Bakgrund: Personal inom hälso- och sjukvård ställs ofta inför akuta situationer. Simuleringsövningar har länge använts i vårdundervisning och beskrivs som en möjlighet att lyfta kompetens och erfarenhet av akuta omhändertaganden för att passa kraven i vården. Det finns olika typer av simuleringar med varierande teknologi samt simuleringar med skådespelade patienter.  Syfte: Syftet med denna litteraturstudie var att beskriva vårdpersonals erfarenheter av simuleringsövningar av akuta omhändertaganden på sjukhus. Metod: En kvalitativ litteraturstudie baserad på nio artiklar. Sökningar gjordes i databaserna PubMed och Cinahl. Analys utfördes med hjälp av dataanalys för litteraturstudier beskriven av Popenoe et al.. Resultat: Analysen resulterade i två kategorier och åtta underkategorier. Kategorierna var ”simuleringar utgör en miljö som kan underlätta lärande och väcker tankar och känslor” och ”simuleringar ger värdefull kunskap som kan användas i vården”.  Konklusion: Det är viktigt hur simuleringarna utformas för att deltagarna ska kunna tillgodose sig bestående kunskap på bästa sätt. Möjlighet till upprepade övningar kan utveckla och bibehålla förmågor som leder till säkrare vård och ett effektivare arbete. / Background: Health care personnel are often faced with emergency situations. Simulations have been used as tools to increase skill, competence and confidence for health care workers in these situations. There are different types of simulation tools available with varying degrees of technical fidelity. Some simulations use human patient actors.  Aim: The aim of this literature study was to describe the experience of health care personnel who have undertaken hospital-based emergency simulation scenarios. Methods: A qualitative literature study based on nine articles. A search of literature using the electronic databases PubMed and Cinahl was conducted. The articles were analysed using the data analysis in general literature reviews by Popenoe et al.. Results: Results are presented in two categories and eight sub categories. The categories were “simulations provide an atmosphere that facilitates learning and evoke thoughts and feelings” and “simulations give valuable knowledge that could be used in health care”.   Conclusion: The design of the simulations is important to facilitate lasting knowledge. The possibility to repeat training can develop and sustain abilities for safe health care and efficient work.

La santé bucco-dentaire est encore aujourd’hui une importante problématique de santé publique en France. Pour une partie des patients, les consultations chez le chirurgien-dentiste reposent sur le ressenti d’un problème, le plus souvent une douleur, qui pourra motiver une demande de prise en charge en urgence en rendant le patient dépendant de l'intervention d'un chirurgien-dentiste. En France, l’offre de soins odontologiques d’urgence dépend majoritairement de soins dispensés au sein de cabinets dentaires privés tandis que l’offre de soins publique reste minoritaire et hétérogène. Cette organisation particulière associée à la difficile définition de ce qui constitue une urgence odontologique est susceptible d’entraîner pour les patients des difficultés d’accès aux soins d’urgence. L’analyse de la littérature internationale montre que des problématiques identiques existent dans des pays de niveau de vie équivalent et ces constatations plaident pour un développement de l’offre de soins odontologiques d’urgence en milieu hospitalier. Ce travail s’articule autour de trois études s’adressant chacune aux différents acteurs de l’urgence odontologique (patients, chirurgiens-dentistes en exercice et étudiants en odontologie). Il a pour objectifs (i) de caractériser la notion d’urgence dans le contexte de l’odontologie, (ii) de discuter des bénéfices et des limites actuels de ses deux modes de prise en charge (privé et public), (iii) d’envisager les enjeux éducationnels relatifs à l’enseignement de l’urgence odontologique et (iv) de discuter des enjeux éthiques relatifs à une meilleure prise en considération professionnelle de cette dernière. / Despite major therapeutic progress, oral health still remains an important public health problem in France. The use of dental care is mainly based on patients’ perception of a dental problem, mostly pain, that may motivate a request for emergency dental care. In contrast to what is available for the management of medical emergencies, the provision of emergency dental care in France relies mainly on care provided in private dental offices while the supply of public emergency dental care remains minor and heterogeneous. This particular organization, associated with the difficulty in identifying precisely what constitutes a dental emergency, is likely to result in patients lacking access to emergency dental care. The analysis of the international literature shows that similar issues have been raised in countries of equivalent standard of living and these findings call for developing the provision of dental care in the hospital environment. This work is based on three complementary studies, each of which addressing the different actors involved in dental emergencies (patients, dentists and dental students). The aim of this work is (i) to characterize the notion of urgency in the context of dentistry, (ii) to discuss the benefits and current limitations of the two co-existing ways of management of dental emergencies (i.e. private offices and public hospital), (iii) to consider the educational issues related to the teaching of dental emergency topic and (iv) to carry out, on the basis of the synthesis of our experimental results, a reflection on the ethical issues related to better consideration of these common care situations by dentists.

