes with assistance from health care providers from the developed world.
In 2005, there were only a few countries with advanced emergency medical systems, and a far greater number
(50+) that were in the process of developing those systems. The process of development usually begins in
academia and patient care, followed by administrative and economic concerns, and finally health policy and
agendas. Given the limited resources of many developing nations, funding vitally effects how emergency medicine
fits into the health system. Preventive care is a crucial part of health care in developing countries, and it may be
difficult to budget for emergency medicine without cutting into those resources. This is a particular problem for
poorer nations such as Zambia, which had a per capita health expenditure of 23 US dollars in 2003. Regardless
of the amount of preventive care available, health problems requiring immediate attention will still occur, and
emergency medical programmes could increase access to care. Kobusingye et al. argue that expanding emergency
medicine does not need to be unreasonably expensive, particularly if developing countries focus on low-cost
but effective treatments administered by first responders.
INITIATIVES TO EXPAND EMERGENCY MEDICINE
Curriculum Development
Hobgood et al. argue that one key component in equipping nations to develop emergency medical systems is
to identify the aspects of training that are essential for health care providers. In their view, a standard curriculum
is useful for identifying core issues, even if countries have very different needs and resources. To address this
goal, the International Federation for Emergency Medicine developed a model curriculum in 2009. This initiative
seeks to provide a minimum basic standard that can be tailored to the specific needs of the various nations
implementing training in emergency medicine. It is targeted towards all medical students in order to produce a
minimum competency in emergency care for all physicians, regardless of their specialty.
Transferring Knowledge
Countries with decades of experience in comprehensive emergency medical systems have expertise that
nations that are just beginning emergency medical programmes lack. Thus, there exists considerable opportunity
for the transfer of knowledge to assist newly founded programmes. Such transfers may be made either from a
distance or in person. For instance, the International Emergency Medicine Fellowship at the University of
Toronto sent a three-person team to Cluj-Napoca, Romania, to promote the local development of emergency
medicine. An assessment of the present status was performed that identified targets for improvement in physical
plant organization and patient flow; staffing, staff education, equipment, medication and supplies; and infection
control practices. Following these designations, plans regarding these areas were collaboratively drawn up and
then implemented, partially through international exchange trips. Another conduit for the transfer of knowledge
is the International Conference on Emergency Medicine, a conference held every two years for worldwide
emergency physicians by the International Federation for Emergency Medicine (IFEM). In 2012, the conference
took place in Dublin, Ireland. The organization was founded in 1991 by four national emergency physician
organizations: the American College of Emergency Physicians, the British Association for Emergency Medicine,
the Canadian Association of Emergency Physicians, and the Australasian College for Emergency Medicine.
The conference rotated between the founding members until 2010, when it was held in Singapore. Many new
members have been accepted since the mid-1990s, when the IFEM decided to open up membership to other
nations’ emergency medicine organizations; the conference will rotate to them as well. For instance, in 2014 the
conference will be hosted in Hong Kong and in 2016 it will be held in Cape Town, South Africa. There are other
conferences on international emergency medicine as well, including the one that the World Association for
Disaster and Emergency Medicine (WADEM) has held every two years since 1987. However, WADEM focuses
more on disaster medicine than emergency medicine system development, and many of its member physicians
are not specialists in emergency medicine. Additionally, the European Society for Emergency Medicine (EuSEM)
has hosted an annual conference since 1998. EuSEM also publishes The European Journal of Emergency
Medicine, develops recommendations for emergency medicine standards for European countries, and supports
a disaster medicine training center and degree programme in San Marino. The Asian Society for Emergency
Medicine (Asian Society), which was founded in 1998, holds its own biennial conference. In addition to that,
the Asian Society, like the EuSEM, develops curriculum recommendations for Asian countries.
Developing Emergency Medicine as a Specialty

One way to advance emergency medical care is to obtain the recognition of emergency medicine as a specialty
in countries that currently lack it. Without such recognition, it is difficult to set up training programmes or recruit
potential students, as they face the uncertainty of training to obtain a credential that may end up being useless to
them. Recognition increases the visibility and prestige of the profession and promotes other efforts to advance its
development. Botswana may serve as a case study. Its recent recognition of emergency medicine as a specialty has
been closely accompanied by the creation of the Botswana Society for Emergency Care, the establishment of a
Resuscitation Training Centre and a Trauma Research Centre at the University of Botswana, and the formation of
a committee to design a national policy for pre-hospital care. An alternate route for developing emergency medicine
is to provide additional training for other specialists to equip them to practice in emergency medicine. This has the
benefit of being more rapid to implement, as physicians already trained in other areas can add the necessary
emergency skills to their repertoire. However, after the initial expansion it is difficult for emergency medicine to
progress further in nations that adopt this strategy, as the retrained practitioners identify more with their original
specialty and have less incentive to continue to press for further innovations in emergency medicine.
CHALLENGES
Training
Educational opportunities in emergency medicine are not available in many countries, and even when present,
they are often in their infancy. Botswana opened its first medical school in 2009, with a programme in emergency
medicine following in 2011. The programme aims to train four to six physicians in emergency medicine each
year. Limitations on in-country training mean that the programme includes six months of training at an
international site. The organization of the programme is modeled on South Africa’s programme due to the
similarities in resource constraints and disease burdens and the eagerness of College of Emergency Medicine of
South Africa and Emergency Medicine Society of South Africa to support the expansion of emergency medicine.
Two years of clinical practice are required before entering the residency programme, as in the South African
and Australian approaches. To deal with this shortage of educational opportunities, Scott Weiner et al. suggest
that countries with developed emergency medical systems should focus on training the trainers. This, he believes,
is a sustainable approach to promote the development of emergency medicine worldwide. It works by sending
developed country health care workers to equip a small group of trainees with the necessary skills to then go on
and teach the concepts to others. As such, it may be able to leverage the insights of developed emergency
medical systems while remaining sustainable, as the newly trained trainers continue to spread the knowledge.
The Tuscan Emergency Medicine Initiative is an example, with physicians from other specialties currently
working in emergency departments being taught how to teach a new group of emergency medical specialists.
Emergency Transport
The limitations on resources available in developing countries are particularly evident in the area of emergency
transport. Ambulances, the developed country standard, are costly and not practical for the road conditions present
in many countries. Indeed, there may be no roads at all. One study found that modes of transport as diverse as
motorboats, canoes, bicycles with trailers, tricycles with platforms, tractors with trailers, reconditioned vehicles,
and ox carts were used for emergency transport. In more advanced developing countries, establishing ambulance
transport systems is more feasible, but still requires considerable expertise and planning. Prior to 2004, Pakistan
did not have an organized emergency medical system. In that year, Rescue 1122 was launched as a professional
pre-hospital emergency service, and it has managed to achieve an average response time of 7 minutes, comparable
to that of developed nations. Some of the critical factors in its success included local manufacture of vehicles,
training instructors to certify emergency medical technicians, adopting training materials to the local context, and
branching out to include fire and rescue service response under a united command structure.
Resources
The vital nature of coping with the lack of resources available in international emergency medicine may be
seen in the proportion of scientific articles that grapple with the topic. Of the top 27 articles identified by a
review of the international emergency medicine literature from 2010, 14 were classified as dealing with the
practice of emergency medicine in resource-constrained environments. A new dimension of thought is that of
the isolated subject of technology for trauma care as published in the World Journal of Surgery by Mihir Shah
et al. Topics covered included the use of the Broselow tape as the best estimate for children’s weight, green
bananas as an effective treatment for diarrhea, and misoprostol as a potential alternative for postpartum
hemorrhage when oxytocin is not available.
Lack of Research
Despite the thought that increasing availability to emergency medicine will improve patient outcomes, little
empirical evidence exists to directly support that claim, even in developed countries. Between 1985 and 1998
only 54 randomized controlled trials related to emergency medical services were published, implying that much
of the current standard of care rests upon meagre support. A similar lack of direct proof exists for the effectiveness
of international assistance in promoting emergency medicine in other countries. Although it may seem that such
efforts must improve health, the failure to quantify international emergency medicine’s impact renders it more
difficult to identify the best practices and target areas in which the most benefit may be achieved. A development
in recent years that seeks to address these issues has been termed evidence-based medicine. As its name suggests,
this approach strives to rigorously study the effects of different interventions instead of relying on logic or
tradition. Jeffrey Arnold argues that its application worldwide could lead to the boon of sharing best practices
between emergency medicine practitioners in various countries, thus advancing the current standard of emergency
care.

