Hot Papers from around the world
Please note: This page contains a selection of comments and recommendations of "hot papers" that are recently published on external websites. Click on index link below to read an introduction to the specific article. When you want to read the complete article click on connected link and a new browser window will open displaying the article in it's original form where published.
Please note that older articles will also be present.
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Rate of decline in oxygen saturation at various pulse oximetry values with prehospital RSI | ||
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Pleural decompression and drainagin during trauma reception and resuscitation | ||
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Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients - what size needle | ||
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Emergency department thoracotomy - still useful after abdominal exsanguination | ||
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Delayed Time to Defibrillation after In-Hospital Cardiac Arrest | ||
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Prehospital intubation? | ||
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Rapid sequence intubation: The who, where, and what | ||
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Public-access defibrillation | ||
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Albumin vs Saline | ||
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Hypoxia and pulse rate reactivity during paramedic rapid sequence intubation | ||
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Bradycardia in acute haemorrhage | ||
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Surgical MCQ's | ||
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X-ray gallery | ||
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Neonate lifesupport | ||
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AED use by bystanders | ||
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Hypertonic saline vs Ringers lactate | ||
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Morphine for abdominal pain | ||
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Prehospital thrombolysis in northern Norway | ||
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Blunt cardiac injury | ||
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Optimal Dose of Succinylcholine | ||
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In memory of Peter Safar | ||
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Helicopter vs Ground-ambulance | ||
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Good long-term outcome for survivors after rapid defibrillation of out-of-hospital cardiac arrest | ||
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Intraosseous Infusion | ||
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Troponin T a predictor of severity in pulmonary embolism? | ||
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Ambulance transport is not a negligible risk for pedestrians | ||
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Changing Incidence of Out-of-Hospital Ventricular Fibrillation | ||
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Changing Incidence of Out-of-Hospital Ventricular Fibrillation | ||
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ECG in Hypothermia | ||
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Missed injuries of the cervical spine | ||
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Noradrenaline for septic shock? | ||
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The systemic inflammatory response after major trauma | ||
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IV fibrinolytic therapy approved for treatment of Stroke patients in the EU | ||
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Public access defibrillators | ||
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Volume resuscitation - an overview | ||
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Pulse oximetry in discharge decision-making | ||
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Quality of cardiac massage | ||
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Clinical Aspects of Prehospital Tube Thoracostomy | ||
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Should family be present during resuscitation in the emergency department? | ||
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Prehospital advanced life support (ALS) provided by specially trained physicians | ||
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Bleeding after crystalloid infusions | ||
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Kobe earthquake in Japan | ||
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Public-access defibrillation | ||
Rate of Decline in Oxygen Saturation at Various Pulse Oximetry Values with Prehospital Rapid Sequence Intubation
Daniel P. Davis; James Q. Hwang; James V. Dunford
This study set out to examine the rate of SpO2 decline at various pulse oximetry values during pre-hospital rapid sequence intubation, and identify a threshold below which active BVM should be performed during prehospital RSI.
Traumatic brain injury patients undergoing prehospital RSI were included. The timeperiod from the highest to the lowest pre-intubation SpO2 was selected. The mean rate of SpO2 decline was calculated and then used to define a hypothetical desaturation curve. The rate of desaturation to hypoxaemia (SpO2 <90%) was then defined for RSI initiated at each SpO2 value.
Results show that lower SpO2 values were associated with a faster rate of SpO2 decline with an inflection point occurring at 93%. The incidence of desaturation to hypoxaemia was much higher when RSI was initiated with SpO2 <93% (100%) compared with SpO2 >93% (6%).
In conclusion, the rate of SpO2 decline increases as the SpO2 decreases. RSI attempted at SpO2 below 93% is almost always associated with hypoxaemia, suggesting that BVM should be used in these patients prior to intubation.
Prehosp Emerg Care. 2008 Jan-Mar;12(1):46-51
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Pleural decompression and drainage during trauma reception and resuscitation
M. Fitzgerald, C.F. Mackenzie, S. Marasco, R. Hoyle and T. Kossmann
This review looks at the different methods of pleural decompression and drainage during the initial hospital treatment of adult trauma patients when it is indicated for haemodynamically unstable patients with clinical signs of pneumothorax or haemothorax.
Key findings of this review are that:
- Needle thoracocentesis is an unreliable means of decompressing the chest of an unstable patient and should only be used as a technique of last resort.
- Blunt dissection and digital decompression through the pleura is the essential first step for pleural decompression, as decompression of the pleural space is a primary goal during reception of the haemodynamically unstable patient with a haemothorax or pneumothorax. Drainage and insertion of a chest tube is a secondary priority.
- Techniques to prevent tube thoracostomy (TT) complications include aseptic technique, avoidance of trocars, digital exploration of the insertion site and guidance of the tube posteriorly and superiorly during insertion.
- Whenever possible, blunt thoracic trauma patients should undergo definitive CT imaging after TT to check for appropriate tube position.
Injury. 2008 Jan;39(1):9-20
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Needle Thoracostomy in the Treatment of a Tension Pneumothorax in Trauma Patients: What Size Needle?
Zengerink, Imme MD; Brink, Peter R. MD, PhD; Laupland, Kevin B. MD, MSc, FRCPC; Raber, Earl L. MD, FRCPC; Zygun, Dave MD, MSc, FRCPC; Kortbeek, John B. MD, FRCSC, FACS
Tension pneumothorax requires immediate decompression with needle thoracostomy. According to ATLS teaching, this is performed in the 2nd intercostal space, mid-clavicular line using a 5cm needle.
Previous studies have demonstrated high failure rates with this method (up to 40%) and recent case reports have suggested that this could be due to insufficient needle length.
This study set out to analyse the average chest wall thickness at the 2nd intercostal space in the mid-clavicular line in a trauma patient and to evaluate the required needle length to perform successful needle thoracostomy for tension pneumothorax.
604 males and 170 females who underwent a CT scan which included the thorax for trauma were examined. Chest wall thickness averaged 3.50cm at the left 2nd ICS and 3.51cm on the right. The mean chest wall thickness was significantly greater for women than men. Over 10% of men and over 25% of women had a chest wall thickness greater than 4.5cm.
In conclusion, a 5cm needle may not penetrate the chest wall in a substantial number of cases depending upon age and gender.
J Trauma. 2008 Jan;64(1):111-4
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Emergency Department Thoracotomy: Still Useful After Abdominal Exsanguination?
Seamon, Mark J. MD; Pathak, Abhijit S. MD; Bradley, Kevin M. MD; Fisher, Carol A. BA; Gaughan, John A. PhD; Kulp, Heather RN, MPH; Pieri, Paola G. MD; Santora, Thomas A. MD; Goldberg, Amy J. MD
The current published evidence regarding emergency department thoracotomy (EDT) for anything other than cardiac wounds describes poor patient outcomes. This study examines the use of EDT for patients with exsanguinating abdominal haemorrhage.
A retrospective study identified 50 patients who underwent EDT for abdominal exsanguination over a 6 year period. The primary endpoint was neurologically-intact hospital survival.
These patients were largely young males suffering from gunshot wounds (98%). 78% presented with signs of life, and GCS was depressed (mean 4.2). Eight patients survived to discharge neurologically intact. All of these had major abdominal vascular (75%) or severe liver (25%) injuries and all required massive blood transfusion (mean 28.6 +/- 17.3 units) and extended intensive care stay (mean 36.3 days).
This study concludes that despite critical injuries, 16% of patients survived to discharge neurologically intact after EDT for exsanguinating abdominal injury.
World J Surg. 2008 Jan 26 [Epub ahead of print]
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Delayed Time to Defibrillation after In-Hospital Cardiac Arrest
Paul S. Chan, M.D., Harlan M. Krumholz, M.D., Graham Nichol, M.D., M.P.H., Brahmajee K. Nallamothu, M.D., M.P.H., and the American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators
The latest resuscitation guidelines advocate defibrillation after an in-hospital cardiac arrest within 2 minutes. This study set out to examine whether delayed access to defibrillation has an impact upon patient morbidity and mortality.
