今日の臨床サポート

窒息

著者: 橘直人 愛媛県立中央病院 救急科

監修: 箕輪良行 みさと健和病院 救急総合診療研修顧問

著者校正/監修レビュー済:2021/04/28
患者向け説明資料

概要・推奨   

  1. 窒息を来す疾患は多岐にわたる。初診時には原因がわからないことも多いが、気道を確保し換気を維持するための蘇生的な処置を行うことが重要である。
  1. 気道管理においては、問診や身体所見、画像検査から、閉塞部位を解剖学的に分類(声門上、声門、声門下・気管)する必要がある[1]
  1. 外科的気道確保については、その適応の理解とともに講習会受講などで手技をトレーニングしておくとよい。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
橘直人 : 特に申告事項無し[2021年]
監修:箕輪良行 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、一部加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 窒息はきわめて緊急性の高い病態であり、気道の完全閉塞により酸素供給が遮断されると数分間で意識が消失し、続いて心停止に至る[2]
  1. 窒息に至った病態を早期に把握し、その病態に応じた処置を速やかに開始しなければならない。
  1. 窒息に対応するには、日頃から気道緊急に対する物品の整備をしておくことはもちろん、個人の手技習得やチームとしてのシミュレーション訓練を積んでおくことが望ましい[3]
 
  1. 窒息による死亡者数は高齢化に伴い近年増加傾向である。
  1. 2009年度に厚生労働省から発表された「不慮の死亡事故統計」では、高齢化に伴い窒息による事故死亡数(08年、9,419人)が交通事故死亡数(同年、7,499人)を上回り、さらに年々増加傾向にあることが明らかとなった[4]
  1. なかでも、高齢化に伴い食事中の窒息による死亡は年間4,000人を超えており、病院や老人ホームでの発症も多い。医療・介護従事者は食事を提供する際には注意が必要であるとともに、適切な初期対応を学んでおくことが必須である[4]
  1. なお、原因食品は、もち、米飯(おにぎり含む)、パンといった穀物がトップ3を占め、魚介類、果実、肉と続く[5]。欧米ではレストランでの食事中に発症することも多く症状が急性心筋梗塞に似ていることから「café coronary」といわれたり、肉が原因として多いので「steakhouse syndrome」といわれたりしている。
 
  1. 外科的気道確保については、その適応の理解とともに講習会受講などで手技をトレーニングしておくとよい。
  1. 輪状甲状靱帯穿刺は、酸素チューブやジェット換気器具を接続することで酸素化を改善させることができる手技である。しかし、換気は不十分であり、早期に高炭酸ガス血症に陥るので長時間は使用できない。また、分泌物や血液の吸引が十分にできないという欠点もある。いずれにせよ穿刺後は速やかに気道の変更を検討する。輪状甲状靱帯切開は、従来のメスによる切開法のほか、直接穿刺法やセルジンガー法(キット化製品あり)で行うこともできる。通常内径5~6mmのカフありチューブを挿入する。なお、輪状甲状間靱帯切開は、12歳以下の小児では喉頭が脆弱で声門下狭窄を生じやすいため禁忌であり、輪状甲状靱帯穿刺を選択する。時間的余裕がある場合は、局所麻酔下の気管切開術(20~30分はかかる)が選択されるが、経皮的な方法も含め超緊急時には適応とならない[6][7][8][9]
  1. 追記:輪状甲状靱帯切開:仰臥位で皮膚を数cm横切開(縦切開は出血少ない)し、輪状甲状靱帯を横切開後、曲ペアンで横方向、次いで90°回転させて縦方向に創を広げる。I.D.=(5.5~)6mmのカフありチューブを挿入すると十分換気できる。輪状軟骨や甲状軟骨をなるべく傷つけないように気遣う。
 
輪状甲状靱帯切開

標準的な輪状甲状靱帯切開の手技。
a.輪状甲状靱帯を触知する。
b.頚部正中をメスで縦切開する。
c. 輪状甲状靱帯を確認する。
d.靱帯は横切開する。
e.フックを用いて頭側に孔を広げる。
f.孔を広げる。
g.気管チューブを挿入する。
h.閉塞栓を抜去する。