Pediatric emergency medicine (PEM) is a medical subspecialty of both pediatrics and emergency
medicine. It involves the care of undifferentiated, unscheduled children with acute illnesses or injuries
that require immediate medical attention. While not usually providing long-term or continuing care, pediatric
emergency doctors undertake the necessary investigations and interventions to diagnose patients in the
acute phase, to liaise with physicians from other specialities, and to resuscitate and stabilize children who
are seriously ill or injured. Pediatric emergency physicians generally practice in hospital emergency
departments.
TRAINING
United States of America

Pediatric emergency physicians in the United States take one of two routes of training; one can do a pediatrics
residency (3 years) followed by a pediatric emergency fellowship (3 years), or an emergency medicine residency
(3-4 years) followed by a pediatric emergency fellowship (3 years). Majority of practicing PEM doctors take
the former route. There are currently 50+ PEM fellowship programmes with 177 total spots in the United
States. A survey published in 2009 found that PEM physicians report higher career satisfaction than doctors in
all other specialties. Per doximity, pediatric emergency physicians in the U.S. make an average of $273,683
yearly. They also work fewer hours than do other subspecialists.
Canada
In Canada, aspiring paediatric emergency physicians must first complete a Doctor of Medicine (M.D.) and
then apply to a paediatrics or emergency medicine residency programme, both of which last on average five
years. Residents, however, will not complete the entire residency programme as they will, upon starting their
final year of residency, switch to the other residency programme in order to receive training in both specialties.
This switch usually extends the length of the residency by a few years. As such, the residency programme in its
entirety usually has a length of about 6 years and leads to certification by the Royal College of Physicians and
Surgeons of Canada. Many institutions, such as McGill University, Université de Montréal, Université de
Sherbrooke, and Université Laval in the province of Quebec, offer this residency programme in collaboration
with various hospital training centres. Other Canadian universities, such as University of Toronto, University
of Ottawa, University of Calgary, University of Saskatchewan, and University of British Columbia, also offer
post-graduate medical programmes in emergency medicine and paediatrics. Another general certification
programme is available for family physicians. Upon completing a two-year residency in family medicine, one
has the possibility of completing a third year of residency in the emergency medicine enhanced skills programme.
Certification is awarded by the College of Family Physicians of Canada and allows family practitioners to work
as emergency physicians in most emergency departments across Canada. The specialty training of family
physicians allows them to treat patients of all ages affected by almost any type of disease. In that sense, family
physicians who hold the emergency medicine certification may work with paediatric patients.
Ì
Ì

Pre-hospital emergency medicine (abbreviated PHEM) is a medical speciality which focuses on caring for
seriously ill or injured patients before they reach hospital, and during emergency transfer to hospital or between
hospitals. It is primarily a subspecialty of emergency medicine, but may also be practised by physicians from
other acute specialties such as anaesthesia, intensive care medicine and acute medicine. Practitioners in PHEM
are usually well-integrated with local emergency medical services, and are dispatched together with emergency
medical technicians or paramedics where potentially life-threatening trauma or illness is suspected that may
benefit from immediate specialist medical treatment. This may involve travelling by car or air ambulance to the
site. In the UK, PHEM was recognised as a subspecialty of emergency medicine and anaesthetics in July 2011
by the General Medical Council.