Using data from 6789 patients (from 369 hospitals using the National Registry of Cardiopulmonary Resusciation in the USA) who had a cardiac arrest in-hospital due to ventricular fibrillation or pulseless ventricular tachycardia, the association between delayed defibrillation (>2 minutes) and survival to discharge was examined.
Delayed defibrillation occurred in 30.1% of cases. Associated factors included non-cardiac admitting diagnosis, occurrence in an unmonitored bed and out-of hours. This delay led to significantly lower probability of surviving to discharge (22.2% compared with 39.3% when defibrillation was not delayed). With increasing time to defibrillation is a trend towards lower rates of survival.
N Engl J Med. 2008 Jan 3;358(1):9-17
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Supplementation of pre-oxygenation in morbidly obese patients using nasopharyngeal oxygen insufflation
S. Baraka, SK. Taha, SM. Siddik-Sayyid, GE. Kanazi, MF. El-Khatib, CM. Dagher, J-MA. Chehade, FW. Abdallah and RE. Hajj
Studies have shown that apnoea following induction of anaesthesia in morbidly obese patients may result in a rapid decrease in oxygen saturation.
This study compares pre-oxygenation alone with pre-oxygenation followed by nasopharyngeal oxygen insufflation during apnoea following induction. Thirty four patients undergoing gastric bypass or gastric band surgery were randomised into the two groups. Time from onset of apnoea until SpO2 fell to 95% was compared.
In the group receiving pre-oxygenation alone, SpO2 fell to 95% in 145 seconds with a significant negative correlation between time to desaturation and BMI.
In the study group, SpO2 was maintained in 16/17 patients at 100% for 4 minutes, when apnoea was terminated.
In conclusion, nasopharygeal oxygen insufflation following pre-oxygenation in morbidly obese patients delays the onset of desaturation during induction of anaesthesia.
Anaesthesia. 2007 Aug;62(8):769-73
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Sedation in the emergency department
Smally, Alan J; Nowicki, Thomas Anthony
The use of sedation outside the anaesthetic room is increasing. Moderate-to-deep sedation is used with greater frequency in the emergency department for a number of reasons with the most common indication being orthopaedic.
This review examines the literature presented in the previous year in this area of practice. It found that procedural sedation and analgesia is performed using propfol, etomidate, midazolam, fentanyl, ketamine and nitrous oxide. Cardiac monitoring, pulse oximetry and capnography are used but often without evidence for need. Complications are higher in prospective than retrospective studies, although clinically important complications are uncommon.
Curr Opin Anaesthesiol. 2007 Aug;20(4):379-83
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Prehospital Procedures Before Emergency Department Thoracotomy: "Scoop and Run" Saves Lives
Seamon, Mark J. MD; Fisher, Carol A. BA; Gaughan, John PhD; Lloyd, Michael MS, RN; Bradley, Kevin M. MD; Santora, Thomas A. MD; Pathak, Abhijit S. MD; Goldberg, Amy J. MD
Do prehospital procedures have a negative impact on critically injured penetrating trauma patients?
The role of prehospital care in the management of acutely injured patients is rapidly evolving. This study, however, set out to test the hypothesis that survival of critically injured penetrating trauma patients requiring thorocotomy would be improved if procedures were restricted until arrival in the emergency department.
A retrospective review of 180 penetrating trauma patients who underwent emergency department thorocotomy was performed. These were divided into two groups based on method of arrival at the emergency department – by emergency medical services (88 patients) or by police / private vehicle (92).
The groups were similar in demographics. Of the EMS-transported group, 8% survived to discharge compared with 17.4% of those arriving by police / private vehicle. The main difference between these groups was that the police / private vehicle group underwent no prehospital procedures, whereas the EMS group had a total of 137 procedures performed.
Multivariate logistic regression analyses identify these prehospital procedures as the sole independent predictor of mortality, with each procedure increasing the patient mortality by 2.63 times.
This study concludes that in this distinct population of crticially injured penetrating trauma patients, the performance of prehospital procedures has a negative effect on survival after emergency department thorocotomy.
J Trauma. 2007 Jul;63(1):113-20
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The Predictive Value and Appropriate Ranges of Prehospital Physiological Parameters for High-Risk Injured Children
Newgard, Craig D. MD, MPH; Cudnik, Michael MD; Warden, Craig R. MD, MPH; Hedges, Jerris R. MD, MS
Which prehospital observations are best at identifying high risk children?
A retrospective cohort analysis of injured children under the age of 14 years was carried out in the USA, including children transported to hospital to emergency medical services between 1998 and 2003. Prehospital observations were analysed, including GCS, systolic blood pressure, respiratory rate, heart rate and airway intervention.
“High risk” children were defined as those dying whilst in hospital, requiring major non-orthopaedic surgery, requiring intensive care unit stay >2 days or ISS >16.
After analysing 3877 children, of which 1111 (29%) were high risk, prehospital GCS was the variable of greatest importance in identifying high risk children. Second to this was airway intervention, and then respiratory rate.
Therefore, prehospital GCS and respiratory compromise were the most important observations in identifying high risk injured children.
Pediatr Emerg Care. 2007 Jul;23(7):450-6
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The epidemiology of fractures in children
Louise Rennie, Charles M. Court-Brown, Jacqueline Y.Q. Mok and Thomas F. Beattie
This is a retrospective study of all paediatric fractures presenting to a Scottish hospital in 2000.
The incidence of fractures in the paediatric population was 20.2/1,000/year with 61% occurring in males. The incidence of fractures increases with age. The commonest cause of a fracture is a fall from <1 metre.
In terms of different injuries, the majority involve the upper limb. Lower limb fractures are mostly associated with twisting injuries and road traffic accidents.
Injury. 2007 Aug;38(8):913-22. Epub 2007 Jul 12
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Emergency medicine in modern Europe
Thomas Fleischmann and Gordian Fulde
Emergency medicine has evolved into two distinct approaches. The Anglo-American system with skilled emergency departments and prehospital paramedic-led emergency medical service; and the Franco-German system of high-developed prehospital emergency physician service but only basic hospital-based emergency medicine. The gap between these is now rapidly closing.
Factors influencing the closing of this gap include the recognition of emergency medicine as a specialty, a specialist training programme, the presence of academic centres of excellence, and the professional organisation of emergency physicians.
The European Society for Emergency Medicine has been working to create a curriculum for emergency medicine for pan-European adoption, which is expected in late 2007, comprising a 5 year training programme.
This paper describes the present situation with emergency medicine in Europe and suggests what the future may hold.
Emerg Med Australas. 2007 Aug;19(4):300-2
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Prehospital anaesthesia in the UK: position statement
David Lockey and Keith Porter
Anaesthesia is carried out in the prehospital environment by a small number of individuals in the United Kingdom. This position statement assesses what is required of these individuals and stresses the important requirement for patient safety systems.
EMJ 2007;24:437-438
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The effect of cricoid pressure on intubation facilitated by the gum elastic bougie
U. McNelis, A. Syndercombe, I. Harper and J. Duggan
Does cricoid pressure on intubation influence its success?
Tracheal tube impingement is common when using a gum elastic bougie and a 90° anti-clockwise rotation of the tube usually relieves it. This study investigates the effect of cricoid pressure on gum elastic bougie-facilitated intubation in 120 patients.
Impingement occurred in 38% of cases with sham cricoid pressure and 60% of case with 30N cricoid pressure. Ninety degree anti-clockwise rotation of the tube was successful in all cases with sham cricoid pressure and 89% of those with 30N cricoid pressure.
This study concludes that although impingement is common, 90° anti-clockwise rotation is highly effective in solving this problem.
Anaesthesia, 2007 May;62(5):456-9
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A history of mechanical devices for providing external chest compressions
Russell Harrison-Paul
This article provides an in-depth overview of some of the mechanical devices which have been developed over the past 45 years in order to deliver external chest compressions. Despite their existence over this period of time, they have failed to become a regular part of resuscitation practice and the article suggests reasons for this.