No / Emergency laparotomies in the U.K., U.S.A. and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395). Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy. / E. LPQuiC Collaborator Group

Syftet med denna masterstudie var att jämföra den smärtlindrande effekten av fullständig utrensning och desinfektion av rotkanalsystemet med enbart utrymning av pulpakavum, utan instrumentering av rotkanalerna, som akutbehandling hos tänder med symtomatisk apikal parodontit. Materialet utgjordes av 16 patienter insamlade på Tandvårdshögskolans jourmottagning. Patienter med svullnad och allmänpåverkan exkluderades. Patienterna valdes slumpmässigt ut till att genomgå någon av behandlingarna. Den preoperativa smärtnivån och ev. analgetikaintag registrerades. Tre till fem dagar efter utförd behandling kontaktades patienterna per telefon och fick då gradera sin postoperativa smärtnivå samt analgetika- och/eller antibiotikaintag. Resultatet visade att 100% av patienterna som behandlades med fullständig utrensning erhöll tillfredställande smärtlindring jämfört med 71% av de patienter som behandlades med enbart utrymning av pulpakavum. Skillnaden var inte statistiskt signifikant. 44% av patienterna som behandlades med fullständig utrensning hade tagit smärtstillande postoperativt medan 29% av patienterna i utrymningsgruppen hade gjort det. Skillnaden var inte signifikant. Ingen av patienterna oavsett behandling hade tagit antibiotika efter behandlingen. Ingen skillnad förelåg i andelen patienter som blev tillräckligt smärtlindrade mellan fullständig utrensning och enbart utrymning av pulpakavum hos tänder med symtomatisk apikal parodontit. Det var inte heller någon skillnad i smärtsänkning mellan de två behandlingarna. / The aim was to compare the pain relieving effect of complete chemo mechanical disinfection of the root canal system with removal of necrotic tissue in the pulp chamber without instrumentation of the root canals as emergency treatment in teeth with symptomatic apical periodontitis. The material consisted of 16 patients collected at the emergency clinic at Malmö University. Patients with swelling and/or systemic involvement were excluded. The patients were randomized to either treatment. The preoperative pain level and intake of analgesics was registered. Three till 5 days postoperatively the patients were contacted and asked to grade the current pain level and intake of analgesics and/or antibiotics. The results showed that 100% of the patients treated with complete chemo mechanical disinfection of the root canal system obtained satisfying pain relief compared to 71% for patients treated with removal of necrotic tissue in the pulp chamber. 44% of the patients treated with chemo mechanical disinfection of the root canal system had some kind of analgesics postoperatively compared to 29% for those treated with removal of necrotic tissue in the pulp chamber. No patients in either group reported use of antibiotics postoperatively. The conclusion was that both complete chemo mechanical disinfection and removal of necrotic tissue implied a significant pain relief as emergency treatment in teeth with symptomatic apical periodontitis. There was no difference between the two treatments concerning the number of patients who obtained sufficient pain relief or in pain relieving effect.

Syftet med denna randomiserade kliniska studie var att jämföra anestesieffekten mellan 2 % lidocain med 1:200,000 adrenalin och 3 % prilocain med 0,03 i.u./ml felypressin vid en blockad av Nervus alveolaris inferior för behandling av patienter med symtomatisk pulpit i en underkäksmolar eller –premolar.Materialet utgjordes av 5 patienter som uppsökt Tandvårdshögskolans jourmottagning för akuta besvär. Patienterna fick upp till 3,6 ml av antingen 2% lidocain (n=4) eller 3% prilocain (n=1). Det valda medlet var okänt för både patient och behandlare under hela behandlingen. Behandling (pulpotomi) påbörjades först när patienten erhållit bedövad läpp. Information om smärta före och under behandling, intag av analgetika och oro inför behandling noterades. Lyckad anestesi ansågs vara ingen eller endast mild smärta under behandling (<54 mm av 170 mm på en visuell analog skala).Lyckandefrekvensen för lidocain var 50 % och för prilocain 100 %. Det insamlade materialet var för litet för möjliggöra statistisk analys.De patienter som inkluderades i denna pilotstudie var för få för att visa eventuella skillnader i anestesieffekt mellan lidocain och prilocain vid en blockad av Nervus alveolaris inferior för behandling