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes
of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot
wounds. Depending on the severity of injury, quickness of management and transportation to an appropriate
medical facility (called a trauma center) may be necessary to prevent loss of life or limb. The initial assessment is
critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of
injuries accurately and to formulate a course of treatment. In 2002, unintentional and intentional injuries were the
fifth and seventh leading causes of deaths worldwide, accounting for 6.23% and 2.84% of all deaths. For research
purposes the definition often is based on an injury severity score (ISS) of greater than 15.
CLASSIFICATION
Injuries generally are classified by either severity, the location of damage, or a combination of both. Trauma
also may be classified by demographic group, such as age or gender. It also may be classified by the type of
force applied to the body, such as blunt trauma or penetrating trauma. For research purposes injury may be
classified using the Barell matrix, which is based on ICD-9-CM. The purpose of the matrix is for international
standardization of the classification of trauma. Major trauma sometimes is classified by body area; injuries
affecting 40% are polytrauma, 30% head injuries, 20% chest trauma, 10%, abdominal trauma, and 2%, extremity
trauma. Various scales exist to provide a quantifiable metric to measure the severity of injuries. The value may
be used for triaging a patient or for statistical analysis. Injury scales measure damage to anatomical parts,
physiological values (blood pressure etc.), comorbidities, or a combination of those. The abbreviated injury
scale and the Glasgow coma scale are used commonly to quantify injuries for the purpose of triaging and allow
a system to monitor or “trend” a patient’s condition in a clinical setting. The data also may be used in
epidemiological investigations and for research purposes. Approximately 2% of those who have experienced
significant trauma have a spinal cord injury.
CAUSES
Injuries may be caused by any combination of external forces that act physically against the body. The
leading causes of traumatic death are blunt trauma, motor vehicle collisions, and falls, followed by penetrating
trauma such as stab wounds or impaled objects. Subsets of blunt trauma are both the number one and two
causes of traumatic death. For statistical purposes, injuries are classified as either intentional such as suicide, or
unintentional, such as a motor vehicle collision. Intentional injury is a common cause of traumas. Penetrating
trauma is caused when a foreign body such as a bullet or a knife enters the body tissue, creating an open wound.
In the United States, most deaths caused by penetrating trauma occur in urban areas and 80% of these deaths are
caused by firearms. Blast injury is a complex cause of trauma because it commonly includes both blunt and
penetrating trauma, and also may be accompanied by a burn injury. Trauma also may be associated with a
particular activity, such as an occupational or sports injury.
PATHOPHYSIOLOGY
The body responds to traumatic injury both systemically and at the injury site. This response attempts to
protect vital organs such as the liver, to allow further cell duplication and to heal the damage. The healing time
of an injury depends on various factors including sex, age, and the severity of injury.
The symptoms of injury may manifest in many different ways, including:
• Altered mental status
• Fever
• Increased heart rate
• Generalized edema
• Increased cardiac output
• Increased rate of metabolism
Various organ systems respond to injury to restore homeostasis by maintaining perfusion to the heart and
brain. Inflammation after injury occurs to protect against further damage and starts the healing process. Prolonged
inflammation may cause multiple organ dysfunction syndrome or systemic inflammatory response syndrome.
Immediately after injury, the body increases production of glucose through gluconeogenesis and its consumption
of fat via lipolysis. Next, the body tries to replenish its energy stores of glucose and protein via anabolism. In
this state the body will temporarily increase its maximum expenditure for the purpose of healing injured cells.
DIAGNOSIS
The initial assessment is critical in determining the extent of injuries and what will be needed to manage an
injury, and for treating immediate life threats.
Physical Examination
Primary physical examination is undertaken to identify any life-threatening problems, after which the
secondary examination is carried out. This may occur during transportation or upon arrival at the hospital. The
secondary examination consists of a systematic assessment of the abdominal, pelvic, and thoracic areas, a
complete inspection of the body surface to find all injuries, and a neurological examination. Injuries that may
manifest themselves later, may be missed during the initial assessment, such as when a patient is brought into a
hospital’s emergency department. Generally, the physical examination is performed in a systematic way that
first checks for any immediate life threats (primary survey), and then taking a more in depth examination
(secondary survey).
Imaging
Persons with major trauma commonly have chest and pelvic x-rays taken, and, depending on the mechanism
of injury and presentation, a focused assessment with sonography for trauma (FAST) exam to check for internal
bleeding. For those with relatively stable blood pressure, heart rate, and sufficient oxygenation, CT scans are
useful. Full-body CT scans, known as pan-scans, improve the survival rate of those who have suffered major
trauma. These scans use intravenous injections for the radiocontrast agent, but not oral administration. There
are concerns that intravenous contrast administration in trauma situations without confirming adequate renal
function may cause damage to kidneys, but this does not appear to be significant. In the U.S., CT or MRI scans
are performed on 15% of those with trauma in emergency departments. Where blood pressure is low or the
heart rate is increased—likely from bleeding in the abdomen—immediate surgery bypassing a CT scan is
recommended. Modern 64-slice CT scans are able to rule out with a high degree of accuracy, significant injuries
to the neck following blunt trauma.
Surgical Techniques
Surgical techniques, using a tube or catheter to drain fluid from the peritoneum, chest, or the pericardium
around the heart, often are used in cases of severe blunt trauma to the chest or abdomen, especially when a
person is experiencing early signs of shock. In those with low blood-pressure, likely because of bleeding in the
abdominal cavity, cutting through the abdominal wall surgically is indicated.
PREVENTION
By identifying risk factors present within a community and creating solutions to decrease the incidence of
injury, trauma referral systems may help to enhance the overall health of a population. Injury prevention strategies
are commonly used to prevent injuries in children, who are a high risk population. Injury prevention strategies
generally involve educating the general public about specific risk factors and developing strategies to avoid or
reduce injuries. Legislation intended to prevent injury typically involves seatbelts, child car-seats, helmets,
alcohol control, and increased enforcement of the legislation. Other controllable factors, such as the use of
drugs including alcohol or cocaine, increases the risk of trauma by increasing the likelihood of traffic collisions,
violence, and abuse occurring.
Prescription drugs such as benzodiazepines may increase the risk of trauma in elderly people. The care of
acutely injured people in a public health system requires the involvement of bystanders, community members,
health care professionals, and health care systems. It encompasses pre-hospital trauma assessment and care by
emergency medical services personnel, emergency department assessment, treatment, stabilization, and in-
hospital care among all age groups. An established trauma system network is also an important component of
community disaster preparedness, facilitating the care of people who have been involved in disasters that cause
large numbers of casualties, such as earthquakes.
MANAGEMENT
Pre-hospital
The pre-hospital use of stabilization techniques improves the chances of a person surviving the journey to
the nearest trauma-equipped hospital. Emergency medicine services determines which people need treatment at
a trauma center as well as provide primary stabilization by checking and treating airway, breathing, and circulation
as well as assessing for disability and gaining exposure to check for other injuries. Spinal motion restriction by
securing the neck with a cervical collar and placing the person on a long spine board was of high importance in
the pre-hospital setting, but due to lack of evidence to support its use, the practice is losing favour. Instead, it is
recommend that more exclusive criteria be met such as age and neurological deficits to indicate the need of
these adjuncts. This may be accomplished with other medical transport devices such as a Kendrick extrication
device, before moving the person. It is important to quickly control severe bleeding with direct pressure to the
wound and consider the use of hemostatic agents or tourniquets if the bleeding continues. Conditions such as
impending airway obstruction, enlargening neck hematoma, or unconsciousness require intubation. It is unclear,
however, if this is best performed before reaching hospital or in the hospital. Rapid transportation of severely
injured patients improves the outcome in trauma. Helicopter EMS transport reduces mortality compared to
ground-based transport in adult trauma patients. Before arrival at the hospital, the availability of advanced life
support does not greatly improve the outcome for major trauma when compared to the administration of basic
life support. Evidence is inconclusive in determining support for pre-hospital intravenous fluid resuscitation
while some evidence has found it may be harmful. Hospitals with designated trauma centers have improved
outcomes when compared to hospitals without them, and outcomes may improve when persons who have
experienced trauma are transferred directly to a trauma center.
In-hospital
Management of those with trauma often requires the help of many health care specialists including
physicians, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed
at once. Generally the first step of managing trauma is to perform a primary survey that evaluates a person’s
airway, breathing, circulation, and neurologic status. After immediate life threats are controlled, a person is
either moved into an operating room for immediate surgical correction of the injuries, or a secondary survey
is performed that is a more detailed head-to-toe assessment of the person. Indications for intubation include
airway obstruction, inability to protect the airway, and respiratory failure. Examples of these indications
include penetrating neck trauma, expanding neck hematoma, and being unconscious, among other indications.
In general, the method of intubation used is rapid sequence intubation followed by ventilation. Assessment
of circulation in those with trauma includes control of active bleeding. When a person is first brought in,
vital signs are checked, an ECG is performed, and, if needed, vascular access is obtained. Other tests should
be performed to get a baseline measurement of their current blood chemistry, such as a arterial blood gas or
thromboelastography. In those with cardiac arrest due to trauma chest compressions are considered futile,
but still recommended. Correcting the underlying cause such as a pneumothorax or pericardial tamponade, if
present, may help. A FAST exam may help assess for internal bleeding. In certain traumas, such as maxillofacial
trauma, it may be beneficial to have a highly trained health care provider available to maintain airway,
breathing, and circulation.
Intravenous Fluids
Traditionally, high-volume intravenous fluids were given to people who had poor perfusion due to trauma.
This is still appropriate in cases with isolated extremity trauma, thermal trauma, or head injuries. In general,
however, giving lots of fluids appears to increase the risk of death. Current evidence supports limiting the use
of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist. Targets include a
mean arterial pressure of 60 mmHg, a systolic blood pressure of 70–90 mmHg, or the re-establishment of
peripheral pulses and adequate ability to think. Hypertonic saline has been studied and found to be of little
difference from normal saline. As no intravenous fluids used for initial resuscitation have been shown to be
superior, warmed Lactated Ringer’s solution continues to be the solution of choice. If blood products are needed,
a greater use of fresh frozen plasma and platelets relative to packed red blood cells has been found to improve
survival and lower overall blood product use; a ratio of 1:1:1 is recommended. The success of platelets has been
attributed to the fact that they may prevent coagulopathy from developing. Cell salvage and autotransfusion
also may be used. Blood substitutes such as hemoglobin-based oxygen carriers are in development; however, as
of 2013 there are none available for commercial use in North America or Europe. These products are only
available for general use in South Africa and Russia.
Medications
Tranexamic acid decreases the mortality rate in people who are bleeding due to trauma. It only appears to be
beneficial, however, if administered within the first three hours after trauma. For severe bleeding, for example
from bleeding disorders, recombinant factor VIIa—a protein that assists blood clotting—may be appropriate.
While it decreases blood use, it does not appear to decrease the mortality rate. In those without previous factor
VII deficiency, its use is not recommended outside of trial situations. Other medications may be used in
conjunction with other procedures to stabilize a person who has sustained a significant injury. While positive
inotropic medications such as norepinephrine sometimes are used in hemorrhagic shock as a result of trauma,
there is a lack of evidence for their use. Therefore, as of 2012 they have not been recommended. Allowing a low
blood pressure may be preferred in some situations.
Surgery
The decision whether to perform surgery is determined by the extent of the damage and the anatomical
location of the injury. Bleeding must be controlled before definitive repair may occur. Damage control surgery
is used to manage severe trauma in which there is a cycle of metabolic acidosis, hypothermia, and hypotension
that may lead to death, if not corrected. The main principal of the procedure involves performing the least
number of procedures to save life and limb; less critical procedures are left until the victim is more stable.
Approximately 15% of all people with trauma have abdominal injuries, and approximately 25% of these require
exploratory surgery. The majority of preventable deaths from trauma result from unrecognised intra-abdominal
bleeding.
PROGNOSIS
Trauma deaths occur in immediate, early, or late stages. Immediate deaths usually are due to apnea, severe
brain or high spinal cord injury, or rupture of the heart or of large blood vessels. Early deaths occur within
minutes to hours and often are due to hemorrhages in the outer meningeal layer of the brain, torn arteries, blood
around the lungs, air around the lungs, ruptured spleen, liver laceration, or pelvic fracture. Immediate access to
care may be crucial to prevent death in persons experiencing major trauma. Late deaths occurs days or weeks
after the injury and often are related to infection. Prognosis is better in countries with a dedicated trauma
system where injured persons are provided quick and effective access to proper treatment facilities. Long-term
prognosis frequently is complicated by pain; more than half of trauma patients have moderate to severe pain
one year after injury. Many also experience a reduced quality of life years after an injury, with 20% of victims
sustaining some form of disability. Physical trauma may lead to development of post-traumatic stress disorder
(PTSD). One study has found no correlation between the severity of trauma and the development of PTSD.
EPIDEMIOLOGY
Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually.
It is the fifth leading cause of significant disability. About half of trauma deaths are in people aged between 15
and 45 years and trauma is the leading cause of death in this age group. Injury affects more males; 68% of
injuries occur in males and death from trauma is twice as common in males as it is in females, this is believed
to be because males are much more willing to engage in risk-taking activities. Teenagers and young adults are
more likely to need hospitalization from injuries than other age groups. While elderly persons are less likely to
be injured, they are more likely to die from injuries sustained due to various physiological differences that
make it more difficult for the body to compensate for the injuries. The primary causes of traumatic death are
central nervous system injuries and substantial blood loss. Various classification scales exist for use with trauma
to determine the severity of injuries, which are used to determine the resources used and, for statistical collection.
HISTORY
The human remains discovered at the site of Nataruk in Turkana, Kenya, are claimed to show major trauma,
blunt and penetrating trauma, caused by violent trauma to the head, neck, ribs, knees, and hands that has been
interpreted by some researchers as establishing the existence of warfare between two groups of hunter-gatherers
10,000 years ago. The evidence for blunt force trauma at Nataruk has been challenged, however, and the
interpretation that the site represents an early example of warfare has been questioned.
SOCIETY AND CULTURE
Economics
The financial cost of trauma includes both the amount of money spent on treatment and the loss of potential
economic gain through absence from work. The average financial cost for the treatment of traumatic injury in
the United States is approximately US$334,000 per person, making it costlier than the treatment of cancer and
cardiovascular diseases. One reason for the high cost of the treatment for trauma is the increased possibility of
complications, which leads to the need for more interventions. Maintaining a trauma center is costly because
they are open continuously and maintain a state of readiness to receive patients, even if there are none. In
addition to the direct costs of the treatment, there also is a burden on the economy due to lost wages and
productivity, which in 2009, accounted for approximately US$693.5 billion in the United States.
Low- and Middle-income Countries