Resuscitation 2007 Jun;73(3):330-6
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The Accuracy of Thoracic Ultrasound for Detection of Pneumothorax is not Sustained Over Time: a Preliminary Study
Dente, Christopher J; Ustin, Jeffrey; Feliciano, David V; Rozycki, Grace S; Wyrzykowski, Amy D; Nicholas, Jeffrey M; Salomone, Jeffrey P; Ingram, Walter L
Does ultrasound remain accurate in the diagnosis of pneumothorax in patients with a thorocostomy?
This study set out to examine all hospitalised patients with a thorocostomy placed to treat a traumatic pneumothorax. Each patient underwent serial daily surgeon-performed ultrasound scans. The results of these were compared with concomitant chest x-ray findings.
Results show that in the first 24 hours, ultrasound is 100% accurate in diagnosing pneumothoraces. After 24 hours, however, sensitivity fell to 55%, specificity to 70%, giving an overall accuracy of 65%.
Therefore, although initially highly accurate, this accuracy is not sustained over time, perhaps due to the formation of intrapleural adhesions.
J Trauma 2007 Jun;62(6):1384-9
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Emergency Department Staff Preparedness for Mass Casualty Events Involving Children
Michal Rassin PhD, Miri Avraham MA, Anat Nasi-Bashari MA, Sigalit Idelman BA, Yaniv Peretz BA, Shani Morag MA, Dina Silner MA, and Gali Weiss MA
Mass casualty incidents are increasingly common, often as a result of terrorism. How prepared are individuals and hospitals for incidents involving children?
This article from Israel examines preparedness for mass casualty incidents involving children – something that is already a reality in parts of Israel and could at any time occur elsewhere as a result of terrorism, natural disaster or public transportation accident.
An initial literature review highlighted both a lack of existing training programs and also lack of certainty on the part of the healthcare providers who may have to deal with these events.
Using a questionnaire, 104 physicians working at an emergency hospital in Israel were surveyed. The study found that preparedness levels for incidents involving children were low and that individuals were concerned about their ability to cope mentally and have the knowledge and skills required if the circumstances arose.
Disaster Manag Response 2007 Apr-Jun;5(2):36-44
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Pathophysiology of traumatic brain injury
C Werner and K Engelhard
A thorough understanding of the pathophysiology of traumatic brain injury is essential for adequate treatment. The target of treatment if the secondary damage which is influenced by changes in cerebral perfusion, cerebrovascular autoregulation, metabolic function and cerebral hypoxia.
This article discusses the pathophysiology of traumatic brain injury and the various mechanisms associated with secondary brain injury, including the therapeutic options on offer.
Br J Anaesth 2007 Jul;99(1):4-9
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Effects of Mannitol Bolus Administration on Intracranial Pressure, Cerebral Extracellular Metabolites, and Tissue Oxygenation in Severely Head-Injured Patients
Sakowitz, Oliver W; Stover, John F; Sarrafzadeh, Asita S; Unterberg, Andreas W; Kiening, Karl L.
Although osmotic agents are widely-used to lower elevated intracranial pressure (ICP), little is known about their cerebral effects in patients with traumatic brain injury (TBI)
The authors set out to examine whether mannitol, prescribed after TBI to lower moderately-raised ICP, improves cerebral metabolism and oxygenation.
Conclusions: at ICP of ≤30mmHg [4kPa], mannitol does not affect cerebral oxygenation, but may cause transient osmotic dehydration.
J Trauma, 2007;62(2):292-298
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Head-Injured Patients Who "Talk and Die": The San Diego Perspective
Davis, Daniel P; Kene, Mamata; Vilke, Gary M; Sise, Michael J; Kennedy, Frank; Eastman, A Brent; Velky, Thomas; Hoyt, David B
Head-injured patients who “talk and die” can potentially be salvaged. This study examines the risk factors for head injuries which deteriorate after initial presentation
Using a county trauma registry in the USA, 7443 patients with GCS 3+ and head AIS 3+ were identified over a 16 year period. Multiple factors were examined to see if they affected outcome.
Overall mortality from head injury in these patients was 6.1% with about a third of deaths occurring within 24 hours of injury and a third after day 5.
Increased mortality was associated with older age, significant mechanism of injury (fall, pedestrian vs car), increased ISS, lower GCS, use of anticoagulants and diagnosis of pulmonary embolus. Two distinct groups were noted – early deaths in young patients with critical extracranial injuries, and later deaths in older patients with less significant injuries.
Conclusion: potentially salvageable patients with head injury are more likely to have severe extracranial injuries and use anticoagulants.
J Trauma,2007;62(2):277-281
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Isolated smoke inhalation injuries: Acute respiratory dysfunction, clinical outcomes, and short-term evolution of pulmonary functions with the effects of steroids
Seung Ick Cha, Chang Ho Kim, Jae Hee Leea, Jae Yong Park, Tae Hoon Jung, Won Il Choi, Seung Bum Han, Young June Jeon, Kyeong Cheol Shin, Jin Hong Chung, Kwan Ho Lee, Yeon Jae Kim, Byeong Ki Lee
The acute manifestations and short-term progression of respiratory injuries after isolated smoke inhalation in victims of fires.
Following a subway fire, 96 patients were admitted for acute respiratory dysfunction and their progress is described.
Immediate respiratory failure was the result of ventilatory insufficiency secondary to mechanical airway obstruction, and occurred in 14%. Overall, 18% required intubation, with 5 patients developing vocal cord and tracheal stenosis.
Pulmonary function improves significantly after 3 months and steroids did not have any additional effect.
Burns, 2007;33(2):200-208
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Emergency department staff can effectively resuscitate in level C personal protective equipment
Ruwangi Udayasiri, Jonathan Knott, David McD Taylor, Jonathan Papson, Fiona Leow, Fariza A Hassan
In the current political climate, chemical, biological, radiological and nuclear incidents and terrorist attacks are a real possibility. As such, there is significant interest in how medical personnel will be able to function wearing appropriate personal protective equipment (PPE).
The authors compared staff performance in a resuscitation scenario between those wearing a gown and gloves and those wearing level C PPE.
Staff opinion was that PPE impairs IV cannulation, use of mini-jet, bag-valve mask ventilation and, perhaps most importantly, communication. However, the only objective difference between performance was time to control haemorrhage.
Conclusion: PPE can be worn and staff can adequately perform resuscitation, although previous experience of wearing and working in PPE are beneficial.
Emerg Med Australas (OnlineEarly article)
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Hypertonic Saline Resuscitation: Efficacy May Require Early Treatment in Severely Injured Patients
Hashiguchi, Naoyuki; Lum, Linda; Romeril, Elizabeth; Chen, Yu; Yip, Linda; Hoyt, David B; Junger,
Wolfgang G
Polymorphonuclear neutrophils (PMN) contribute to host tissue injury and organ damage after injury. Hypertonic saline prevents their activation in vitro and in animal models.
The authors set out to examine the clinical requirements and appropriate time of administration of hypertonic saline required to influence PMN.
26 injured patients and 16 healthy controls were treated with hypertonic saline and PMN oxidative burst and degranulation were measured using flow cytometry.
Conclusion: hypertonic saline solution may prevent PMN activation most effectively when treated pre-hospitally or very early in the treatment cycle.
J Trauma, 2007;62(2):299-306
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The Resuscitative Fluid You Choose May Potentiate Bleeding.
Brummel-Ziedins, Kathleen PhD; Whelihan, Matthew F. BS; Ziedins, Eduards G. MD; Mann, Kenneth G. PhD
A great deal of controversy exists over the methods of volume resuscitation required during haemorrhagic shock. However, little is known about how the different options affect the coagulation cascade, essential in the control of haemorrhagic shock.
A new model of whole blood was used to assess the effects of the various resuscitative formulae on blood coagulation. This was measured using thrombin generation, fibrin formation and platlet activation. The resuscitative fluids assessed were 0.9% NaCl, lactated Ringer’s solution, 6% hydroxyethyl starch and 3% NaCl. Their effects were assessed at varying blood dilutions from 0% to 75%.