 
予後:
  1. 予後は原因疾患によるので一定しない。
  1. 神経学的後遺症に関しても、窒息解除後に昏睡状態である患者の予後を予測できる指標は明らかではない。
問診・診察のポイント  
  1. 問診や診察から気道閉塞が疑われたら、ABC(A:気道、B:換気、C:循環)の評価とともに病態の把握に努め、ただちに蘇生的な処置であるOMI(O:高濃度酸素投与、M:モニター装着、IV access:静脈路確保)を開始する。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

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文献 

著者: Antoine Eskander, John R de Almeida, Jonathan C Irish
雑誌名: N Engl J Med. 2019 Nov 14;381(20):1940-1949. doi: 10.1056/NEJMra1811697.
Abstract/Text
PMID 31722154  N Engl J Med. 2019 Nov 14;381(20):1940-1949. doi: 10.10・・・
著者: Matthias Helm, Andre Gries, Till Mutzbauer
雑誌名: Best Pract Res Clin Anaesthesiol. 2005 Dec;19(4):623-40.
Abstract/Text In all difficult airway algorithms, cricothyroidotomy is the life-saving procedure and is the final 'cannot ventilate, cannot intubate' option, whether in pre-hospital, emergency department, intensive care unit, or operating room patients. Cricothyroidotomy is a relatively safe and rapid means of securing an emergency airway. As with all other critical procedures in emergency medicine, a thorough knowledge of the technique and adequate practice prior to attempting to perform an emergency cricothyroidotomy are essential.

PMID 16408538  Best Pract Res Clin Anaesthesiol. 2005 Dec;19(4):623-40・・・
著者: L S Aboussouan, J K Stoller
雑誌名: Clin Chest Med. 1994 Mar;15(1):35-53.
Abstract/Text Upper airway obstruction is a potentially fatal condition that requires prompt diagnosis and treatment. Common causes include foreign body aspiration, infections (even in the adult population) and sequelae of intubation, tracheostomy, and transtracheal oxygen catheters. Spirometry is an insensitive test for diagnosing upper airway obstruction and reflects the functional, rather than anatomic, severity of an obstruction. Although simple tomography still plays an important role, CT and magnetic resonance imaging scans are useful additions to our diagnostic armamentarium. Advances in laser technology, surgery, and bronchoscopy have broadened treatment options but require further evaluation.

PMID 8200192  Clin Chest Med. 1994 Mar;15(1):35-53.
著者: A Patel, A Pearce
雑誌名: Anaesthesia. 2011 Dec;66 Suppl 2:93-100. doi: 10.1111/j.1365-2044.2011.06938.x.
Abstract/Text There is no consensus as to the ideal approach for the anaesthetic management of the adult obstructed airway and there are advocates of awake fibreoptic intubation, inhalational induction and intravenous induction techniques. This review considers the different options available for obstruction at different anatomical levels. Decisions must also be made on the urgency of the required intervention. Particular controversies revolve around the role of inhalational vs intravenous induction of anaesthesia, the use or avoidance of neuromuscular blockade and the employment of cannula cricothyroidotomy vs surgical tracheostomy.