Citizens of low- and middle-income countries (LMICs) often have higher mortality rates from injury. These
countries accounted for 89% of all deaths from injury worldwide. Many of these countries do not have access
to sufficient surgical care and many do not have a trauma system in place. In addition, most LMICs do not have
a pre-hospital care system that treats injured persons initially and transports them to hospital quickly, resulting
in most casualty patients being transported by private vehicles. Also, their hospitals lack the appropriate
equipment, organizational resources, or trained staff. By 2020, the amount of trauma-related deaths is expected
to decline in high-income countries, while in low- to middle-income countries it is expected to increase.
SPECIAL POPULATIONS
Children
Due to anatomical and physiological differences, injuries in children need to be approached differently from
those in adults. Accidents are the leading cause of death in children between 1 and 14 years old. In the United
States, approximately sixteen million children go to an emergency department due to some form of injury every
year, with boys being more frequently injured than girls by a ratio of 2:1. The world’s five most common
unintentional injuries in children as of 2008 are road crashes, drowning, burns, falls, and poisoning. Weight
estimation is an important part of managing trauma in children because the accurate dosing of medicine may be
critical for resuscitative efforts. A number of methods to estimate weight, including the Broselow tape, Leffler
formula, and Theron formula exist.
Pregnancy
Trauma occurs in approximately 5% of all pregnancies, and is the leading cause of maternal death.
Additionally, pregnant women may experience placental abruption, pre-term labour, and uterine rupture.
There are diagnostic issues during pregnancy; ionizing radiation has been shown to cause birth defects,
although the doses used for typical exams generally are considered safe. Due to normal physiological changes
that occur during pregnancy, shock may be more difficult to diagnose. Where the woman is more than 23
weeks pregnant, it is recommended that the fetus be monitored for at least four hours by cardiotocography. A
number of treatments beyond typical trauma care may be needed when the patient is pregnant. Because the
weight of the uterus on the inferior vena cava may decrease blood return to the heart, it may be very beneficial
to lay a women in late pregnancy on her left side. also recommended are Rho(D) immune globulin in those
who are rh negative, corticosteroids in those who are 24 to 34 weeks and may need delivery or a caesarian
section in the event of cardiac arrest.
RESEARCH
Most research on trauma occurs during war and military conflicts as militaries will increase trauma
research spending in order to prevent combat related deaths. Some research is being conducted on patients
who were admitted into an intensive care unit or trauma center, and received a trauma diagnosis that
caused a negative change in their health-related quality of life, with a potential to create anxiety and
symptoms of depression. New preserved blood products also are being researched for use in pre-hospital
care; it is impractical to use the currently available blood products in a timely fashion in remote, rural
settings or in theaters of war.

A trauma center (or trauma centre) is a hospital equipped and staffed to provide care for patients suffering
from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds. A trauma center may
also refer to an emergency department (also known as a “casualty department” or “accident and emergency”)
without the presence of specialized services to care for victims of major trauma. In the United States of America,
a hospital can receive trauma center status by meeting specific criteria established by the American College of
Surgeons (ACS) and passing a site review by the Verification Review Committee. Official designation as a
trauma center is determined by individual state law provisions. Trauma centers vary in their specific capabilities
and are identified by “Level” designation: Level-I (Level-1) being the highest, to Level-III (Level-3) being the
lowest (some states have five designated levels, in which case Level-V (Level-5) is the lowest). The highest
levels of trauma centers have access to specialist medical and nursing care including emergency medicine,
trauma surgery, critical care, neurosurgery, orthopedic surgery, anesthesiology and radiology, as well as highly
sophisticated surgical and diagnostic equipment.
Lower levels of trauma centers may only be able to provide initial care and stabilization of a traumatic injury
and arrange for transfer of the victim to a higher level of trauma care. The operation of a trauma center is
extremely expensive. Some areas—especially rural regions—are under-served by trauma centers because of
this expense. As there is no way to schedule the need for emergency services, patient traffic at trauma centers
can vary widely. A variety of methods have been developed for dealing with this. A trauma center will often
have a helipad for receiving patients that have been airlifted to the hospital. In many cases, persons injured in
remote areas and transported to a distant trauma center by helicopter can receive faster and better medical care
than if they had been transported by ground ambulance to a closer hospital that does not have a designated
trauma center. The trauma level certification can directly affect the patient’s outcome and determine if the
patient needs to be transferred to a higher level trauma center.
HISTORY
UK
Trauma centres grew into existence out of the realisation that traumatic injury is a disease process unto
itself requiring specialised and experienced multidisciplinary treatment and specialised resources. The
world’s first trauma centre, the first hospital to be established specifically to treat injured rather than ill
patients, was the Birmingham Accident Hospital, which opened in Birmingham, England in 1941, after a
series of studies found that the treatment of injured persons within England was inadequate. By 1947, the
hospital had three trauma teams, each including two surgeons and an anaesthesiologist, and a burns team
with three surgeons. The hospital became part of the National Health Service on its formation in July 1948
and closed in 1993.
US
According to the CDC, injuries are the leading cause of death for American children and adults ages 1–44.
The leading causes of trauma are motor vehicle collisions, falls, and assaults with a deadly weapon. In the
United States of America, Drs. Robert J. Baker and Robert J. Freeark established the first civilian Shock Trauma
Unit at Cook County Hospital in Chicago, IL on March 16, 1966. The concept of a shock trauma center was also
developed at the University of Maryland, Baltimore, in the 1950s and 1960s by thoracic surgeon and shock
researcher R Adams Cowley, who founded what became the Shock Trauma Center in Baltimore, Maryland, on
July 1, 1966. The R Adams Cowley Shock Trauma Center is one of the first shock trauma centers in the world.
Cook County Hospital in Chicago trauma center (opened in 1966). Dr. David R. Boyd interned at Cook County
Hospital from 1963 to 1964 before being drafted into the Army of the United States of America. Upon his
release from the Army, Dr. Boyd became the first shock-trauma fellow at the R Adams Cowley Shock Trauma
Center, from 1967 to 1968. Boyd returned to Cook County Hospital, where he would later serve as resident
director of the Cook County Trauma Unit.
Canada
According to the founder of the Trauma Unit at Sunnybrook Health Sciences Centre in Toronto, Ontario, Dr.
Marvin Tile, “the nature of injuries at Sunnybrook has changed over the years. When the trauma center first
opened in 1976, about 98 percent of patients suffered from blunt-force trauma caused by accidents and falls.
Now, as many as 20 percent of patients arrive with gunshot and knife wounds”. Fraser Health Authority in
British Columbia, located at Royal Columbian Hospital and Abbotsford Regional Hospital, services the BC
area, “Each year, Fraser Health treats almost 130,000 trauma patients as part of the integrated B.C. trauma
system”
DEFINITIONS IN THE UNITED STATES OF AMERICA