The authors found that coagulation makers were significantly different according to blood dilution and according to dilutent. Ringer’s solution caused the least amount of variation in thrombin generation whilst 3% NaCl produced the most dramatic changes in all makers. No coagulation was seen between 30 and 75% dilution.
They conclude that Ringer’s solution and 0.9% NaCl have the least effect upon thrombin generation, clot formation and platelet activation, suggesting that volume expanders such as hydroxyethyl starch and 3% NaCl may be detrimental in haemorrhagic shock.
Journal of Trauma-Injury Infection & Critical Care. 61(6):1350-1358, December 2006
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Association between interval between call for ambulance and return of spontaneous circulation and survival in out-of-hospital cardiac arrest
Herlitz J, Svensson L, Engdahl J, Angquist KA, Silfverstolpe J, Holmberg S.
This paper examines the association between the time an ambulance is called and the return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest (OHCA).
Patients suffering OHCA where CPR was commenced who were included in the Swedish Cardiac Arrest Registry (SCAR) were included. Full information was available in 4847 patients.
The authors describe a very strong relationship between the interval between the call for an ambulance and ROSC and survival to one month. 47% patients survive if the time interval is less that 5 minutes, but only 5% survive if it is more than 30 minutes. Those that survive are predominantly patients having a shockable rhythm at some point during resuscitation.
Resuscitation 2006 Oct;71(1):40-6
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Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service
John Woodall, Molly McCarthy, Trisha Johnston, Vivienne Tippett and Richard Bonham
Do advanced cardiac life support-trained paramedics improve survival?
Research has previously shown little evidence in support of advanced cardiac life support (ACLS) for out-of-hospital cardiac arrest (OHCA). However, these studies have been generally based in urban environments and the poor outcome of OHCA suggests that it may be difficult to gather significant numbers of subjects.
The authors have examined the effect of ACLS on cardiac arrest in Queensland, Australia, which utilises a two-tier EMS model where advanced treatments (intubation etc) are provided by intensive care paramedics. They retrospectively analysed the effect of the presence of an intensive care paramedic on the survival to discharge of individuals suffering OHCA.
They have found that ACLS-trained paramedics provide a significant survival benefit in EMS systems which are not optimised for early defibrillation. The exact reasons for this, however, remain somewhat unclear.
EMJ 2007;24:134-138
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Prehospital rapid-sequence intubation of patients with trauma with a Glasgow Coma Score of 13 or 14 and the subsequent incidence of intracranial pathology
Daniel Y Ellis, Gareth E Davies, John Pearn and David Lockey
The authors set out to identify the proportion of trauma patients with GCS 13 or 14 who require prehosptial intubation and ventilation as a result of intracranial pathology.
A retrospective review of 81 patients found that 43 (51%) required prehospital rapid sequence intubation (RSI). Overall, 31.5% of patients GCS 13-14 had an abnormal CT head, with 20.5% having an intracranial haemorrhage.
Therefore, the incidence of intracranial pathology is approximately 1 in 3.
EMJ, 2007;24:139-141
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Trauma 10-Year Report 1995-2004.
The Trauma Department at Liverpool Hospital, a teaching hospital of the University of New South Wales in Sydney, Australia, has published an amazing report about the last ten years trauma cases with substantial statistics, times, responses, outcomes... Definitively worth reading!!!
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Accuracy of Trauma Ultrasound in Major Pelvic Injury.
Tayal, Vivek S. MD; Nielsen, Amie MD; Jones, Alan E. MD; Thomason, Michael H. MD; Kellam, James MD; Norton, H James PhD
Focused assessment with sonography in trauma (FAST) is commonly used to assess for traumatic free peritoneal fluid (FPF). However, its accuracy is unclear in patients with traumatic major pelvic injury.
The authors performed a retrospective analysis of a Level 1 trauma registry for all adult patients with pelvic fractures who had FAST scans performed during initial emergency department assessment. Results of the FAST scans were compared with one of three reference standards - abdominal / pelvic CT, diagnostic peritoneal tap or exploratory laparotomy.
Ninety seven patients were identified with a range of pelvic fractures. Then overall ultrasound sensitivity for detection of FPF was 80.8%, specificity was 86.9%. Of the true-positive results, blood was the FPF in 76% of cases and urine from bladder rupture in 19%.
This paper concludes that US investigation of free peritoneal fluid in major pelvic injury has a lower sensitivity and specificity than previously reported for blunt trauma.
Journal of Trauma-Injury Infection & Critical Care. 61(6):1453-1457, December 2006.
PubMed: http://pmid.us/17159690
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Early Predictors of Mortality in Hemodynamically Unstable Pelvis Fractures.
B Borman, L Aharonson-Daniel, B Savitsky, K Peleg the Israeli Trauma Group
Iirola TT, Laaksonen MI, Vahlberg TJ, Palve HK OBJECTIVE: The aim of the study was to assess the immediate and long-term effect of a helicopter emergency physician giving advanced life support on-scene compared with conventional load and go principle in urban and rural settings in treating blunt trauma patients. METHODS: In a retrospective study, 81 blunt trauma patients treated prehospitally by a physician-staffed helicopter emergency medical service were compared with 77 patients treated before the era of the helicopter emergency medical service. The data were collected in the prehospital and hospital files and a questionnaire was sent to the survivors 3 years after the trauma. RESULTS: The physicians treated the patients more aggressively (gave drugs, intubated and cannulated) and had the patients transported directly to a university hospital. The given treatment did not delay arrival at the hospital. No statistically significant difference was found, but a trend (P=0.065) to lower survival in the helicopter emergency medical service group. Almost half of the deaths in the helicopter emergency medical service group and none in the control group, however, occurred in the emergency department. No difference was found 3 years later between the groups in the health-related quality of life or decrease in the income owing to the accident. CONCLUSION: The physicians treated the patients more aggressively, but it did not delay the arrival at the hospital. A beneficial effect of this aggressive treatment or direct transport to a university hospital could not be seen in the immediate physiological parameters or later health-related quality of life. The physician-staffed helicopter emergency medical service was not beneficial to blunt trauma patients in this setting. Klemen P, Grmec S BACKGROUND: The role of pre-hospital trauma care and the effect of pre-hospital rapid sequence intubation (RSI) on patient outcome are still not clear. This study evaluated the impact of pre-hospital trauma care by emergency physicians (EP) on mortality from severe traumatic brain injury (TBI) and a 180-day Glasgow Outcome Scale (GOS). METHODS: A 48-month parallel non-controlled cohort study compared a group of 64 patients with severe TBI [Glasgow Coma Scale (GCS) < 9; Injury Severity Score (ISS) > 15] who received pre-hospital advanced life support (ALS) with RSI and were transported to the hospital by EPs (EP group), with a group of 60 patients who did not receive pre-hospital ALS with RSI [emergency medical technicians (EMT) group]. RESULTS: There were no significant statistical differences between the groups in age (P= 0.79), mechanism of injury (P= 0.68), gender (P= 0.82), initial GCS (P= 0.63), initial SaO(2) in the field (P= 0.63), initial systolic blood pressure in the field (P= 0.47) and on-scene time (P= 0.41). In the EP group, there was significantly better first hour survival (97% vs. 79%, P= 0.02), first day survival (90% vs. 72%, P= 0.02), better functional outcome (GOS 4-5: 53% vs. 33%, P < 0.01; GOS 2-3: 8% vs. 20%, P < 0.01) and shortened hospitalization time in intensive care unit (ICU) (P= 0.03) and other departments (P= 0.04). In total hospital mortality, we detected no differences between both groups [EP group: 40% (95% CI: 34-45%) vs. EMT group 42% (95% CI: 36-47%, P= 0.76], except in a subgroup of patients with GCS 6-8 where there was significantly lower total hospital mortality in the EP group (24% vs. 78%, P < 0.01). CONCLUSION: After starting the trauma care system with emergency physicians in our region, there was a decrease in the number of deaths on hospital admission, a reduction in hospital mortality in the GCS group 6-8, a change in the temporal distribution of deaths, an