av patienter med symtomatisk pulpit i en underkäksmolar eller –premolar. Ett större underlag krävs för att kunna dra slutsatser om något av de testade bedövningsmedlen är överlägset. Ett stickprov på 57 deltagare i varje grupp krävs för att upptäcka en skillnad i lyckandefrekvens på 25 % (power 80 %). Protokollet har nu testats och visat sig vara lämpligt att använda i en större studie. / The aim of this randomized clinical trial was to compare the anesthetic efficacy of 2% lidocaine with 1:200,000 epinephrine and 3% prilocaine with 0,03 i.u./ml felypressin used for the inferior alveolar nerve block (IANB) in endodontic treatment of adult patients with symptomatic pulpitis in posterior mandibular teeth.5 patients visiting the emergency clinic of the Faculty of Odontology, Malmö University participated in the study. They randomly received, in a double-blind manner, up to 3,6 ml of either 2% lidocaine (n=4) or 3% prilocaine (n=1) in a conventional IANB. Treatment (pulpotomy) was only initiated after profound lip numbness was obtained. Pre- and perioperative pain, intake of analgesics and anxiety was recorded. Anesthetic success was defined as no or only mild pain (a rating of <54mm on a 170mm Visual Analogue Scale) during treatment.The success rate for IANB using lidocaine was 50% and for prilocaine 100%. The material size was insufficient to enable statistical analysis.The few patients selected for this pilot study were insufficient to assess any difference in anesthetic efficacy between lidocaine and prilocaine for IANB in endodontic treatment of adult patients with symptomatic pulpitis in a posterior mandibular tooth. Further data collection is needed to make conclusions about possible superiority of any of the tested substances. A sample size of 57 test subjects in each group would give a power of 80% to detect a difference of 25% in success rate. The protocol appears to be suitable for use in a larger-scale study.

RESUMO: Introdução: as estatísticas progressivamente preocupantes demonstram que as doenças cardiovasculares são a principal causa de morbimortalidade no Brasil e no mundo e, entre elas, estão as que levam à parada cardiorrespiratória (PCR). O aprimoramento contínuo do ensino do atendimento às vítimas de PCR pré ou intra-hospitalar torna-se fundamental para a boa formação dos profissionais de saúde, incluindo os de Enfermagem. Objetivo: o presente estudo teve por objetivo avaliar o processo de ensino aprendizagem no atendimento pré-hospitalar às vítimas de PCR, utilizando as manobras de Ressuscitação Cardiopulmonar (RCP) e o Desfibrilador Externo Automático (DEA), no aspecto teórico (CONHECIMENTO) e prático (HABILIDADE), seguindo as recomendações do guideline de 2010 da Aliança Internacional dos Comitês de Ressuscitação (ILCOR). Casuística e Método: a amostra foi constituída por 37 alunos do 1º ano, da Escola de Enfermagem da Universidade de São Paulo, que não tiveram nenhuma orientação prévia sobre o tema. A pesquisa foi executada no Laboratório de Enfermagem da EEUSP (LE-EEUSP), em três fases. Na 1ª fase, houve a avaliação prévia desses alunos por meio de prova teórica (avaliação do CONHECIMENTO) constituída por 40 questões e prova prática avaliada pela execução de um check list com 20 itens (avaliação da HABILIDADE). Na 2ª fase, foi realizado um Curso teórico-prático com exposição do assunto em aula teórica e, a seguir, a demonstração prática, em simulação no LE-EEUSP, com manequim e outros materiais e equipamentos específicos. Esse ambiente para simulação, assim organizado, foi disponibilizado, durante um mês, para o treinamento dos alunos sob orientação de instrutores que aferiram o tempo e o número de treinamentos de cada aluno. Após essa etapa, na 3ª fase, esses alunos foram submetidos à nova avaliação, com prova teórica (avaliação do CONHECIMENTO) e prática (avaliação da HABILIDADE), utilizando os mesmos instrumentos da 1ª fase. Os parâmetros avaliados no estudo foram: desempenho dos alunos antes e após Curso teórico-prático; tempo de execução e número de treinamentos de cada aluno. Resultados: observou-se acréscimo de acertos na prova teórica (CONHECIMENTO) em 37 questões, com significado estatístico em 30 delas (p<0,05). Quanto à avaliação da HABILIDADE, houve aumento de acertos em 19 dos 20 itens do check list (p<0,05). Quanto à relação do percentual de acertos e/ou escores com o número de treinamentos, não houve correlação (p>0,05). No entanto, quanto à relação do percentual de acertos e/ou escores com o tempo de execução a correlação foi