In the United States of America, trauma centers are ranked by the American College of Surgeons (ACS),
from Level I (comprehensive service) to Level III (limited-care). The different levels refer to the types of
resources available in a trauma center and the number of patients admitted yearly. These are categories that
define national standards for trauma care in hospitals. Level I and Level II designations are also given adult and
or pediatric designations. Additionally, some states have their own trauma-center rankings separate from the
ACS. These levels may range from Level I to Level IV. Some hospitals are less-formally designated Level V.
The ACS does not officially designate hospitals as trauma centers. Numerous US hospitals that are not verified
by ACS claim trauma center designation. Most states have legislation which determines the process for designation
of trauma centers within that state.
The ACS describes this responsibility as “a geopolitical process by which empowered entities, government
or otherwise, are authorized to designate.” The ACS’s self-appointed mission is limited to confirming and
reporting on any given hospital’s ability to comply with the ACS standard of care known as Resources for
Optimal Care of the Injured Patient. The Trauma Information Exchange Programme (TIEP) is a programme of
the American Trauma Society in collaboration with the Johns Hopkins Center for Injury Research and Policy
and is funded by the Centers for Disease Control and Prevention. TIEP maintains an inventory of trauma
centers in the US, collects data and develops information related to the causes, treatment and outcomes of
injury, and facilitates the exchange of information among trauma care institutions, care providers, researchers,
payers and policy makers.
Level I
A Level I trauma center provides the highest level of surgical care to trauma patients. Being treated at a
Level I trauma center increases a seriously injured patient’s chances of survival by an estimated 20 to 25
percent. It has a full range of specialists and equipment available 24 hours a day and admits a minimum required
annual volume of severely injured patients. In addition, these trauma centers must be able to provide care for
pediatric patients. Many Level II trauma centers would qualify for Level I if they were equipped to handle all
pediatric emergencies.
A Level I trauma center is required to have a certain number of the following people on duty 24 hours a day
at the hospital:
• Surgeons
• Emergency physicians
• Anesthesiologists
• Nurses
• An education programme
• Preventive and outreach programmes.
Key elements include 24hour inhouse coverage by general surgeons and prompt availability of care in
varying specialties—such as orthopedic surgery, cardiothoracic surgery, neurosurgery, plastic surgery,
anesthesiology, emergency medicine, radiology, internal medicine, otolaryngology and oral and maxillofacial
surgery (trained to treat injuries of the facial skin, muscles, bones), and critical care, which are needed to
adequately respond and care for various forms of trauma that a patient may suffer and rehabilitation services.
Most Level I trauma centers are teaching hospitals/campuses. Additionally, a Level I center has a programme
of research, is a leader in trauma education and injury prevention, and is a referral resource for communities
in nearby regions.
Level II
A Level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma
care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all
essential specialties, personnel, and equipment. Minimum volume requirements may depend on local
conditions. These institutions are not required to have an ongoing programme of research or a surgical
residency programme.
Level III
A Level III trauma center does not have the full availability of specialists, but does have resources for
emergency resuscitation, surgery, and intensive care of most trauma patients. A Level III center has transfer
agreements with Level I or Level II trauma centers that provide back-up resources for the care of patients with
exceptionally severe injuries (e.g., multiple trauma).
Level IV
A Level IV trauma center exists in some states where the resources do not exist for a Level III trauma center.
It provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. It may
also provide surgery and critical-care services, as defined in the scope of services for trauma care. A trauma-
trained nurse is immediately available, and physicians are available upon the patient’s arrival to the Emergency
Department. Transfer agreements exist with other trauma centers of higher levels, for use when conditions
warrant a transfer.
Level V
Provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. May
provide surgical and critical-care services, as defined in the service’s scope of trauma-care services. A trauma-
trained nurse is immediately available, and physicians are available upon patient arrival in the Emergency
Department. If not open 24 hours daily, the facility must have an after-hours trauma response protocol.
Pediatric Trauma Centers

A facility can be designated an adult trauma center, a pediatric trauma center, or an adult and pediatric
trauma center. If a hospital provides trauma care to both adult and pediatric patients, the Level designation may
not be the same for each group. For example, a Level I adult trauma center may also be a Level II pediatric
trauma center. This is because pediatric trauma surgery is a specialty unto itself. Adult trauma surgeons are not
generally specialized in providing surgical trauma care to children, and vice versa, and the difference in practice
is significant.

Triage is the process of determining the priority of patients’ treatments based on the severity of their condition.
This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The
term comes from the French verb trier, meaning to separate, sift or select. Triage may result in determining the
order and priority of emergency treatment, the order and priority of emergency transport, or the transport
destination for the patient. Triage may also be used for patients arriving at the emergency department, or
telephoning medical advice systems, among others. This article deals with the concept of triage as it occurs in
medical emergencies, including the prehospital setting, disasters, and emergency department treatment. The
term triage may have originated during the Napoleonic Wars from the work of Dominique Jean Larrey. The
term was used further during World War I by French doctors treating the battlefield wounded at the aid stations
behind the front.
Those responsible for the removal of the wounded from a battlefield or their care afterwards would divide
the victims into three categories:
• Those who are likely to live, regardless of what care they receive;
• Those who are unlikely to live, regardless of what care they receive;
• Those for whom immediate care might make a positive difference in outcome.
For many emergency medical services (EMS) systems, a similar model may sometimes still be applied. In
the earliest stages of an incident, such as when one or two paramedics exist to twenty or more patients,
practicality demands that the above, more “primitive” model will be used. However once a full response has
occurred and many hands are available, paramedics will usually use the model included in their service
policy and standing orders. As medical technology has advanced, so have modern approaches to triage,
which are increasingly based on scientific models. The categorizations of the victims are frequently the
result of triage scores based on specific physiological assessment findings. Some models, such as the START
model may be algorithm-based. As triage concepts become more sophisticated, triage guidance is also evolving
into both software and hardware decision support products for use by caregivers in both hospitals and the
field.
Types
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Simple triage is usually used in a scene of an accident or “mass-casualty incident” (MCI), in order to
sort patients into those who need critical attention and immediate transport to the hospital and those with
less serious injuries. This step can be started before transportation becomes available. Upon completion of
the initial assessment by physicians, nurses or paramedical personnel, each patient may be labelled which
may identify the patient, display assessment findings, and identify the priority of the patient’s need for
medical treatment and transport from the emergency scene. At its most primitive, patients may be simply
marked with coloured flagging tape or with marker pens. Pre-printed cards for this purpose are known as
a triage tags.
A triage tag is a prefabricated label placed on each patient that serves to accomplish several objectives:
• Identify the patient.
• Bear record of assessment findings.
• Identify the priority of the patient’s need for medical treatment and transport from the emergency
scene.
• Track the patients’ progress through the triage process.

• Identify additional hazards such as contamination.
Triage tags may take a variety of forms. Some countries use a nationally standardized triage tag, while in
other countries commercially available triage tags are used, and these will vary by jurisdictional choice. The
most commonly used commercial systems include the METTAG, the SMARTTAG, E/T LIGHT tm and the
CRUCIFORM systems. More advanced tagging systems incorporate special markers to indicate whether or not
patients have been contaminated by hazardous materials, and also tear off strips for tracking the movement of
patients through the process. Some of these tracking systems are beginning to incorporate the use of handheld
computers, and in some cases, bar code scanners.
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In advanced triage, doctors and specially trained nurses may decide that some seriously injured people
should not receive advanced care because they are unlikely to survive. It is used to divert scarce resources away
from patients with little chance of survival in order to increase the chances for others with higher likelihoods.
The use of advanced triage may become necessary when medical professionals decide that the medical resources
available are not sufficient to treat all the people who need help. The treatment being prioritized can include the
time spent on medical care, or drugs or other limited resources. This has happened in disasters such as terrorist
attacks, mass shootings, volcanic eruptions, earthquakes, tornadoes, thunderstorms, and rail accidents. In these
cases some percentage of patients will die regardless of medical care because of the severity of their injuries.
Others would live if given immediate medical care, but would die without it. In these extreme situations, any
medical care given to people who will die anyway can be considered to be care withdrawn from others who
might have survived (or perhaps suffered less severe disability from their injuries) had they been treated instead.
It becomes the task of the disaster medical authorities to set aside some victims as hopeless, to avoid trying to
save one life at the expense of several others. If immediate treatment is successful, the patient may improve
(although this may be temporary) and this improvement may allow the patient to be categorized to a lower
priority in the short term. Triage should be a continuous process and categories should be checked regularly to
ensure that the priority remains correct given the patient’s condition. A trauma score is invariably taken when
the victim first comes into hospital and subsequent trauma scores are taken to account for any changes in the
victim’s physiological parameters. If a record is maintained, the receiving hospital doctor can see a trauma
score time series from the start of the incident, which may allow definitive treatment earlier.
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Continuous integrated triage is an approach to triage in mass casualty situations which is both efficient and
sensitive to psychosocial and disaster behavioural health issues that affect the number of patients seeking care
(surge), the manner in which a hospital or health care facility deals with that surge (surge capacity) and the
overarching medical needs of the event. Continuous integrated triage combines three forms of triage with
progressive specificity to most rapidly identify those patients in greatest need of care while balancing the needs
of the individual patients against the available resources and the needs of other patients.
Continuous integrated triage employs:
• Group (Global) Triage (i.e., M.A.S.S. triage)
• Physiologic (Individual) Triage (i.e., S.T.A.R.T.)
• Hospital Triage (i.e., E.S.I. or Emergency Severity Index).
However any Group, Individual and/or Hospital Triage system can be used at the appropriate level of
evaluation.
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Usually, triage refers to prioritising admission. A similar process can be applied to discharging patients early
when the medical system is stressed. This process has been called “reverse triage”. During a “surge” in demand,
such as immediately after a natural disaster, many hospital beds will be occupied by regular non-critical patients.
In order to accommodate a greater number of the new critical patients, the existing patients may be triaged, and
those who will not need immediate care can be discharged until the surge has dissipated, for example through
the establishment of temporary medical facilities in the region.
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Undertriage is the underestimating the severity of an illness or injury. An example of this would be categorizing
a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3 (Minimal). Historically, acceptable
undertriage rates have been deemed 5% or less. Overtriage is the overestimating of the severity of an illness or
injury. An example of this would be categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or
Priority 1 (Immediate). Acceptable overtriage rates have been typically up to 50% in an effort to avoid undertriage.
Some studies suggest that overtriage is less likely to occur when triaging is performed by hospital medical
teams, rather than paramedics or EMTs.
OUTCOMES
Palliative Care
For those patients that have a poor prognosis and are expected to die regardless of the medical treatment
available, palliative care such as painkillers may be given to ease suffering before they die.
Evacuation
In the field, triage sets priorities for evacuation or relocation to other care facilities.
Alternative Care Facilities