improvement in functional neurological outcome and shortened hospitalization time. Vella AE, Wang VJ, McElderry C Advanced Trauma Life Support (ATLS) is accepted as the standard for the first hours of trauma care. However, ATLS is designed primarily for adults. In children, vascular access can be difficult and time-consuming. Due to the differences in the epidemiology of children suffering traumatic injury, they may not require aggressive fluid resuscitation. The objective of the study was to establish predictors of fluid resuscitation, and to determine whether all pediatric Level I Trauma victims require two intravenous catheters. Medical charts of all patients aged < 18 years meeting Level I Trauma criteria who presented to Childrens Hospital Los Angeles (CHLA) between January 1 and December 31, 1999 were retrospectively reviewed. There were 152 patients reviewed with a median age of 6 years (range 4 months to 17 years); 64% were boys. The mechanism of injury was motor vehicle crash 49%, fall 37%, crush 8%, gunshot 5%, and knife 1%. Injuries included closed head 88%, penetrating abdomen/chest 6%, and other 6%. Vital signs over time showed no change in 59%, got better in 34%, and got worse in 7%. Fluid resuscitation included no bolus in 70%, 1 bolus in 20%, 2 boluses in 7%, > 2 boluses in 3%. The ICU admitted 23%, 12% were intubated, survival was 95%, and 59% received a prehospital i.v. The i.v. #1 site: antecubital 51%, hand 41%, foot 5%, femoral 1%. The i.v. #2 site: hand 30%, antecubital 20%, foot 2%, none 48%. T test showed no statistically significant differences in fluid resuscitation or second i.v. placement based on the mechanism of injury. T test for unequal variances showed a statistically significant difference in means with p < 0.001 for second i.v. placement as compared with only i.v. fluid amount, age, and Injury Severity Score (ISS). Revised Trauma Score was the only predictor of worsening of vital signs (logistic regression [LR], p < 0.001). Age was the only predictor of second i.v. placement (LR, p < 0.03). ISS was the only predictor of a bolus being given (LR, p < 0.01). In our study, blunt trauma occurred in 90% of children, with 10% requiring > 1 fluid bolus. ISS was the only predictor of the need for fluid resuscitation and is not likely to be helpful in the clinical setting. In our population, nearly 50% had no second i.v. This preliminary review of the nature of pediatric trauma suggests that ATLS guidelines may not always be appropriate for the management of pediatric trauma. Tsai SH, Chen WL, Yang CM, Lu LH, Chiang MF, Chi LJ, Chiu WT BACKGROUND: Patients suffering head injury in remote islands of Taiwan, which have a shortage of manpower and facilities, depend on EAMS for prompt and definitive treatment. Emergency air medical services are becoming an increasingly important issue in improving the quality of primary care and avoiding medicolegal problems. The purpose of this study was to investigate the characteristics of patients with head injury and use of EAMS. METHODS: We reviewed all patients, especially head injury transported by air ambulance from a remote island, Kinmen (400 km from Taiwan Main Island), from January 2001 to December 2003. Data were collected with regard to demographics, disease classification, mechanism of injury, severity of head injury, ventilator use, and mortality rate. RESULTS: A total of 215 patients were transferred, of whom 57 (27%) had head injury. The mean age of patients was 48.6 +/- 23.8 years. Males accounted for 72% of the cases (male/female ratio, 2.6:1). Motor-vehicle accidents were the most common mechanism of injury (68%). There were 21 (37%), 20 (35%), and 16 (28%) patients in the minor, moderate, and severe head-injury groups, respectively. Nineteen patients (33%) received mechanical ventilation. The overall mortality rate was 14 % (8/57). In the severe head-injury group, the mortality rate was 44% (7/16). CONCLUSIONS: The higher incidence of head injury (26.5%) in EAMS than in ground transportation (19.8%) suggests that preflight assessment and in-flight management of patients conducted by an experienced escort team following guidelines for head injury in EAMS are a very important issue. Soreide K, Soiland H, Lossius HM, Vetrhus M, Soreide JA, Soreide E OBJECTIVE: Resuscitative emergency thoracotomy (ET) is of value in selected (penetrating) trauma patients. Current survival-estimates and recommended guidelines are based on data from the United States. However, reports from European trauma centres are lacking. We report the current experience from a Scandinavian trauma hospital. METHODS: Identification of all consecutive ETs performed during a 5-year period. Data on demographics, and injury severity score (ISS), mechanism and location were recorded. Physiological status on admission (revised trauma score, RTS) and probability of survival (P(s)) were calculated. Signs of life (SOL) and need for closed-chest cardiopulmonary resuscitation (CC-CPR) were recorded through the post-injury phase. RESULTS: Ten patients underwent ET with no survivors. The annual incidence of ET was 0.7 per 100,000 inhabitants during the study period, with an increasing trend during the last years (r=0.74, p=0.014). ETs were performed in 0.7% of all trauma admissions, and in 2.5% of all severely injured patients (ISS>/=16). Blunt mechanism dominated; only three had penetrating injuries. Most frequent location of major injury was "multiple" (n=4) and "thoracic" (n=4). The male to female ratio was 7:3. Median age was 51 years (range 21-77). Median ISS was 34.5 (range 26-75), indicating severely injured patients, with seriously deranged physiology (median RTS of 0.0, range 0-6.1) with poor chance of survival (median P(s) of 4.4%, range 0-89.5%). Males had significantly lower RTS and P(s) (p=0.007 and 0.03, respectively) than females. Eight patients had signs of life at some time post-injury, but only four in the emergency room. Six patients had both pre- and in-hospital CC-CPR. Four patients had additional surgery to ET. Two possible preventable deaths were identified (P(s) of 51 and 89%), one in a third trimester pregnancy. CONCLUSION: Emergency thoracotomy is a rarely performed procedure in a rather busy Scandinavian trauma hospital, and outcome is dismal. Reevaluation of our decision-making process concerning the use of emergency thoracotomy is needed. How survival data and clinical experience in Europe compare to current figures from North America deserves further attention. Skaga NO, Eken T, Hestnes M, Jones JM, Steen PA. BACKGROUND: Although several changes were implemented in the 1998 update of the abbreviated injury scale (AIS 98) versus the previous AIS 90, both are still used worldwide for coding of anatomic injury in trauma. This could possibly invalidate comparisons between systems using different AIS versions. Our aim was to evaluate whether the use of different coding dictionaries affected estimation of Injury Severity Score (ISS), New Injury Severity Score (NISS) and probability of survival (Ps) according to TRISS in a hospital-based trauma registry. MATERIALS AND METHODS: In a prospective study including 1654 patients from Ulleval University Hospital, a Norwegian trauma referral centre, patients were coded according to both AIS 98 and AIS 90. Agreement between the classifications of ISS, NISS and Ps according to TRISS methodology was estimated using intraclass correlation coefficients (ICC) with 95% CI. RESULTS: ISS changed for 378 of 1654 patients analysed (22.9%). One hundred and forty seven (8.9%) were coded differently due to different injury descriptions and 369 patients (22.3%) had a change in ISS value in one or more regions due to the different scoring algorithm for skin injuries introduced in AIS 98. This gave a minimal change in mean ISS (14.74 versus 14.54). An ICC value of 0.997 (95% CI 0.9968-0.9974) for ISS indicates excellent agreement between the scoring systems. There were no significant changes in NISS and Ps. CONCLUSIONS: There was excellent agreement for the overall population between ISS, NISS and Ps values obtained using AIS 90 and AIS 98 for injury coding. Injury descriptions for hypothermia were re-introduced in the recently published AIS 2005. We support this change as coding differences due to hypothermia were encountered in 4.3% of patients in the present study. Knobloch K, Hubrich V, Rohmann P, Lupkemann M, Gerich T, Krettek C, Phillips R BACKGROUND: Cardiac output (CO) and systemic vascular resistance (SVR) are important hemodynamic parameters in emergency patients and for clinical early goal-directed therapy. This study evaluated the feasibility of CO and SVR determination using preclinical continuous wave Doppler ultrasound in a helicopter emergency medical service (HEMS) on emergency patients presenting with or without thoracic pain as a pilot observational study. METHODS: Forty-four consecutive medical emergency patients (62.8 +/- 22 years of age, 23 males) were classified at the scene as with (15 patients, 69 +/- 14 years of age, 40% male) or without (29 patients, 60 +/- 25 years of age, 59% male) thoracic pain by an emergency physician. Hemodynamic parameters were determined based on