significativa (p<0,05) e classificada como moderada. Conclusões: após o Curso teórico prático ministrado, utilizando as estratégias de ensino descritas, houve melhora significativa do desempenho dos alunos em ambos os aspectos avaliados: CONHECIMENTO e HABILIDADE. / Abstract: Introduction: Increasingly worrisome statistics show that cardiovascular diseases are the main cause of morbimortality in Brazil and worldwide, among these conditions being those that lead to cardiopulmonary arrest (CPA). Continuous improvement of education on CPA pre or intra-hospital care is essential for the development of health professionals, including nursing professionals. Objective: This study aimed at assessing the teaching/ learning process of pre-hospital care to CPA victims with Cardiopulmonary Resuscitation Maneuvers (CPR) and Automated External Defibrillators (AED), as far as theoretical aspects (KNOWLEDGE) and practical aspects (SKILLS) are concerned, according to the 2010 guidelines of the International Liaison Committee on Resuscitation (ILCOR). Case Description and Method: The sample consisted of 37 first-year students enrolled at the School of Nursing of Universidade de São Paulo, who had not received any previous instruction on the theme. The research was carried out in the Nursing Laboratory of the Schoof of Nursing (LE-EEUSP), in three phases. In the 1st phase, students sat a preliminary theoretical test (KNOWLEDGE assessment), with 40 questions, and took a practical test in which they had to go over a 20-item check list (SKILLS assessment). In the 2nd phase, a theoretical-practical course was offered, based on explanatory theoretical classes and subsequent practical demonstrations, with simulations at the LE-EEUSP laboratory employing dummies and other specific materials and equipment. This specially prepared simulation environment remained available for training during a month, supervised by instructors that were responsible for keeping track of the time spent and the number of training sessions taken by each student. Later on, in the 3rd phase, students were evaluated again by means of a theoretical test (KNOWLEDGE assessment) and a practical test (SKILLS assessment), with the same assessment tools used in the 1st phase. The study then considered the performance of students before and after the course and the number of sessions and time spent on training. Results: An increase in the percentage of correct answers was observed in 37 questions of the theoretical test (KNOWLEDGE), with statistical significance (p<0.05) in 30 of these cases. As to the SKILLS assessment, there was an increase in the percentage of correct answers given to 19 of the 20 items in the check list (p<0.05). As far as the relation between the correct answers percentage and/or test scores and the number of training sessions, no correlation was observed (p>0.05). However, the relation between the correct answers percentage and/or test scores and time spent on training was significant (p<0.05), classified as moderate correlation. Conclusion: After taking the theoretical-practical course, applying the strategies taught, students significantly improved their performance in relation to the aspects that were assessed: KNOWLEDGE and SKILLS.

RESUMO: Introdução: as estatísticas progressivamente preocupantes demonstram que as doenças cardiovasculares são a principal causa de morbimortalidade no Brasil e no mundo e, entre elas, estão as que levam à parada cardiorrespiratória (PCR). O aprimoramento contínuo do ensino do atendimento às vítimas de PCR pré ou intra-hospitalar torna-se fundamental para a boa formação dos profissionais de saúde, incluindo os de Enfermagem. Objetivo: o presente estudo teve por objetivo avaliar o processo de ensino aprendizagem no atendimento pré-hospitalar às vítimas de PCR, utilizando as manobras de Ressuscitação Cardiopulmonar (RCP) e o Desfibrilador Externo Automático (DEA), no aspecto teórico (CONHECIMENTO) e prático (HABILIDADE), seguindo as recomendações do guideline de 2010 da Aliança Internacional dos Comitês de Ressuscitação (ILCOR). Casuística e Método: a amostra foi constituída por 37 alunos do 1º ano, da Escola de Enfermagem da Universidade de São Paulo, que não tiveram nenhuma orientação prévia sobre o tema. A pesquisa foi executada no Laboratório de Enfermagem da EEUSP (LE-EEUSP), em três fases. Na 1ª fase, houve a avaliação prévia desses alunos por meio de prova teórica (avaliação do CONHECIMENTO) constituída por 40 questões e prova prática avaliada pela execução de um check