© 2011 The Authors. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland.
PMID 22074083  Anaesthesia. 2011 Dec;66 Suppl 2:93-100. doi: 10.1111/j・・・
著者: J L Benumof, R Dagg, R Benumof
雑誌名: Anesthesiology. 1997 Oct;87(4):979-82.
Abstract/Text
PMID 9357902  Anesthesiology. 1997 Oct;87(4):979-82.
著者: American Society of Anesthesiologists Task Force on Management of the Difficult Airway
雑誌名: Anesthesiology. 2003 May;98(5):1269-77.
Abstract/Text
PMID 12717151  Anesthesiology. 2003 May;98(5):1269-77.
著者: Joakim Engström, Göran Hedenstierna, Anders Larsson
雑誌名: Crit Care. 2010;14(3):R93. doi: 10.1186/cc9027. Epub 2010 May 24.
Abstract/Text INTRODUCTION: Endotracheal intubation in critically ill patients is associated with severe life-threatening complications in about 20%, mainly due to hypoxemia. We hypothesized that apneic oxygenation via a pharyngeal catheter during the endotracheal intubation procedure would prevent or increase the time to life-threatening hypoxemia and tested this hypothesis in an acute lung injury animal model.
METHODS: Eight anesthetized piglets with collapse-prone lungs induced by lung lavage were ventilated with a fraction of inspired oxygen of 1.0 and a positive end-expiratory pressure of 5 cmH2O. The shunt fraction was calculated after obtaining arterial and mixed venous blood gases. The trachea was extubated, and in randomized order each animal received either 10 L oxygen per minute or no oxygen via a pharyngeal catheter, and the time to desaturation to pulse oximeter saturation (SpO2) 60% was measured. If SpO2 was maintained at over 60%, the experiment ended when 10 minutes had elapsed.
RESULTS: Without pharyngeal oxygen, the animals desaturated after 103 (88-111) seconds (median and interquartile range), whereas with pharyngeal oxygen five animals had a SpO2 > 60% for the 10-minute experimental period, one animal desaturated after 7 minutes, and two animals desaturated within 90 seconds (P < 0.016, Wilcoxon signed rank test). The time to desaturation was related to shunt fraction (R2 = 0.81, P = 0.002, linear regression); the animals that desaturated within 90 seconds had shunt fractions >40%, whereas the others had shunt fractions <25%.
CONCLUSIONS: In this experimental acute lung injury model, pharyngeal oxygen administration markedly prolonged the time to severe desaturation during apnea, suggesting that this technique might be useful when intubating critically ill patients with acute respiratory failure.

PMID 20497538  Crit Care. 2010;14(3):R93. doi: 10.1186/cc9027. Epub 20・・・
著者: G Frova, M Sorbello
雑誌名: Minerva Anestesiol. 2009 Apr;75(4):201-9. Epub 2008 Oct 23.
Abstract/Text Difficult airway management and maintenance of oxygenation remain the two most challenging tasks for anesthetists, while also being controversial items in terms of clinically based-evidence to support relevant guidelines in the literature. Nevertheless, different expert groups and scientific societies from several countries have published guidelines dedicated to the management of difficult airways. These documents have been demonstrated to be useful in reducing airway management related critical accidents, despite their limited use in litigations and legal issues. The aim of this review is to compare different airway management guidelines published by the United States, United Kingdom, France, Italy, Germany, and Canada while trying to elucidate the main differences, weaknesses, and strengths for identifying critical concepts in the management of difficult airways.

PMID 18946426  Minerva Anestesiol. 2009 Apr;75(4):201-9. Epub 2008 Oct・・・
著者: K Chen, J Varon, O C Wenker
雑誌名: J Emerg Med. 1998 Jan-Feb;16(1):83-92.
Abstract/Text Malignant airway obstruction affects up to 80,000 patients annually, many of whom will present acutely to the emergency department (ED). This clinical entity should be sought in any patient presenting to the ED with increasing shortness of breath, recurrent chest infections, hemoptysis, and an inability to lie flat. Interventions suggested in malignant airway obstruction include: maintenance of spontaneous ventilation by avoiding respiratory depressing sedation, muscle relaxants or narcotics; changes in patient's position; avoidance of general anesthesia and positive pressure ventilation, if possible; placement of endotracheal tube beyond the level of obstruction; radiotherapy; corticosteroids; availability of helium-oxygen mixtures, cardiopulmonary bypass, or extracorporeal membrane oxygenation. If time allows, further diagnostic studies will be of assistance in assessing the best therapy before definitive intervention.

PMID 9472765  J Emerg Med. 1998 Jan-Feb;16(1):83-92.
著者: Stuart F Reynolds, John Heffner
雑誌名: Chest. 2005 Apr;127(4):1397-412. doi: 10.1378/chest.127.4.1397.
Abstract/Text Advances in emergency airway management have allowed intensivists to use intubation techniques that were once the province of anesthesiology and were confined to the operating room. Appropriate rapid-sequence intubation (RSI) with the use of neuromuscular blocking agents, induction drugs, and adjunctive medications in a standardized approach improves clinical outcomes for select patients who require intubation. However, many physicians who work in the ICU have insufficient experience with these techniques to adopt them for routine use. The purpose of this article is to review airway management in the critically ill adult with an emphasis on airway assessment, algorithmic approaches, and RSI.