continuous wave Doppler noninvasively (USCOM, Sydney, Australia): stroke volume (SV), CO, cardiac index (CI), minute distance (MD), and SVR. RESULTS: Noninvasive SV, MD, CO, CI, and SVR determination is feasible using preclinical ultrasound in HEMS. Thoracic pain patients had higher SVR (2,709 +/- 891 vs 1,499 +/- 661 dyne*sec*cm-5) and lower CO/CI (3.37 +/- 1.1 vs 5.06 +/- 2.9 L/min, CI: 1.67 +/- 0.58 vs 3.18 +/- 1.34 L/min/m2) as well as a reduced aortic minute distance (11.2 +/- 3.3 m/min vs 19.1 +/- 8 m/min, P = .001) than patients without thoracic pain. Highest cardiac outputs were measured during and within 30 minutes after seizures (n = 5, 7.5 +/- 3.05 L/min). The range of CO measured in six cardiopulmonary resuscitation patients was 2.7 to 12 L/min; the level of CO was not associated with the establishing of sustained circulation. CONCLUSIONS: Determining SV, CO/CI, and SVR in different emergency situations in HEMS using rapid CW Doppler ultrasound is feasible. Thoracic pain patients have increased SVR and lower CO/CI and reduced aortic minute distance than do non-thoracic pain patients in the preclinical setting. Fries M, Beckers S, Bickenbach J, Skorning M, Krug S, Nilson E, Rossaint R, Kuhlen R BACKGROUND: Emergency medical service (EMS) systems in Europe have developed differently due to legal, educational and organisational aspects. The aim of the present study was to compare cardiopulmonary resuscitation (CPR) outcomes and characteristics in three differently organised and staffed EMS systems in close vicinity. METHODS: We analysed the charts of patients treated in the EMS systems of the cities of Aachen (Germany), Heerlen (The Netherlands) and Eupen (Belgium), retrospectively. Main outcome measures were the rate of return of spontaneous circulation (ROSC), hospital discharge and cerebral performance after 1 year. Furthermore, factors influencing neurological outcome and the incidence of cross-border emergency assistance were assessed. RESULTS: Of 852 patients found unresponsive with no palpable pulse and/or the absence of breathing, CPR was performed in 322 patients. The overall rate of ROSC was 44.1 and 13.7% of patients were discharged alive. A good neurological outcome was observed in 95.5% of survivors. The rate of ventricular fibrillation was significantly higher (46.9% versus 21.9 and 21.2%, p<0.05) and the total amount of epinephrine given during CPR significantly lower (4.5+/-5.2mg versus 9.8+/-10.8 and 8.4+/-6.2mg, p<0.05) in the Dutch system. No significant differences in outcome variables were observed between the systems. Neurological outcome was favourable when the arrest was witnessed, occurred in a public place, the initial rhythm was shockable, a low total amount of adrenaline (epinephrine) was given and the call-response interval was short. In 1.2% of the cases cross-border emergency care was provided. CONCLUSIONS: Despite medical and organisational discrepancies, outcomes of CPR in three neighbouring EMS systems are comparable. Neurological outcome is influenced by demographical, organisational and medical factors. Cross-border emergency assistance for CPR is almost undetectable and needs improvement. Busch M, Soreide E, Lossius HM, Lexow K, Dickstein K BACKGROUND: The implementation of therapeutic hypothermia (TH) into daily clinical practice appears to be slow. We present our experiences with rapid implementation of a simple protocol for TH in comatose out-of-hospital cardiac arrest (OHCA) survivors. METHODS: From June 2002, we started cooling pre-hospitally with sport ice packs in the groin and over the neck. In the intensive care unit (ICU), we used ice-water soaked towels over the torso. All patients were endotracheally intubated, on mechanical ventilation and sedated and paralysed. The target temperature was 33 +/- 1 degrees C to be maintained for 12-24 h. We used simple inclusion criteria: (i) no response to verbal command during the ambulance transport independent of initial rhythm and cause of CA; (ii) age 18-80 years; and (iii) absence of cardiogenic shock (SBP < 90 mmHg despite vasopressors). We compared the first 27 comatose survivors with a presumed cardiac origin of their OHCA with 34 historic controls treated just before implementation. Results: TH was initiated in all 27 eligible patients. The target temperature was reached in 24 patients (89% success rate). ICU- and hospital- length of stay did not differ significantly before and after implementation of TH. Hypokalemia (P= 0.001) and insulin resistance (P= 0.025) were more common and seizures (P= 0.01) less frequently reported with the use of TH. The implementation of TH was associated with a higher hospital survival rate (16/27; 59% vs. 11/34; 32%, respectively; P</= 0.05). Our results indicate a population-based need of approximately seven cooling patients per 100,000 person-years served. CONCLUSION: Our simple, external cooling protocol can be implemented overnight in any system already treating post-resuscitation patients. It was well accepted, feasible and safe, but not optimal in terms of cooling rate. Neither safety concerns nor costs should be a barrier for implementation of TH. Axelsson C, Nestin J, Svensson L, Axelsson AB, Herlitz J AIM: To evaluate the outcome among patients suffering from out-of-hospital cardiac arrest (OHCA) after the introduction of mechanical chest compression (MCC) compared with standard cardiopulmonary resuscitation (SCPR) in two emergency medical service (EMS) systems. METHODS: The inclusion criterion was witnessed OHCA. The exclusion criteria were age < 18 years, the following judged etiologies behind OHCA: trauma, pregnancy, hypothermia, intoxication, hanging and drowning or return of spontaneous circulation (ROSC) prior to the arrival of the advanced life support (ALS) unit. Two MCC devices were allocated during six-month periods between four ALS units for a period of two years (cluster randomisation). RESULTS: In all, 328 patients fulfilled the criteria for participation and 159 were allocated to the MCC tier (the device was used in 66% of cases) and 169 to the SCPR tier. In the MCC tier, 51% had ROSC (primary end-point) versus 51% in the SCPR tier. The corresponding values for hospital admission alive (secondary end-point) were 38% and 37% (NS). In the subset of patients in whom the device was used, the percentage who had ROSC was 49% versus 50% in a control group matched for age, initial rhythm, aetiology, bystander-/crew-witnessed status and delay to CPR. The percentage of patients discharged alive from hospital after OHCA was 8% versus 10% (NS) for all patients and 2% versus 4%, respectively (NS) for the patients in the subset (where the device was used and the matched control population). CONCLUSION: In this pilot study, the results did not support the hypothesis that the introduction of mechanical chest compression in OHCA improves outcome. However, there is room for further improvement in the use of the device. The hypothesis that this will improve outcome needs to be tested in further prospective trials. Hubble MW, Richards ME INTRODUCTION: Colleges and universities are experiencing increasing demand for online courses in many healthcare disciplines, including emergency medical services (EMS). Development and implementation of online paramedic courses with the quality of education experienced in the traditional classroom setting is essential in order to maintain the integrity of the educational process. Currently, there is conflicting evidence of whether a significant difference exists in student performance between online and traditional nursing and allied health courses. However, there are no published investigations of the effectiveness of online learning by paramedic students. HYPOTHESIS: Performance of paramedic students enrolled in an online, undergraduate, research methods course is equivalent to the performance of students enrolled in the same course provided in a traditional, classroom environment. METHODS: Academic performance, learning styles, and course satisfaction surveys were compared between two groups of students. The course content was identical for both courses and taught by the same instructor during the same semester. The primary difference between the traditional course and the online course was the method of lecture delivery. Lectures for the on-campus students were provided live in a traditional classroom setting using PowerPoint slides. Lectures for the online students were provided using the same PowerPoint slides with prerecorded streaming audio and video. RESULTS: A convenience sample of 23 online and 10 traditional students participated in this study. With the exception of two learning domains, the two groups of students exhibited similar learning styles as assessed using the Grasha-Riechmann Student Learning Style Scales instrument. The online students scored significantly lower in the competitive and dependent dimensions than did the on-campus students. Academic performance was similar between the two groups. The online students devoted slightly more time to the course than did the campus students, although this difference did not reach statistical significance. In general, the online students believed