Title: Critical Care Quickies
题目：危重病热题解答
Author 作者: Mike Winters, MD

I. High flow nasal cannula 高流量鼻导管
a. Heated & humidified, b. Can deliver almost 100% FiO2 , c. 20-50L/min (some devices up to 60L/min), d. Enhances washout of nasopharyngeal “deadspace”, reducing CO2 re-breathing, improving oxygenation, e. Provides ~3-6cm/H20 PEEP, f. Increasing body of literature (observational) to support
a. 加热和加湿; b. 可提供几乎100％的氧浓度; c. 20-50 L/min（某些设备可以到60L/min）；d. 增强鼻咽部“死腔”的排出，减少二氧化碳再吸入，改善氧合；e. 提供3-6cm/H20 PEEP; f. 越来越多的文献（观察性）支持其使用。

II. Vascular access in crashing patient 急救患者的血管通路
a. Intraosseous access 骨髓内针
Very few contraindications (proximal fracture, hardware, vascular injury, overlying skin infection)
没有什么禁忌症（近端骨折，金属固定，血管损伤，局部皮肤感染）
Sites: Proximal tibia (>90% 1st attempt success rate); Humerus; Distal femur; Distal radius; and Medial malleolus
穿刺部位：胫骨近端（第一次尝试的成功率> 90％ ），肱骨，股骨远端，桡骨远端，及内踝
Can infuse any medication (except adenosine) or drip
可以注入或滴注任何药物（腺苷除外）
Use 2% lidocaine w/o epi (1-2mL followed by 10mL saline flush) to improve
tolerance in a responsive patient
如病人神志清楚 可用2％不含肾上腺素的利多卡因（1-2 ML，然后用10ml生理盐水冲洗），以改善病人的耐受性
b. Central line 中心静脉
i. Ultrasound for subclavian1 超声直视下锁骨下静脉1
Higher success rate, fewer attempts, see http://ultrarounds.com/Ultrarounds/Subclavian_Ultrasound.html
较高的成功率，减少穿刺次数，详细见http://ultrarounds.com/Ultrarounds/Subclavian_Ultrasound.html
ii. How bad is the femoral, really2 股静脉有多不好，真的吗2
Femoral vs. subclavian – no difference in infection rates
股静脉与锁骨下静脉 - 感染率没有什么差别
Femoral vs. IJ – lower rates for IJ
股静脉与颈内静脉 – 颈内静脉有较低的感染率
Externally rotating the leg increases diameter of femoral vein and
brings it closer to the skin3
将腿向外部旋转一点可增加股静脉的直径并使其更接近皮肤3

III. Bougie-aided cricothyrotomy4,5 探条辅助环夹膜切开4,5

a. Vertical incision through skin, blunt dissection, horizontal incision through cricothyroid membrane, b. Feed coude tip of bougie through cricothyroid membrane caudally; c. Slide ET tube over bougie; d. May take <1 minute!
a.上下皮肤切口，钝性分离，横向切开环甲膜; b.将探条尖尾端向脚方向通过环甲膜; c.将气管导管通过探条插入; d.可能只需要1分钟左右！

IV. Needle decompression for tension pneumothorax6,7,8 张力性气胸的穿刺减压6,7,8
a. 2nd intercostal space, mid-clavicular line frequently fails!
第2肋间，锁骨中线穿刺经常失败！
b. 5th intercostal space, anterior-axillary line being used more frequently
第5肋间， 腋前线被更频繁地使用

V. Ultrasound in cardiac arrest9 超声在心脏骤停时应用9
Absence of cardiac motion on cardiac echo cannot be used as the sole determinant of when to stop resuscitation
心脏超声没有心脏运动是不能用来作为唯一决定是否停止复苏的指征

References 参考文献:
1. Critical Care Medicine 2011;39(7)1607-12.
2. Critical Care Medicine 2012;40(8):2479-85.
3. Emergency Medicine Australasia 2012;24(4):408-13.
4. Air Medical Journal 2009;28(40:191-4.
5. Academic Emergency Medicine 2010;17(6):666-9.
6. Journal of Trauma-Injury Infection & Critical Care 2011;71(5):1099-103.
7. Archives of Surgery 2012;147(9):813-8.
8. Journal of Trauma & Acute Care Surgery 2012; 73(6):1412-1417.
9. Academic Emergency Medicine 2012;19(10)1119-1126.