PMID 15821222  Chest. 2005 Apr;127(4):1397-412. doi: 10.1378/chest.127・・・
著者: David C Willms, Ruben Mendez, Vanjah Norman, Joseph H Chammas
雑誌名: Respir Care. 2012 Apr;57(4):646-9. doi: 10.4187/respcare.01417.
Abstract/Text A 39-year-old man experienced total obstruction of a distal tracheal plastic stent by a tumor mass, preventing effective ventilation and resulting in cardiac arrest. Resuscitation by emergency bedside venoarterial extracorporeal membrane oxygenation (ECMO) permitted time to physically remove the obstructing tumor and reestablish successful ventilation and liberation from ventilatory support. We review several other reported cases of emergency ECMO to resuscitate patients with acute airway obstruction.

PMID 22472502  Respir Care. 2012 Apr;57(4):646-9. doi: 10.4187/respcar・・・
著者: Michele Blanda, Ugo E Gallo
雑誌名: Emerg Med Clin North Am. 2003 Feb;21(1):1-26.
Abstract/Text Airway control is one of the most critical interventions required for saving a life. It is essential that practitioners be as well trained as possible in the numerous techniques available to establish airway control. This article reviews some of the available techniques, though other techniques that are not discussed (such as fiberoptic-assisted endotracheal intubation) may also be useful. Perhaps the most important aspect of advanced airway management is the ability to anticipate and prepare for the difficult airway. This article gives numerous options for the difficult airway situation.

PMID 12630729  Emerg Med Clin North Am. 2003 Feb;21(1):1-26.
著者: Roger Zoorob, Mohamad Sidani, John Murray
雑誌名: Am Fam Physician. 2011 May 1;83(9):1067-73.
Abstract/Text Croup is a common illness responsible for up to 15 percent of emergency department visits due to respiratory disease in children in the United States. Croup symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress. In most children, the symptoms subside quickly with resolution of the cough within two days. Croup is often caused by viruses, with parainfluenza virus (types 1 to 3) as the most common. However, physicians should consider other diagnoses, including bacterial tracheitis, epiglottitis, foreign body aspiration, peritonsillar abscess, retropharyngeal abscess, and angioedema. Humidification therapy has not been proven beneficial. A single dose of dexamethasone (0.15 to 0.60 mg per kg usually given orally) is recommended in all patients with croup, including those with mild disease. Nebulized epinephrine is an accepted treatment in patients with moderate to severe croup. Most episodes of croup are mild, with only 1 to 8 percent of patients with croup requiring hospital admission and less than 3 percent of admitted patients requiring intubation.

PMID 21534520  Am Fam Physician. 2011 May 1;83(9):1067-73.
著者: R Bryan Bell, David S Verschueren, Eric J Dierks
雑誌名: Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):415-30. doi: 10.1016/j.coms.2008.03.004.
Abstract/Text Fractures of the larynx are uncommon injuries that may be associated with maxillofacial trauma. Clinicians treating maxillofacial injuries should be familiar with the signs and symptoms of laryngeal fractures and with proper airway management. A timely evaluation of the larynx, rapid airway intervention, and proper surgical repair are essential for a successful outcome.

PMID 18603200  Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):415-・・・
著者: Pierre R Theodore
雑誌名: Emerg Med Clin North Am. 2009 May;27(2):231-41. doi: 10.1016/j.emc.2009.01.009.
Abstract/Text Acute obstruction of the airway in the emergent situation results from a wide variety of malignant and benign disease processes. Acute management involves establishing a secure and patent route for adequate gas exchange. This requires rapid determination of the location of the obstruction and nature of the obstruction followed by a thoughtful management approach based on findings. Difficult anatomy, hemorrhage, dense secretions, inflammation, and bulky tumor mass can significantly complicate the task of clearing the airway. Obstruction of the central airways by malignant tumor is associated with poor prognosis, but quality of life is considerably improved by restoration of adequate central airways. For both the patient and the clinician, the presentation can be frightening, and advanced interventional pulmonary/endobronchial techniques are required to achieve prompt relief of symptoms. The alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life the primary goal rather than cure. This review will cover covers an approach to the patient with airway obstruction that results from malignancy involving the trachea or proximal bronchial tree and affecting gas exchange.