list com 20 itens (avaliação da HABILIDADE). Na 2ª fase, foi realizado um Curso teórico-prático com exposição do assunto em aula teórica e, a seguir, a demonstração prática, em simulação no LE-EEUSP, com manequim e outros materiais e equipamentos específicos. Esse ambiente para simulação, assim organizado, foi disponibilizado, durante um mês, para o treinamento dos alunos sob orientação de instrutores que aferiram o tempo e o número de treinamentos de cada aluno. Após essa etapa, na 3ª fase, esses alunos foram submetidos à nova avaliação, com prova teórica (avaliação do CONHECIMENTO) e prática (avaliação da HABILIDADE), utilizando os mesmos instrumentos da 1ª fase. Os parâmetros avaliados no estudo foram: desempenho dos alunos antes e após Curso teórico-prático; tempo de execução e número de treinamentos de cada aluno. Resultados: observou-se acréscimo de acertos na prova teórica (CONHECIMENTO) em 37 questões, com significado estatístico em 30 delas (p<0,05). Quanto à avaliação da HABILIDADE, houve aumento de acertos em 19 dos 20 itens do check list (p<0,05). Quanto à relação do percentual de acertos e/ou escores com o número de treinamentos, não houve correlação (p>0,05). No entanto, quanto à relação do percentual de acertos e/ou escores com o tempo de execução a correlação foi significativa (p<0,05) e classificada como moderada. Conclusões: após o Curso teórico prático ministrado, utilizando as estratégias de ensino descritas, houve melhora significativa do desempenho dos alunos em ambos os aspectos avaliados: CONHECIMENTO e HABILIDADE. / Abstract: Introduction: Increasingly worrisome statistics show that cardiovascular diseases are the main cause of morbimortality in Brazil and worldwide, among these conditions being those that lead to cardiopulmonary arrest (CPA). Continuous improvement of education on CPA pre or intra-hospital care is essential for the development of health professionals, including nursing professionals. Objective: This study aimed at assessing the teaching/ learning process of pre-hospital care to CPA victims with Cardiopulmonary Resuscitation Maneuvers (CPR) and Automated External Defibrillators (AED), as far as theoretical aspects (KNOWLEDGE) and practical aspects (SKILLS) are concerned, according to the 2010 guidelines of the International Liaison Committee on Resuscitation (ILCOR). Case Description and Method: The sample consisted of 37 first-year students enrolled at the School of Nursing of Universidade de São Paulo, who had not received any previous instruction on the theme. The research was carried out in the Nursing Laboratory of the Schoof of Nursing (LE-EEUSP), in three phases. In the 1st phase, students sat a preliminary theoretical test (KNOWLEDGE assessment), with 40 questions, and took a practical test in which they had to go over a 20-item check list (SKILLS assessment). In the 2nd phase, a theoretical-practical course was offered, based on explanatory theoretical classes and subsequent practical demonstrations, with simulations at the LE-EEUSP laboratory employing dummies and other specific materials and equipment. This specially prepared simulation environment remained available for training during a month, supervised by instructors that were responsible for keeping track of the time spent and the number of training sessions taken by each student. Later on, in the 3rd phase, students were evaluated again by means of a theoretical test (KNOWLEDGE assessment) and a practical test (SKILLS assessment), with the same assessment tools used in the 1st phase. The study then considered the performance of students before and after the course and the number of sessions and time spent on training. Results: An increase in the percentage of correct answers was observed in 37 questions of the theoretical test (KNOWLEDGE), with statistical significance (p<0.05) in 30 of these cases. As to the SKILLS assessment, there was an increase in the percentage of correct answers given to 19 of the 20 items in the check list (p<0.05). As far as the relation between the correct answers percentage and/or test scores and the number of training sessions, no correlation was observed (p>0.05). However, the relation between the correct answers percentage and/or test scores and time spent on training was significant (p<0.05), classified as moderate correlation. Conclusion: After taking the theoretical-practical course, applying the strategies taught, students significantly improved their performance in relation to the aspects that were assessed: KNOWLEDGE and SKILLS.