Alternative care facilities are places that are set up for the care of large numbers of patients, or are places that
could be so set up. Examples include schools, sports stadiums, and large camps that can be prepared and used
for the care, feeding, and holding of large numbers of victims of a mass casualty or other type of event. Such
improvised facilities are generally developed in cooperation with the local hospital, which sees them as a
strategy for creating surge capacity. While hospitals remain the preferred destination for all patients, during a
mass casualty event such improvised facilities may be required in order to divert low-acuity patients away from
hospitals in order to prevent the hospitals becoming overwhelmed.
Secondary (in-hospital) Triage

In advanced triage systems, secondary triage is typically implemented by emergency nurses, skilled
paramedics, or battlefield medical personnel within the emergency departments of hospitals during disasters,
injured people are sorted into five categories. Some crippling injuries, even if not life-threatening, may be
elevated in priority based on the available capabilities. During peacetime, most amputation injuries may be
triaged “Red” because surgical reattachment must take place within minutes, even though in all probability the
person will not die without a thumb or hand.
SPECIFIC SYSTEMS
Practical Applied Triage

During the early stages of an incident, first responders may be overwhelmed by the scope of patients and
injuries. One valuable technique is the Patient Assist Method (PAM). The responders quickly establish a casualty
collection point (CCP) and advise, either by yelling, or over a loudspeaker, that “anyone requiring assistance
should move to the selected area (CCP)”. This does several things at once, it identifies patients that are not so
severely injured, that they need immediate help, it physically clears the scene, and provides possible assistants
to the responders. As those who can move, do so, the responders then ask, “anyone who still needs assistance,
yell out or raise your hands”; this further identifies patients who are responsive, yet maybe unable to move.
Now the responders can rapidly assess the remaining patients who are either expectant, or are in need of
immediate aid. From that point the first responder is quickly able to identify those in need of immediate attention,
while not being distracted or overwhelmed by the magnitude of the situation. Using this method assumes the
ability to hear. Deaf, partially deaf, or victims of a large blast injury may not be able to hear these instructions.
Scoring Systems
Examples of scoring systems used:
• In Western Europe the Triage Revised Trauma Score (TRTS) is sometimes used and integrated into
triage cards.
• The Injury Severity Score (ISS) is another example of a trauma scoring system. This assigns a score
from 0 to 75 based on severity of injury to the human body divided into three categories: A (face/
neck/head), B(thorax/abdomen), C(extremities/external/skin). Each category is scored from 0 to 5
using the Abbreviated Injury Scale, from uninjured to critically injured, which is then squared and
summed to create the ISS. A score of 6, for “unsurvivable”, can also be used for any of the three
categories, and automatically sets the score to 75 regardless of other scores. Depending on the triage
situation, this may indicate either that the patient is a first priority for care, or that he or she will not
receive care owing to the need to conserve care for more likely survivors.
S.T.A.R.T. Model
S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly
trained lay and emergency personnel in emergencies. It is not intended to supersede or instruct medical personnel
or techniques. It has been taught to California emergency workers for use in earthquakes. It was developed at
Hoag Hospital in Newport Beach, California for use by emergency services. It has been field-proven in mass
casualty incidents such as train wrecks and bus accidents, though it was developed for use by community
emergency response teams (CERTs) and firefighters after earthquakes.
Triage separates the injured into four groups:
• The expectant who are beyond help
• The injured who can be helped by immediate transportation
• The injured whose transport can be delayed
• Those with minor injuries, who need help less urgently
Triage also sets priorities for evacuation and transport as follows:
• Deceased are left where they fell. These people are not breathing and an effort to reposition their
airway has been unsuccessful.
• Immediate or Priority 1 (red) evacuation by MEDEVAC if available or ambulance as they need

advanced medical care at once or within 1 hour. These people are in critical condition and would die
without immediate assistance.
• Delayed or Priority 2 (yellow) can have their medical evacuation delayed until all immediate persons
have been transported. These people are in stable condition but require medical assistance.
• Minor or Priority 3 (green) are not evacuated until all immediate and delayed persons have been evacuated.
These will not need advanced medical care for at least several hours. Continue to re-triage in case their
condition worsens. These people are able to walk, and may only require bandages and antiseptic.
Hospital Systems
Within the hospital system, the first stage on arrival at the emergency department is assessment by the hospital
triage nurse. This nurse will evaluate the patient’s condition, as well as any changes, and will determine their
priority for admission to the emergency department and also for treatment. Once emergency assessment and
treatment are complete, the patient may need to be referred to the hospital’s internal triage system. For a typical
inpatient hospital triage system, a triage nurse or physician will either field requests for admission from the ER
physician on patients needing admission or from physicians taking care of patients from other floors who can be
transferred because they no longer need that level of care (i.e. intensive care unit patient is stable for the medical
floor). This helps keep patients moving through the hospital in an efficient and effective manner. This triage
position is often done by a hospitalist. A major factor contributing to the triage decision is available hospital bed
space. The triage hospitalist must determine, in conjunction with a hospital’s “bed control” and admitting team,
what beds are available for optimal utilization of resources in order to provide safe care to all patients. A typical
surgical team will have their own system of triage for trauma and general surgery patients. This is also true for
neurology and neurosurgical services. The overall goal of triage, in this system, is to both determine if a patient is
appropriate for a given level of care and to ensure that hospital resources are utilized effectively.
CONVENTIONAL CLASSIFICATIONS
In an advanced triage process injured people are sorted into categories. Conventionally there are five
classifications with corresponding colors and numbers although this may vary by region.
• Black/ Expectant: They are so severely injured that they will die of their injuries, possibly in
hours or days (large-area burns, severe trauma, lethal radiation dose), or in life-threatening medical
crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe
head or chest wounds); their treatment is usually palliative, such as being given painkillers, to
reduce suffering.
• Red/ Immediate: They require immediate surgery or other life-saving intervention, and have first
priority for surgical teams or transport to advanced facilities; they “cannot wait” but are likely to
survive with immediate treatment.
• Yellow/ Observation: Their condition is stable for the moment but requires watching by trained
persons and frequent re-triage, will need hospital care (and would receive immediate priority care
under “normal” circumstances).
• Green/ Wait (walking wounded): They will require a doctor’s care in several hours or days but not
immediately, may wait for a number of hours or be told to go home and come back the next day
(broken bones without compound fractures, many soft tissue injuries).
• White/ Dismiss (walking wounded): They have minor injuries; first aid and home care are sufficient,
a doctor’s care is not required. Injuries are along the lines of cuts and scrapes, or minor burns.
Australia and New Zealand

The Australasian Triage Scale (abbreviated ATS and formally known as the National Triage Scale) is a triage
system that is implemented in both Australia and New Zealand. The scale has been in use since 1994. The scale
consists of 5 levels, with 1 being the most critical (resuscitation), and 5 being the least critical (non-urgent).
Australasian Triage Scale
Level Description Should be seen by provider within
1 Resuscitation 0 minutes
2 Emergency 10 minutes
3 Urgent 30 minutes
4 Semi-Urgent 60 minutes
5 Non-urgent 120 minutes
Canada
In the mid-1980s, The Victoria General Hospital, in Halifax, Nova Scotia, Canada, introduced paramedic
triage in its Emergency Department. Unlike all other centres in North America that employ physician and
primarily nurse triage models, this hospital began the practice of employing Primary Care level paramedics to
perform triage upon entry to the Emergency Department. In 1997, following the amalgamation of two of the
city’s largest hospitals, the Emergency Department at the Victoria General closed. The paramedic triage system
was moved to the city’s only remaining adult emergency department, located at the New Halifax Infirmary. In
2006, a triage protocol on whom to exclude from treatment during a flu pandemic was written by a team of
critical-care doctors at the behest of the Ontario government.
For routine emergencies, many locales in Canada now employ the Canadian Triage and Acuity Scale (CTAS)
for all incoming patients. The system categorizes patients by both injury and physiological findings, and ranks
them by severity from 1–5 (1 being highest). The model is used by both paramedics and E/R nurses, and also for
pre-arrival notifications in some cases. The model provides a common frame of reference for both nurses and
paramedics, although the two groups do not always agree on scoring. It also provides a method, in some
communities, for benchmarking the accuracy of pre-triage of calls using AMPDS (What percentage of emergency
calls have return priorities of CTAS 1,2,3, etc.) and these findings are reported as part of a municipal performance
benchmarking initiative in Ontario. Curiously enough the model is not currently used for mass casualty triage,
and is replaced by the START protocol and METTAG triage tags.
Canadian Triage and Acuity Scale (CTAS)
Level Description Should be seen by provider within
1 Resuscitation 0 minutes
2 Emergency 15 minutes
3 Urgent 30 minutes
4 Less Urgent 60 minutes
5 Non Urgent 120 minutes
Finland
Triage at an accident scene is performed by a paramedic or an emergency physician, using the four-level
scale of Can wait, Has to wait, Cannot wait, and Lost.
France
In France, the Prehospital triage in case of a disaster uses a four-level scale:
• DCD: décédé (deceased), or urgence dépassée (beyond urgency)
• UA: urgence absolue (absolute urgency)