PMID 19447308  Emerg Med Clin North Am. 2009 May;27(2):231-41. doi: 10・・・
著者: Andrea Campione, Marco Agostini, Mario Portolan, Antonella Alloisio, Carlo Fino, Giuseppe Vassallo
雑誌名: J Thorac Cardiovasc Surg. 2007 Jun;133(6):1673-4. doi: 10.1016/j.jtcvs.2007.02.011.
Abstract/Text
PMID 17532988  J Thorac Cardiovasc Surg. 2007 Jun;133(6):1673-4. doi: ・・・
著者: Ashish Udeshi, Shawn Michael Cantie, Edgar Pierre
雑誌名: J Crit Care. 2010 Sep;25(3):508.e1-5. doi: 10.1016/j.jcrc.2009.12.014. Epub 2010 Apr 22.
Abstract/Text Postobstructive pulmonary edema (POPE; also known as negative pressure pulmonary edema) is a potentially life-threatening complication in which pulmonary edema occurs shortly after the relief of an upper airway obstruction. The incidence of POPE has been reported to be as high as 1 in 1000 general anesthetic cases and commonly presents as acute respiratory distress that requires immediate intervention. This review examines the 2 subclasses of POPE and describes the etiologic factors, pathophysiology, clinical manifestations, diagnostic criteria, and treatment strategies associated with each. The aim of this review was to equip clinicians with the knowledge base necessary to identify patients at increased risk for POPE and to expeditiously diagnose and treat this potentially catastrophic complication.

Copyright © 2010 Elsevier Inc. All rights reserved.
PMID 20413250  J Crit Care. 2010 Sep;25(3):508.e1-5. doi: 10.1016/j.jc・・・
著者: Shawn Chillag, Jake Krieg, Ranjana Bhargava
雑誌名: South Med J. 2010 Feb;103(2):147-50. doi: 10.1097/SMJ.0b013e3181c99140.
Abstract/Text The very young and the very old are vulnerable to choking, and there are over 4000 choking-related deaths annually in the United States. Complications from the Heimlich maneuver (HM), as reported in infrequent case reports, predominantly relate to the elderly. It is doubtful that the denominator, numerator, appropriateness, expertise, and problems of maneuvers applied to choking victims will ever be known. This case report and literature review suggests that the treatment for acute elderly choking victims should be applied carefully and that esophageal food impaction, which should be rapidly distinguishable from choking, can have serious complications with application of the HM.

PMID 20065901  South Med J. 2010 Feb;103(2):147-50. doi: 10.1097/SMJ.0・・・
著者: Christina W Fidkowski, Hui Zheng, Paul G Firth
雑誌名: Anesth Analg. 2010 Oct;111(4):1016-25. doi: 10.1213/ANE.0b013e3181ef3e9c. Epub 2010 Aug 27.
Abstract/Text Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%). Although rigid bronchoscopy is the traditional diagnostic "gold standard," the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported. Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred ("what, where, when"). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