Hintergrund: Triage und Ersteinschätzung von Patienten in der Krankenhaus-Notaufnahme als Instrument der Prozeßgestaltung. Übersicht: In den vergangenen Jahren zeigte sich deutschlandweit ein Trend. Die Versorgung von Patienten in den Notaufnahmen der Krankenhäuser erlangt eine immer größere Bedeutung. Bedeutendste Ressource in der Notaufnahme ist die ärztliche Arbeit. Diagnosestellung und Festlegung der Therapie sind die wesentlichen Leistungen. Es ist entscheidend, die Prozessqualität am Punkt des Erstkontaktes des Notfallpatienten mit dem Krankenhaus zu verbessern. Das Universitätsklinikum Dresden eröffnete 2012 mit der Konservativen Notaufnahme (KNA-S1) eine neue, interdisziplinäre Funktionsstelle. Organisatorische Intervention war die Entlastung und Steuerung der Ressource „Arbeitszeit Arzt“. Es wurde das Manchester Triage System als Steuerungsinstrument implementiert mit den Zielen: • Optimale Nutzung der Infrastruktur • Neu definierter und verbesserter Ablauf der Integration von Notfallpatienten in den Behandlungsprozeß und den Geschäftsprozeß des UKD. • Entwicklung von Handlungsempfehlungen für das Pflegepersonal für Maßnahmen am Patienten vor Arztkontakt Schlussfolgerungen: Die strukturierte Ersteinschätzung von Patienten ist ein zielführendes Instrument, um den organisatorischen Reifegrad des Workflows in der Notaufnahme zu erhöhen. Auf dieser Grundlage entwickelte Handlungsempfehlungen für das Pflegepersonal schaffen für Patienten, Ärzte und Pflegepersonal ein optimiertes, Risiko-reduziertes Umfeld. / Background: Triage and initial assessment of patients in Emergency Departments as organizational tool for process improvement. Summary: A trend occurred throughout Germany during the past years. Hospital Emergency Departments achieve increasing importance in patient care. Crucial resource in the ED is physician´s work and authority for diagnosis and therapy. It is important to improve process quality at the point of emergency patient´s first contact to hospital. In 2012 University Hospital Dresden established a new interdisciplinary infrastructure in emergency care for medical and neurological patients (KNA-S1). Organizational intervention has been to relieve and control workload and schedule of the physicians. The Manchester Triage System was implemented as instrument for process control aiming: • Optimized utilization of resources • improved workflow of how emergency patients are introduced into treatment and hospital workflow • Development of guidelines for nursing staff to accomplish appropriate procedures on patients before seeing the physician first Conclusion: Operating an initial assessment on emergency patients leads to improvement of quality and proficiency throughout the operating procedures of an Emergency Department. Guidelines for nursing staff on this foundation will create an optimized and risk reduced environment for patients, physicians and all medical professionals in the ED.

Os primeiros indícios de tentativas de abordagem e manejo da via aérea (VA) datam de cerca de 4000 anos. A intubação traqueal (IT) consiste na introdução de um tubo na luz da traquéia, e é responsável por salvar muitas vidas. O manejo da VA nos serviços de emergência é um dos principais desafios e seguramente um dos momentos mais críticos do cuidado com o paciente grave. As principais complicações e efeitos adversos da IT decorrem da laringoscopia direta e da introdução do tubo traqueal na VA. A sequência rápida de intubação (SRI) é a realização do procedimento de IT através de uma abordagem organizada que envolve a utilização de agentes sedativos, analgésicos e bloqueador neuromuscular. A SRI tem por objetivo diminuir ou limitar os efeitos adversos do procedimento de IT, em especial da laringoscopia direta. A SRI é o método de escolha na maioria dos procedimentos de IT de emergência em pediatria na literatura internacional. Os registros de dados sobre o manejo da VA em serviços de emergência pediátricos no Brasil são raros e não abordam a SRI como técnica de IT. Dessa forma os objetivos do presente estudo foram descrever a experiência do pronto-socorro de um hospital pediátrico de atendimento terciário com o uso da SRI, e detectar possíveis fatores associados ao sucesso da SRI. Para tanto foi realizado estudo prospectivo observacional tipo \"coorte\" de julho de 2005 a dezembro de 2007, onde foram coletados os dados relacionados a todas as ITs realizadas no pronto-socorro do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP). Foram incluídos no estudo todos os pacientes que foram submetidos a SRI. Foi considerado IT com sucesso aquela realizada na primeira tentativa. O registro dos dados foi realizado pelo profissional que participou diretamente do procedimento em formulário específico. Durante o período de estudo ocorreram 117 ITs, sendo que 84% delas foram realizadas sob SRI; a idade dos pacientes variou de 29 dias a 17 anos (mediana=4,4anos) e 60% eram do sexo masculino; setenta e nove por cento eram portadores de patologias de base, sendo 21% doenças neurológicas, 18% oncológicas e 8% respiratórias; a insuficiência respiratória aguda foi a causa imediata da IT em 40% dos procedimentos e alteração do nível de consciência e choque em 20% e 18% respectivamente; todas as ITs foram realizadas no pronto-socorro e por um dos médicos da equipe; a taxa de sucesso foi de 39%; o residente de pediatria do segundo ano foi o responsável por 74% das ITs, e com taxa de sucesso de 35%; foi realizada ventilação com pressão positiva em 74% dos procedimentos, sendo menor a sua utilização entre os pacientes que foram intubados com sucesso (21 versus 49 p=0,002). O midazolam