• UR: urgence relative (relative urgency)
• UMP: urgence médico-psychologique (medical-psychological urgency) or impliqué (implied, i.e. lightly
wounded or just psychologically shocked).
This triage is performed by a physician called médecin trieur (sorting medic). This triage is usually
performed at the field hospital (PMA–poste médical avancé, i.e. forward medical post). The absolute
urgencies are usually treated onsite (the PMA has an operating room) or evacuated to a hospital. The
relative urgencies are just placed under watch, waiting for an evacuation. The involved are addressed to
another structure called the CUMP–Cellule d’urgence médico-psychologique (medical-psychological
urgency cell); this is a resting zone, with food and possibly temporary lodging, and a psychologist to take
care of the brief reactive psychosis and avoid post-traumatic stress disorder. In the emergency department
of a hospital, the triage is performed by a physician called MAO–médecin d’accueil et d’orientation
(reception and orientation physician), and a nurse called IOA– infirmière d’organisation et d’accueil
(organisation and reception nurse). Some hospitals and SAMU organisations now use the “Cruciform”
card referred to elsewhere. France has also a Phone Triage system for Medical Emergencies Phone Demands
in its Samu Medical Regulation Centers through the 15 medical free national hot line. “Medical Doctor
Regulator” decides what is to be the most efficient solution = Emergency Telemedecine or dispatch of an
Ambulance, a General Practitioner or a Physician+ Nurse + Ambulance Man, Hospital based MICU (Mobile
Intensive Care Unit).
Germany
Preliminary assessment of injuries is usually done by the first ambulance crew on scene, with this role
being assumed by the first doctor arriving at the scene. As a rule, there will be no cardiopulmonary
resuscitation, so patients who do not breathe on their own or develop circulation after their airways are
cleared will be tagged “deceased”. Also, not every major injury automatically qualifies for a red tag. A
patient with a traumatic amputation of the forearm might just be tagged yellow, have the bleeding stopped,
and then be sent to a hospital when possible. After the preliminary assessment, a more specific and definite
triage will follow, as soon as patients are brought to a field treatment facility. There, they will be disrobed
and fully examined by an emergency physician. This will take approximately 90 seconds per patient. The
German triage system also uses four, sometimes five colour codes to denote the urgency of treatment.
Typically, every ambulance is equipped with a folder or bag with coloured ribbons or triage tags. The
urgency is denoted as follows:
Category Meaning Consequences Examples
T1 (I) Acute danger Immediate treatment, Arterial lesions, internal
for life transport as soon as haemorrhage, major
possible amputations
T2 (II) Severe injury Constant observation and Minor amputations, flesh
rapid treatment, transport wounds, fractures and
as soon as practical dislocations
T3 (III) Minor injury Treatment when practical, Minor lacerations, sprains,
or no injury transport and/or discharge abrasions
when possible
T4 (IV) No or small Observation and if Severe injuries, uncompensated
chance of possible administration of blood loss, negative neurological
survival analgesics assessment
Deceased Collection and guarding of Injuries not compatible with life,
bodies, identification when no spontaneous breathing after
possible clearing of airway, downgraded
from T1-4
Hong Kong
In Hong Kong, triage in Accident and Emergency Departments is performed by experienced registered
nurses, patients are divided into five triage categories: Critical, Emergency, Urgent, Semi-urgent and Non-
urgent.
Japan
In Japan, the triage system is mainly used by health professionals. The categories of triage, in corresponding
colour codes, are:
• Category I: Used for viable victims with potentially life-threatening conditions.
• Category II: Used for victims with non-life-threatening injuries, but who urgently require treatment.
• Category III: Used for victims with minor injuries that do not require ambulance transport.
• Category 0: Used for victims who are dead, or whose injuries make survival unlikely.
Spain
In Spain, there are 2 models which are the most common found in hospitals around the country:
• The Sistema Estructurado de Triaje (SET), which is an adaptation of the Model Andorrà de Triatge
(MAT). The system uses 650 reasons for medical appointment in 32 symptomatic categories, that
together with some patient information and basic exploratory data, classifies the emergency within 5
levels of urgency.
• The “Manchester”, based on the system with the same name in the UK, use 51 reasons for consultation.
Through some yes/no questions, addressed in a diagram, it classifies the emergency in 5 severities.
Some autonomous communities in Spain, like Navarre and the Valencian Community, have created their
own systems for the community own hospitals.
United Kingdom
In the UK, the commonly used triage system is the Smart Incident Command System, taught on the MIMMS
(Major Incident Medical Management (and) Support) training programme. The UK Armed Forces use this
system on operations. This grades casualties from Priority 1 (needs immediate treatment) to Priority 3 (can wait
for delayed treatment). There is an additional Priority 4 (expectant, likely to die even with treatment) but the
use of this category requires senior medical authority.
In the UK and Europe, the triage process used is sometimes similar to that of the United States, but the
categories are different:
• Dead – patients who have a trauma score of 0 to 2 and are beyond help
• Priority 1 – patients who have a trauma score of 3 to 10 (RTS) and need immediate attention
• Priority 2 – patients who have a trauma score of 10 or 11 and can wait for a short time before
transport to definitive medical attention
• Priority 3 – patients who have a trauma score of 12 (maximum score) and can be delayed before
transport from the scene
United States
Triage in a multi-scale destruction, disaster, catastrophic, casualty event, such as following a tornado or an
explosion in a populated area, first responders follow a similar triage category scale as the US military. The
civilian medical industry uses a similar system for triage. Normally medical personnel aren’t immediately
available on scene. First responders are usually the first to arrive on scene. They could be police, fire rescue,
paramedics, or community individuals with disaster training (CERT certified). They are trained to perform first
aid, basic life saving and rescue techniques while performing the greatest good, for the greatest number of
people. They will rapidly classify victims and sort them into 4 categories, treating quickly as they go. This
system is intended to rapidly identify and classify victims for arriving transport or advanced care medical
personnel such as doctors and nurses. The local National Guard and other military units responding would be
using the military system of triage rather than civilian.
The triage categories are general and the names may vary by region of the nation:
• Minimal: Known as walking wounded or uninjured, green classified individuals typically require
very little medical aid if any. Their injuries are minor, usually scrapes, cuts, and bruising with normal
capillary refill. They can walk, function freely without assistance, are cognizant, and able to respond
accurately to questioning. These individuals will sometimes be asked to assist the responder with
transport and applying direct aid to other victims. They will afterwards be staged in an area to be
checked more thoroughly later.
• Injured - Moderate: Yellow individuals require medical attention but it is not needed immediately.
Individuals in this category may have cuts, bruises, lacerations, some confusion, minor fractures,
and a capillary refill between 4 and 7 seconds(sometimes longer in cold environments). Field dressing
of the wounds is usually applied quickly. Fractures are stabilized and individuals listed as green will
be asked to assist with collection of yellow individuals for transport to the medical staging area.
• Immediate - Severe: Red requires immediate medical attention and will not survive if not seen soon.
A person with a severe head injury, multiple fractures to the skeletal system, fractures in delicate
areas such as the spinal cord, massive confusion, in-cohesive, unable to answer simple questions,
unresponsive but with vital signs, arterial bleeding, internal bleeding, or capillary refill exceeding 7
seconds is classified red. Immediate aid is applied to stop external arterial bleeding and airways are
adjusted to ensure un-obstruction as they are carefully moved to a medical staging area, usually with
the aid of those marked green or unable to provide medical assistance.
• Presumed Deceased: Individuals listed as black have died. The person’s pulse and breathing is checked
to confirm no vitals present. In low scale disaster with few victims involved, immediate CPR is
started in attempt to revive the vital signs. In larger events with more victims, the head is positioned
to open the airway, the body is rolled onto its side and the responder will move on to the next
victim. The positioning is done so if the body’s vitals return, vomiting will not be as likely to choke
the victim. The bodies will not be collected until all surviving individuals have been removed from
the immediate disaster area. There will be a body collection staging area set up away from any
medical staging areas. Usually this will begin the recovery phase.
50;,+;(;,:030;(9@
A battlefield situation, however, requires medics and corpsmen to rank casualties for precedence in MEDEVAC
or CASEVAC. The casualties are then transported to a higher level of care, either a Forward Surgical Team or
Combat Support Hospital and re-triaged by a nurse or doctor. In a combat situation, the triage system is based
solely on resources and ability to save the maximum number of lives within the means of the hospital supplies
and personnel.
The triage categories (with corresponding colour codes), in precedence, are:
• Immediate: The casualty requires immediate medical attention and will not survive if not treated
soon. Any compromise to the casualty’s respiration, hemorrhage control, or shock control could be
fatal.
• Delayed: The casualty requires medical attention within 6 hours. Injuries are potentially life-
threatening, but can wait until the Immediate casualties are stabilized and evacuated.
• Minimal: “Walking wounded,” the casualty requires medical attention when all higher priority patients
have been evacuated, and may not require stabilization or monitoring.
• Expectant: The casualty is expected not to reach higher medical support alive without compromising
the treatment of higher priority patients. Care should not be abandoned, spare any remaining time
and resources after Immediate and Delayed patients have been treated.
Afterwards, casualties are given an evacuation priority based on need:
• Urgent: Evacuation is required within two hours to save life or limb.
• Priority: Evacuation is necessary within four hours or the casualty will deteriorate to “Urgent”.
• Routine: Evacuate within 24 hours to complete treatment.
In a “naval combat situation”, the triage officer must weigh the tactical situation with supplies on hand and
the realistic capacity of the medical personnel. This process can be ever-changing, dependent upon the situation
and must attempt to do the maximum good for the maximum number of casualties.
Field assessments are made by two methods: primary survey (used to detect and treat life-threatening injuries)
and secondary survey (used to treat non-life-threatening injuries) with the following categories:
• Class I: Patients who require minor treatment and can return to duty in a short period of time.
• Class II: Patients whose injuries require immediate life sustaining measures.
• Class III: Patients for whom definitive treatment can be delayed without loss of life or limb.
• Class IV: Patients requiring such extensive care beyond medical personnel capability and time.
LIMITATIONS OF CURRENT PRACTICES