PMID 20802055  Anesth Analg. 2010 Oct;111(4):1016-25. doi: 10.1213/ANE・・・
著者: F Estelle R Simons
雑誌名: J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S161-81. doi: 10.1016/j.jaci.2009.12.981.
Abstract/Text Anaphylaxis occurs commonly in community settings. The rate of occurrence is increasing, especially in young people. Understanding potential triggers, mechanisms, and patient-specific risk factors for severity and fatality is the key to performing appropriate risk assessment in those who have previously experienced an acute anaphylactic episode. The diagnosis of anaphylaxis is based primarily on clinical criteria and is valid even if the results of laboratory tests, such as serum total tryptase levels, are within normal limits. Positive skin test results or increased serum specific IgE levels to potential triggering allergens confirm sensitization but do not confirm the diagnosis of anaphylaxis because asymptomatic sensitization is common in the general population. Important patient-related risk factors for severity and fatality include age, concomitant diseases, and concurrent medications, as well as other less well-defined factors, such as defects in mediator degradation pathways, fever, acute infection, menses, emotional stress, and disruption of routine. Prevention of anaphylaxis depends primarily on optimal management of patient-related risk factors, strict avoidance of confirmed relevant allergen or other triggers, and, where indicated, immunomodulation (eg, subcutaneous venom immunotherapy to prevent Hymenoptera sting-triggered anaphylaxis, an underused, potentially curative treatment). The benefits and risks of immunomodulation to prevent food-triggered anaphylaxis are still being defined. Epinephrine (adrenaline) is the medication of first choice in the treatment of anaphylaxis. All patients at risk for recurrence in the community should be equipped with 1 or more epinephrine autoinjectors; a written, personalized anaphylaxis emergency action plan; and up-to-date medical identification. Improvements in the design of epinephrine autoinjectors will help to optimize ease of use and safety. Randomized controlled trials of pharmacologic agents, such as antihistamines and glucocorticoids, are needed to strengthen the evidence base for treatment of acute anaphylactic episodes.

Copyright 2010 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.
PMID 20176258  J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S161-81・・・
著者: Cenker Eken, Ozlem Yigit
雑誌名: Int J Emerg Med. 2009 Aug 1;2(4):255-6. doi: 10.1007/s12245-009-0115-x. Epub 2009 Aug 1.
Abstract/Text
PMID 20436897  Int J Emerg Med. 2009 Aug 1;2(4):255-6. doi: 10.1007/s1・・・
著者: Yekta Altemur Karamustafaoglu, Ilkay Yavasman, Sevinc Tiryaki, Yener Yoruk
雑誌名: Int J Emerg Med. 2010 Aug 25;3(4):379-80. doi: 10.1007/s12245-010-0204-x. Epub 2010 Aug 25.
Abstract/Text BACKGROUND: Traumatic asphyxia is probably much more common than the surgical literature shows and should always be kept in mind as a possible complication of injuries of the chest and abdomen.
AIMS: Traumatic asphyxia or Perte's syndrome results from a severe crush injury causing sudden compression of the thorax. During a 3-year period, we treated five cases of traumatic asphyxia, which we report in this manuscript.
METHODS: The patients were all male, ranging in age from 26 to 64. They suffered different types of crushing injuries: industrial accidents in two patients, run over by motor vehicles in two patients, and a farm accident in one patient. Most of the patients suffered some associated injuries, including fracture of the sternum in one patient, fracture of the right clavicle in one patient, and bilateral hemopneumothoraces in one patient.
RESULTS: The treatment included bilateral chest tube thoracostomy in one patient, and the others required supportive treatment. There was no mortality.
CONCLUSION: Treatment for traumatic asphyxia is supportive, and patient recovery is related to the generally associated injuries. Traumatic asphyxia should always be kept in mind as a possible complication of injuries of the chest and abdomen.