the online audio lectures were more effective than the traditional live lectures. CONCLUSION: Distance learning technology appears to be an effective mechanism for extending didactic paramedic education off-campus, and may be beneficial particularly to areas that lack paramedic training programs or adequate numbers of qualified instructors. Aneman A, Parr M BACKGROUND: A high incidence of preventable adverse events and deaths in hospitals has triggered initiatives to improve the quality of care of acutely ill in-hospital patients. System changes involving the introduction of medical emergency teams, outreach services or rapid response teams are an integral part of these initiatives. The rationale for implementing a designated team is that early recognition and rapid institution of adequate therapy for the deteriorating patient can improve outcome. The concept of bringing intensive care expertise to any acutely ill patient irrespective of location within the hospital is envisioned as "critical care without walls". METHODS: Studies were identified by a PubMed search and cited references in key publications provided additional material including www-resources. More than 80 studies were identified and selected for review, however, no formal search strategy for a systematic review or meta-analysis was attempted. Only studies published in English were considered. CONCLUSION: Several key operational issues need to be addressed before introducing medical emergency response teams based on current evidence. These issues include differences in healthcare systems and performance, patient case-mix, resources available, composition of the teams and calling criteria, and strategies for education, audit and governance. Gellerstedt M, Bang A, Herlitz J OBJECTIVES: To evaluate whether a computer-based decision support system could be useful for the emergency medical system when identifying patients with acute myocardial infarction (AMI) or life-threatening conditions and thereby improve the allocation of life support level. METHODS: Patients in the Municipality of Goteborg who dialled the dispatch centre due to chest pain during a period of 3 months. To analyse the relationship between patient characteristics (according to a case record form used during an interview) and the response variables (AMI or life-threatening condition), multivariate logistic regression was used. For each patient, the probability of AMI/life-threatening condition was estimated by the model. We used these probabilities retrospectively to allocate advanced life support or basic life support. This model allocation was then compared with the true allocation made by the dispatchers. RESULTS: The sensitivity, that is, the percentage of AMI patients allocated to advanced life support, was 85.7% in relation to the true allocation made by the dispatchers. The corresponding sensitivity regarding allocation made by the model was 92.4% (P=0.17). The specificity was also slightly higher for the model allocation than the dispatcher allocation. Among the 15 patients with AMI who were allocated to basic life support by the dispatchers, nine died (eight during and one after hospitalization). Among the eight patients with AMI allocated to basic life support by the model, only one patient died (in hospital) (P=0.02). CONCLUSION: A computer-based decision support system including a prevalence function could be a valuable tool for allocating the level of life support. The case record form, however, used for the interview can be refined and a model based on a larger sample and confirmed in a prospective study is recommended. Part 1: Clinical guidelines and evidence base P J Shirley and S Hearns Emergency Medicine Journal 2006;23:937-942 (Part1)
Chest compressions with the LUCAS device during experimental cardiopulmonary resuscitation resulted in higher cerebral blood flow and cardiac output than standard manual external chest compressions. Resuscitation. 2005 Jun;65(3):357-63. This study compares the use of the laryngeal tube, tracheal This site from The Emergency Department of Manchester Royal Infirmary, UK, provides rapid evidence-based answers to real-life clinical questions. This site has lots of systematic reviews of current litterature in various topics - most regarding emergency medicine. Does prehospital endotracheal intubation for trauma improve survival over bag-valve-mask ventilation. Emergency rapid sequence intubation performed outside the operating room on emergency patients is the cornerstone of emergency airway management. Intubating teams comprised anaesthetists, non-anaesthetists, or both. There were no significant differences in complication rates between these groups. The likelihood of immediate complications depends on the patient's underlying condition, and relevant diagnoses should be emphasised in airway management training. New England Journal of Medicine: Training and equipping volunteers to attempt early defibrillation with AEDs can increase the number of survivors. Saline versus albumin fluid evaluation (SAFE) trial of nearly 7000 critically ill patients showed that 28 day mortality for patients randomised to albumin was 20.9%, whereas mortality in the saline arm was 21.1%. Referanser: N Engl J Med 2004 ; 350 : 2247-2256 This study called the San Diego RSI determine the incidence of desaturation and pulse rate reactivity during paramedic rapid sequence intubation of patients with severe head injuries (GCS 8). Lesson of the week from BMJ. 3 case reports and a discussion. Test your knowledge with hundreds of surgical Multiple Choice Questions from the Royal College of Surgeons of England Refresh your X-ray knowledge Read the newest European guidelines for neonate lifesupport 1-year survival of 56% in Chicago airports, when AED's are placed in public In this Australia study, patients with traumatic brain injury and hypotension had similar outcomes whether they received prehospital hypertonic saline or Ringer's lactate. The surgeons say: YES Experiences with prehospital thrombolysis 1992 to 1999 in Finmark Fylke Normal ECG and Troponin I rule out blunt cardiac injury The use of 1.0 mg/kg of succinylcholine may be excessive Peter Safar died on August 3, 2003. He was the father of modern cardiopulmonary resuscitation methods, a great scientist, teacher, mentor and friend What are the pros and cons of doctor-manned helicopters and ground-ambulances. Read report from Fyn county in Denmark This study followed patients who underwent rapid defibrillation after out-of-hospital cardiac arrest with ventricular fibrillation. The five-year survival rate and quality of life were registered. The authors are members of the international medical aid organisation Médecins Sans Frontières (MSF). From World Anaesthesia Online This cohort study assesses the association between cardiac troponin T concentration and the severity of pulmonary embolism and its potential in predicting mortality. Six had fulminant pulmonary embolism, in 37 it was massive, in 62 it was submassive, and in one it was minor. Troponin T concentrations increased with the severity of PE. The median troponin T concentration in patients with signs of right ventricular strain in the electrocardiogram was 0.03 ng/ml and in patients without these signs <0.01 ng/ml. A cut-off value for troponin of 0.09 ng/ml was a suitable predictor for death in hospital. At a cutoff value of 0.09 ng/mL, troponin T concentration predicted in-hospital death with a negative predictive value of 0.99, and positive predictive value of 0.34. Over the last 10 years 82 ambulance occupants and 275 pedestrians/occupants of other vehicles died in ambulance-related crash injuries in the U.S. Does the decline in the incidence of out-of-hospital VF represent a decline in coronary heart disease mortality? How good are you ?? Read more in this study about the normal and abnormal ECG in the hypothermic patient In more than nine percent of patients with spinal cord injury, the diagnosis were missed for a varying period of time Two articles are opening for the idea of using noradrenaline for the treatment of septic shock even though this has been banned for years Few investigations have elucidated the acute inflammatory response after accidental trauma before the patients were anesthetized and treated with analgetics and intravenous fluid. This Danish study takes a closer look The European Medicines Evaluation Agency (EMEA) has temporarily approved Alteplase for treatment of stroke in the period 2003-2005. Of 15 189 arrests, 12 004 (79.0%) occurred in sites not suitable for the location of public access defibrillators. BMJ, 2002 Read about pros and cons of volume resuscitation in this article by proff. Mattox, Texas, USA on www.trauma.org Can pulse oximetry be used by general and pediatric emergency physicians as a discharge thresholds for well-appearing children with bronchiolitis and pneumonia Is the ratio of 5/1 is better than 15/2 ? The discussion has just begun.... Dr. Charles D. Deakin, MA MD MB BChir MRCP FRCA , er «Consultant Anaesthetist» ved Southampton General Hospital i England. Videre er han Honarary Anaesthetist ved den verdensberømte Helicopter Emergency Medical Service lokalisert i London.