Notions of mass casualty triage as an efficient rationing process of determining priority based upon injury
severity are not supported by research, evaluation and testing of current triage practices, which lack scientific
and methodological bases. START and START-like (START) triage that use colour-coded categories to prioritize
provide poor assessments of injury severity and then leave it to providers to subjectively order and allocate
resources within flawed categories.
Some of these limitations include:
• Lacking the clear goal of maximizing the number of lives saved, as well as the focus, design and
objective methodology to accomplish that goal (a protocol of taking the worst Immediate – lowest
chances for survival – first can be statistically invalid and dangerous)
• Using trauma measures that are problematic (e.g., capillary refill) and grouping into broad colour-
coded categories that are not in accordance with injury severities, medical evidence and needs.
Categories do not differentiate among injury severities and survival probabilities, and are invalid
based on categorical definitions and evacuation priorities
• Ordering (prioritization) and allocating resources subjectively within Immediate and Delayed
categories, which are neither reproducible nor scalable, with little chance of being optimal
• Not considering/addressing size of incident, resources, and injury severities and prioritization within
its categories – e.g., protocol does not change whether 3, 30 or 3,000 casualties require its use, and
regardless of available resources to be rationed
• Not considering differences in injury severities and survival probabilities between types of trauma
(blunt versus penetrating, etc.) and ages
• Resulting in inconsistent tagging and prioritizing/ordering of casualties and substantial overtriage
Research indicates there are wide ranges and overlaps of survival probabilities of the Immediate and Delayed
categories, and other START limitations. The same physiologic measures can have markedly different survival
probabilities for blunt and penetrating injuries. For example, a START Delayed (second priority) can have a
survival probability of 63% for blunt trauma and a survival probability of 32% for penetrating trauma with the
same physiological measures – both with expected rapid deterioration, while a START Immediate (first priority)
can have survival probabilities that extend to above 95% with expected slow deterioration. Age categories
exacerbate this. For example, a geriatric patient with a penetrating injury in the Delayed category can have an
8% survival probability, and a pediatric patient in the Immediate category can have a 98% survival probability.
Issues with the other START categories have also been noted. In this context, colour-coded tagging accuracy
metrics are not scientifically meaningful. Poor assessments, invalid categories, no objective methodology and
tools for prioritizing casualties and allocating resources, and a protocol of worst first triage provide some
challenges for emergency and disaster preparedness and response. These are clear obstacles for efficient triage
and resource rationing, for maximizing savings of lives, for best practices and National Incident Management
System (NIMS) compatibilities, and for effective response planning and training. Inefficient triage also provides
challenges in containing health care costs and waste. Field triage is based upon the notion of up to 50% overtriage
as being acceptable. There have been no cost-benefit analyses of the costs and mitigation of triage inefficiencies
embedded in the health care system. Such analyses are often required for health care grants funded by taxpayers,
and represent normal engineering and management science practice.
These inefficiencies relate to the following cost areas:
• Tremendous investment in time and money since 9/11 to develop and improve responders’ triage
skills
• Cited benefits from standardization of triage methodology, reproducibility and interoperability, and
NIMS compatibilities
• Avoided capital costs for taxpayer investment in additional EMS and trauma infrastructure
• Wasteful daily resource utilization and increased operating costs from acceptance of substantial levels
of overtriage
• Prescribed values of a statistical life and estimated savings in human lives that could reasonably be
expected using evidence-based triage practices
• Ongoing performance improvements that could reasonably be expected from a more objective
optimization-based triage system and practices
ETHICAL IMPLICATIONS
Because treatment is intentionally delayed or withheld from patients, advanced triage has ethical implications.
Bioethical concerns have historically played an important role in triage decisions, such as the allocation of iron
lungs during the polio epidemics of the 1940s and of dialysis machines during the 1960s. As many health care
systems in the developed world continue to plan for an expected influenza pandemic, bioethical issues regarding
the triage of patients and the rationing of care continue to evolve. Similar issues may occur for paramedics in
the field in the earliest stages of mass casualty incidents when large numbers of potentially serious or critical
patients may be combined with extremely limited staffing and treatment resources. Research continues into
alternative care, and various centers propose medical decision-support models for such situations. Some of
these models are purely ethical in origin, while others attempt to use other forms of clinical classification of
patient condition as a method of standardized triage.
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Index 241
Index
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Joan Forsyth - Clinical Application of Mechanical Ventilation-White Press Academic (2018)

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Joan Forsyth - Clinical Application of Mechanical Ventilation-White Press Academic (2018)

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Clinical Application of

© 2018 White Press Academic

Ebook ISBN: 978-1-68469-083-1

3. Mechanical Ventilation during Cardiopulmonary Resuscitation 51

4. Artificial Airways and Management 73

5. Life Support System and Equipments 85

6. Managing Initial Mechanical Ventilation in the Emergency Department 177

NEGATIVE PRESSURE MACHINES

INTERMITTENT ABDOMINAL PRESSURE VENTILATOR

WEANING FROM MECHANICAL VENTILATION

Pressure = Elastance*Volume + Resistance*Flow

Terms no longer in use:

Assisted Ventilation or Breath

Patient Triggered Breath

• PEEP — Positive end-expiratory pressure, pressure created by a backpressure valve.

     

SYNCHRONIZED INTERMITTENT MECHANICAL VENTILATION (SIMV)

MANDATORY MINUTE VENTILATION (MMV)

PROPORTIONAL ASSIST VENTILATION (PAV)

ADAPTIVE SUPPORT VENTILATION (ASV)

EXPECTED OUTCOMES AND CONSIDERATIONS

CONTINUOUS POSITIVE AIRWAY PRESSURE

Fig. CPAP therapy: flow generator, hose, full face mask.

High Flow Therapy

Settings and Measurements

AIRWAY PRESSURE RELEASE VENTILATION

Fig. A pressure-time graphic.

Inverse Ratio Ventilation

Settings and Measurements

Perceptions and Receptions

Continuous Pressure Devices

Bi-level Pressure Devices

Expiratory Positive Airway Pressure Devices

CARE AND MAINTENANCE

  

Ventilation of Neonatal Patients

HIGH FREQUENCY JET VENTILATION (PASSIVE)

Bunnell LifePulse Jet Ventilator

High Frequency Percussive Ventilation

High Frequency Positive Pressure Ventilation

High Frequency Flow Interruption

High Frequency Ventilation (Active)

Fig. Tidal volume versus power setting.

TRANSTRACHEAL JET VENTILATION

Fig. Pneumomediastinum with Angel wing sign.

Fig. Pneumomediastinum as seen on ultrasound.

Pulmonary Interstitial Emphysema

• Meconium aspiration syndrome (MAS)

Mechanical Ventilation during

FIRST ATTEMPTS AT RESUSCITATION IN THE 18TH CENTURY

The Use of Compression and Ventilation Together

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Interface with Person

Society and Culture

THE DEVELOPMENT OF EMERGENCY MEDICAL SERVICES

RECENT DEVELOPMENTS IN CPR

COMPRESSIONS WITH RESCUE BREATHS

Pressure = ElastanceVolume + ResistanceFlow

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