PMID 21373308  Int J Emerg Med. 2010 Aug 25;3(4):379-80. doi: 10.1007/・・・
著者: P Ibarra, L M Capan, S Wahlander, K M Sutin
雑誌名: Anesth Analg. 1997 Jul;85(1):216-8. doi: 10.1097/00000539-199707000-00039.
Abstract/Text
PMID 9212151  Anesth Analg. 1997 Jul;85(1):216-8. doi: 10.1097/000005・・・
著者: Gary M Vilke, Theodore C Chan
雑誌名: J Emerg Med. 2011 Mar;40(3):355-8. doi: 10.1016/j.jemermed.2010.02.018. Epub 2010 Apr 3.
Abstract/Text BACKGROUND: Carotid dissection (CD) is often overlooked as a concern in strangulation and choking cases. When the diagnosis is considered, the question remains what is the best means of evaluation, and which imaging study should be obtained.
OBJECTIVE: To evaluate the literature for evaluation of choking- and strangulation-related injuries and their association with CD.
DISCUSSION: This article will review the literature on blunt carotid injuries, with particular attention to subjects with choking and strangulation mechanisms of injury, and will include important physical findings, when and which radiographic evaluations are indicated, and treatment.
CONCLUSION: Although rare, CD can occur after strangulation and choking. When suspected, evaluation should include imaging studies including computed tomography angiography.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 20363580  J Emerg Med. 2011 Mar;40(3):355-8. doi: 10.1016/j.jemer・・・
著者: Richard D Branson
雑誌名: Respir Care. 2007 Oct;52(10):1328-42; discussion 1342-7.
Abstract/Text Secretion management in the mechanically ventilated patient includes routine methods for maintaining mucociliary function, as well as techniques for secretion removal. Humidification, mobilization of the patient, and airway suctioning are all routine procedures for managing secretions in the ventilated patient. Early ambulation of the post-surgical patient and routine turning of the ventilated patient are common secretion-management techniques that have little supporting evidence of efficacy. Humidification is a standard of care and a requisite for secretion management. Both active and passive humidification can be used. The humidifier selected and the level of humidification required depend on the patient's condition and the expected duration of intubation. In patients with thick, copious secretions, heated humidification is superior to a heat and moisture exchanger. Airway suctioning is the most important secretion removal technique. Open-circuit and closed-circuit suctioning have similar efficacy. Instilling saline prior to suctioning, to thin the secretions or stimulate a cough, is not supported by the literature. Adequate humidification and as-needed suctioning are the foundation of secretion management in the mechanically ventilated patient. Intermittent therapy for secretion removal includes techniques either to simulate a cough, to mechanically loosen secretions, or both. Patient positioning for secretion drainage is also widely used. Percussion and postural drainage have been widely employed for mechanically ventilated patients but have not been shown to reduce ventilator-associated pneumonia or atelectasis. Manual hyperinflation and insufflation-exsufflation, which attempt to improve secretion removal by simulating a cough, have been described in mechanically ventilated patients, but neither has been studied sufficiently to support routine use. Continuous lateral rotation with a specialized bed reduces atelectasis in some patients, but has not been shown to improve secretion removal. Intrapulmonary percussive ventilation combines percussion with hyperinflation and a simulated cough, but the evidence for intrapulmonary percussive ventilation in mechanically ventilated patients is insufficient to support routine use. Secretion management in the mechanically ventilated patient consists of appropriate humidification and as-needed airway suctioning. Intermittent techniques may play a role when secretion retention persists despite adequate humidification and suctioning. The technique selected should remedy the suspected etiology of the secretion retention (eg, insufflation-exsufflation for impaired cough). Further research into secretion management in the mechanically ventilated patient is needed.

PMID 17894902  Respir Care. 2007 Oct;52(10):1328-42; discussion 1342-7・・・
著者: Gavin G Lavery, Brian V McCloskey
雑誌名: Crit Care Med. 2008 Jul;36(7):2163-73. doi: 10.1097/CCM.0b013e31817d7ae1.
Abstract/Text INTRODUCTION: The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer.
AIMS: This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed.
RESULTS: All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation.
CONCLUSIONS: Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.

PMID 18552680  Crit Care Med. 2008 Jul;36(7):2163-73. doi: 10.1097/CCM・・・
著者: Heidi H O'Connor, Alexander C White
雑誌名: Respir Care. 2010 Aug;55(8):1076-81.
Abstract/Text Tracheostomy tubes are placed for a variety of reasons, including failure to wean from mechanical ventilation, inability to protect the airway due to impaired mental status, inability to manage excessive secretions, and upper-airway obstruction. A tracheostomy tube is required in approximately 10% of patients receiving mechanical ventilation and allows the patient to move to a step-down unit or long-term care hospital. The presence of a tracheostomy tube in the trachea can cause complications, including tracheal stenosis, bleeding, infection, aspiration pneumonia, and fistula formation from the trachea to either the esophagus or the innominate artery. Final removal of the tracheostomy tube is an important step in the recovery from chronic critical illness and can usually be done once the indication for the tube placement has resolved.

PMID 20667155  Respir Care. 2010 Aug;55(8):1076-81.

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