foi o sedativo de escolha, utilizado em 80% dos procedimentos, e o rocurônio foi o bloqueador neuromuscular em 100% dos procedimentos; complicações decorrentes da SRI foram descritas em 75 (80%) dos procedimentos, sendo queda da saturação de oxigênio relatada em 47% do total, e significativamente menor nos pacientes que foram intubados com sucesso (p<0.001); dificuldades relativas à IT foram menos relatadas nos procedimentos realizados com sucesso (p<0,001). Em conclusão, pode-se afirmar que a SRI foi o método de escolha nas ITs realizadas no pronto-socorro do ICr-HCFMUSP, que a população que necessitou de manejo da via aérea foi composta em sua grande maioria por pacientes portadores de doenças de base com problemas respiratórios e que, complicações do procedimento de SRI são mais frequentes quando há necessidade de maior número de tentativas de laringoscopia direta. / The first signs of attempts to approach and manage airways date from about 4000 years. The tracheal intubation (TI) consists in to introduce a tube in the trachea lumen and it is responsible for saving many lives. The airway management in the emergency services is one of the most challenges and critical moments of care for the critically ill patient. The major complications and adverse effects of TI stem from the direct laryngoscopy and tracheal tube introduction into the airway. The Rapid Sequence Intubation (RSI) is the actual procedure of TI through an organized approach that involves the use of sedative agents, analgesics and neuromuscular blocker. The objective of SRI is to minimize and limit the main adverse effects of the TI procedure and in special of the direct laryngoscopy. SRI is the method of choice in most of TI procedures in emergency pediatrics in the international literature. The data records on airway management in pediatric emergency services are rare and do not address the SRI as a technique to perform TI. The objectives of this study were to describe the experience of a pediatric tertiary care emergency department with the use of RSI, and identify possible factors associated with the success of RSI. For this, a prospective observational study type \"cohort\" was conducted from July 2005 through December 2007, where all data related to TI performed in the emergency room of the Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP) was collected. The study included all patients who underwent to RSI. Intubation was considered successful when it was performed on the first try. Data registration was done by the professional who directly participated in the procedure in a specific form. During the study period 117 tracheal intubations were performed, and 84% of these events were held under RSI; the patients\' ages ranged from 29 days to 17 years (median = 4.4 years) and 60 % were male; seventy-nine percent of patients had underlying diseases, 21% of them were neurological diseases, 18% cancer and 8% respiratory diseases; the acute respiratory failure was the immediate cause of TI in 40% of the procedures and altered level of consciousness and shock in 20% and 18% respectively; all TIs were performed in the emergency room by emergency physician with success rate of 39%; the pediatric resident\'s from the second year was responsible for 74% of the TIs, and with a success rate of 35%; positive pressure ventilation was performed in 74% of procedures, their use was lower among patients who were successfully intubated (21 vs. 49 p = 0.002); Midazolam was chosen as a sedative in 80% of procedures, and rocuronium as a neuromuscular blocking agent in 100% of procedures; Complications from the procedure of TI have been described in 75 (80%) of procedures, where a decrease in oxygen saturation was reported by 47% and significantly lower in patients who were successfully intubated (p <0.001). Difficulties related to TI were reported less in procedures performed with success (p <0.001). In conclusion, it can be stated that RSI was the method of choice in TI performed in the emergency room of ICr-FMUSP, that the patients who required airway management was composed mostly of patients with underlying diseases with respiratory problems and that complications of the RSI procedure are more frequent when there is need for a higher number of direct laryngoscopy attempts.

Os primeiros indícios de tentativas de abordagem e manejo da via aérea (VA) datam de cerca de 4000 anos. A intubação traqueal (IT) consiste na introdução de um tubo na luz da traquéia, e é responsável por salvar muitas vidas. O manejo da VA nos serviços de emergência é um dos principais desafios e seguramente um dos momentos mais críticos do cuidado com o paciente grave. As principais complicações e efeitos adversos da IT decorrem da laringoscopia direta e da introdução do tubo traqueal na VA. A sequência rápida de intubação (SRI) é a realização do procedimento de IT através de uma abordagem organizada que envolve a utilização de agentes sedativos, analgésicos e bloqueador neuromuscular. A SRI tem por objetivo diminuir ou limitar os efeitos adversos do procedimento de IT, em especial da laringoscopia direta. A SRI é o método de escolha na maioria dos procedimentos de IT de emergência em pediatria na literatura internacional. Os registros de dados sobre o manejo da VA em serviços de emergência pediátricos no Brasil são raros e não abordam a SRI como técnica de IT. Dessa forma os objetivos do presente estudo foram descrever a experiência do pronto-socorro de um hospital pediátrico de atendimento terciário com o uso da SRI, e detectar possíveis fatores associados ao sucesso da SRI. Para tanto foi realizado estudo prospectivo observacional tipo \"coorte\" de julho de 2005 a dezembro de 2007, onde foram coletados os dados relacionados a todas as ITs realizadas no pronto-socorro do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP). Foram incluídos no estudo todos os pacientes que foram submetidos a SRI. Foi considerado IT com sucesso aquela realizada na primeira tentativa. O registro dos dados foi realizado pelo profissional que participou diretamente do procedimento em formulário específico. Durante o período de estudo ocorreram 117 ITs, sendo que 84% delas foram realizadas sob SRI; a idade dos pacientes variou de 29 dias a 17 anos (mediana=4,4anos) e 60% eram do sexo masculino; setenta e nove por cento eram portadores de patologias de base, sendo 21% doenças neurológicas, 18% oncológicas e 8% respiratórias; a insuficiência respiratória aguda foi a causa imediata da IT em 40% dos procedimentos e alteração do nível de consciência e choque em 20% e 18% respectivamente; todas as ITs foram realizadas no pronto-socorro e por um dos médicos da equipe; a taxa de sucesso foi de 39%; o residente de pediatria do segundo ano foi o responsável por 74% das ITs, e com taxa de sucesso de 35%; foi realizada ventilação com pressão positiva em 74% dos procedimentos, sendo menor a sua utilização entre os pacientes que foram intubados com sucesso (21 versus 49 p=0,002). O midazolam foi o sedativo de escolha, utilizado em 80% dos procedimentos, e o rocurônio foi o bloqueador neuromuscular em 100% dos procedimentos; complicações decorrentes da SRI foram descritas em 75 (80%) dos procedimentos, sendo queda da saturação de oxigênio relatada em 47% do total, e significativamente menor nos pacientes que foram intubados com sucesso (p<0.001); dificuldades relativas à IT foram menos relatadas nos procedimentos realizados com sucesso (p<0,001). Em conclusão, pode-se afirmar que a SRI foi o método de escolha nas ITs realizadas no pronto-socorro do ICr-HCFMUSP, que a população que necessitou de manejo da via aérea foi composta em sua grande maioria por pacientes portadores de doenças de base com problemas respiratórios e que, complicações do procedimento de SRI são mais frequentes quando há necessidade de maior número de tentativas de laringoscopia direta. / The first signs of attempts to approach and manage airways date from about 4000 years. The tracheal intubation (TI) consists in to introduce a tube in the trachea lumen and it is responsible for saving many lives. The airway management in the emergency services is one of the most challenges and critical moments of care for the critically ill patient. The major complications and adverse effects of TI stem from the direct laryngoscopy and tracheal tube introduction into the airway. The Rapid Sequence Intubation (RSI) is the actual procedure of TI through an organized approach that involves the use of sedative agents, analgesics and neuromuscular blocker. The objective of SRI is to minimize and limit the main adverse effects of the TI procedure and in special of the direct laryngoscopy. SRI is the method of choice in most of TI procedures in emergency pediatrics in the international literature. The data records on airway management in pediatric emergency services are rare and do not address the SRI as a technique to perform TI. The objectives of this study were to describe the experience of a pediatric tertiary care emergency department with the use of RSI, and identify possible factors associated with the success of RSI. For this, a prospective observational study type \"cohort\" was conducted from July 2005 through December 2007, where all data related to TI performed in the emergency room of the Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP) was collected. The study included all patients who underwent to RSI. Intubation was considered successful when it was performed on the first try. Data registration was done by the professional who directly participated in the procedure in a specific form. During the study period 117 tracheal intubations were performed, and 84% of these events were held under RSI; the patients\' ages ranged from 29 days to 17 years (median = 4.4 years) and 60 % were male; seventy-nine percent of patients had underlying diseases, 21% of them were neurological diseases, 18% cancer and 8% respiratory diseases; the acute respiratory failure was the immediate cause of TI in 40% of the procedures and altered level of consciousness and shock in 20% and 18% respectively; all TIs were performed in the emergency room by emergency physician with success rate of 39%; the pediatric resident\'s from the second year was responsible for 74% of the TIs, and with a success rate of 35%; positive pressure ventilation was performed in 74% of procedures, their use was lower among patients who were successfully intubated (21 vs. 49 p = 0.002); Midazolam was chosen as a sedative in 80% of procedures, and rocuronium as a neuromuscular blocking agent in 100% of procedures; Complications from the procedure of TI have been described in 75 (80%) of procedures, where a decrease in oxygen saturation was reported by 47% and significantly lower in patients who were successfully intubated (p <0.001). Difficulties related to TI were reported less in procedures performed with success (p <0.001). In conclusion, it can be stated that RSI was the method of choice in TI performed in the emergency room of ICr-FMUSP, that the patients who required airway management was composed mostly of patients with underlying diseases with respiratory problems and that complications of the RSI procedure are more frequent when there is need for a higher number of direct laryngoscopy attempts.