Annals of emergency medicine
A Norwegian study: Plasma substitutes such as hydroxyethyl starch (HES) and various dextrans may compromise the haemostatic system, thereby causing potentially dangerous bleeding. Dying patterns, and cause and preventability of deaths in a major earthquake disaster New England Journal of Medicine: Training and equipping volunteers to attempt early defibrillation with AEDs can increase the number of survivors. Experiences from the London EMS. Early morning-lecture on Friday 9th.
Smith, Wade; Williams, Allison, Agudelo Juan; Shannon, Michael; Morgan, Steven; Stahel, Phillip; Moore, Ernest
The authors set out to retrospectively analyse data in order to identify early indicators of mortality and causes of death in haemodynamically unstable patients with pelvic fractures.
Data was gathered from a Level 1 trauma centre for 187 patients. Two groups were compared - those who died and those who did not. The statistically significant predictors of death were ISS, RTS, age >60 and requirement for blood transfusion. RTS was found to be the most reliable predictor of outcome. Death within 24h of pelvic fracture is most often due to acute blood loss, whilst death after 24h is most often due to multiorgan failure.
Pubmed:
Not yet referenced
J Orthop Trauma, 2007;21(1):31-37
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Waiting for the Patient to "Sober Up": Effect of Alcohol Intoxication on Glasgow Coma Scale Score of Brain Injured Patients.
Sperry, Jason L. MD; Gentilello, Larry M. MD; Minei, Joseph P. MD; Diaz-Arrastia, Ramon R. MD, PhD; Friese, Randall S. MD; Shafi, Shahid MD, MPH
Alcohol can have a significant effect upon Glascow Coma Score (GCS), meaning that it often cannot be used effectively to assess the severity of the injury. Up to 50% of traumatic brain injury (TBI) patients have consumed alcohol.
The authors undertook a retrospective analysis of a Level 1 trauma registry over a 10 year period. Patients suffering traumatic brain injury were divided into two groups – intoxicated and non-intoxicated – based upon blood alcohol levels. TBI was classified according to ICD-10 into concussion alone or intracranial injury and severity was further categorised using the Abbreviated Injury Scale. Mean GCS was compared between the two groups and those who were intubated or hypotensive on arrival were analysed separately to exclude confounding factors.
Alcohol intoxication had little effect on GCS, with less than 1 point difference at all levels of TBI. Results were not influenced by intubation, hypotension or severe intoxication.
Journal of Trauma-Injury Infection & Critical Care. 61(6):1305-1311, December 2006.
Pubmed:
http://pmid.us/17159670
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Unilateral flail chest is seldom a lethal injury
Thoracic trauma is relatively common. Although flail chest is relatively rare, it has a high reported associated morbidity and mortality.
This group set out to examine the factors linked to mortality when flail chest was diagnosed in a trauma patient. To do this, they examined all patients recorded in the Israel National Trauma Registry between 1998 and 2003 with flail chest injuries and looked at what influenced mortality.
The most common mechanism of injury leading to flail chest was road traffic accidents (76%). Overall mortality was 20.6% (54 of 262) with 68.5% of these occurring within the first 24hours. Mortality in moderate-to-severe injuries (ISS 9-24) was found to be 3.6% compared with 28.5% in critical injuries (ISS >24). Interestingly, unilateral flail chest without other injury, had just a 6% mortality rate.
They concluded that increasing age and extra-thoracic concurrent traumatic injuries were associated with higher mortality, whilst unilateral flail chest had a low mortality.
Emergency Medicine Journal 2006; 23: 903-905
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Latest publications in trauma, resuscitation and emergency medicine selected by editor-in-chief Hans Morten Lossius
Effect of physician-staffed helicopter emergency medical service on blunt trauma patient survival and prehospital care
Eur J Emerg Med 2006; 13: 335-339
Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury
Acta Anaesthesiol Scand 2006; 50: 1250-1254
Predictors of fluid resuscitation in pediatric trauma patients
J Emerg Med 2006; 31: 151-155.
Emergency air medical services for patients with head injury
Surg Neurol 2006; 66S2: S32-S36.
Resuscitative emergency thoracotomy in a Scandinavian trauma hospital-Is it justified?
Injury 2006; in press
Scoring of anatomic injury after trauma: AIS 98 versus AIS 90-do the changes affect overall severity assessment?
Injury 2006; in press
Feasibility of preclinical cardiac output and systemic vascular resistance in HEMS in thoracic pain-the ultrasonic cardiac output monitor
Air Med J 2006; 25: 270-275
Incidence of cross-border emergency care and outcomes of cardiopulmonary resuscitation in a unique European region
Resuscitation 2006; in press
Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors
Acta Anaesthesiol Scand 2006; 50: 1277-1283.
Clinical consequences of the introduction of mechanical chest compression in the EMS system for treatment of out-of-hospital cardiac arrest-a pilot study.
Resuscitation 2006; 71: 47-55
Paramedic student performance: comparison of online with on-campus lecture delivery methods
Prehospital Disaster Med 2006; 21: 261-267.
Medical emergency teams: a role for expanding intensive care?
Acta Anaesthesiol Scand 2006; 50: 1255-1265.
cal emergency teams and equivalents can reduce the incidence of cardiac arrests, unexpected deaths, and unplanned intensive care admissions. However, one recent randomized, controlled trial of medical emergency teams failed to demonstrate any differences in outcomes.
Could a computer-based system including a prevalence function support emergency medical systems and improve the allocation of life support level?
Eur J Emerg Med 2006; 13: 290-294.
www.euro-emergencymed.com
Retrieval medicine: a review and guide for UK practitioners
Part 2: Safety in patient retrieval systems
This two-part paper examines the principles of ‘retrieval medicine’ as practised in many parts of the world, including Australia and Scandinavia, and uses these well-organised services to propose a structure for a similar service in the United Kingdom.
Currently, there is no regional or national strategy to deal with medical retrieval, despite a constant requirement for such. Although there are distinct differences between ‘pre-hospital care’ and ‘retrieval medicine’, the authors draw comparisons and propose that those involved the former would be ideally skilled to assist in the latter.
All aspects of retrieval medicine are examined, including equipment, personal safety, clinical governance, communications and operating procedures.
This is an interesting paper proposing the methods and structure required in the UK to set up such a retrieval service and provides an insight into the concepts of retrieval medicine around the world.
Emergency Medicine Journal 2006;23:943-947 (Part2)
Increased cortical cerebral blood flow with LUCAS
Ventricular fibrillation was induced in 14 anaesthetized pigs. One group received external chest compressions using a new mechanical device, LUCAS. The other group received standard manual external chest compressions.
During CPR, the cortical cerebral blood flow was significantly higher in the group treated with LUCAS. End-tidal CO2, was significantly higher in the group treated with the LUCAS device.
Chest compressions with the LUCAS device during experimental cardiopulmonary resuscitation resulted in higher cerebral blood flow and cardiac output than standard manual external chest compressions.
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Airway management in cardiac arrest
intubation and bag-valve mask ventilation in emergency medical training
Endotracheal intubation (ETI) ETI requires skills which are difficult to maintain especially if practised infrequently.
To compare the initiation and success of ventilation with the LT, ETI and bag-valve mask (BVM) in a cardiac arrest scenario, 60 fire-fighter emergency medical technician (EMT) students were tested in the use of all 3 devices.
The group found that teams using the LT were able to initiate ventilation
more rapidly than those performing ETI. The LT and ETI
provided equal minute volumes of ventilation, which was significantly higher
than that delivered with the BVM.
The data suggest that the LT may enable airway control more rapidly and as effectively as the ETI, and compared to BVM, may provide better minute ventilation when used by inexperienced personnel.
Ref.: Resuscitation. 2004 May;61(2):149-53
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Best BETs
Best Evidense Topics
Physicians need rapid access to the best current evidence on a wide range of clinical topics.
BETs were developed in the Emergency Department of Manchester Royal Infirmary, UK, to provide rapid evidence-based answers to real-life clinical questions, using a systematic approach to reviewing the literature.
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Prehospital intubation?
This study by Stockinger and McSwain from New Orleans including 5,773 patients concludes, that prehospital endotracheal intubation gives no advantages in terms of survival for trauma patients.
When corrected for Injury Severity Score, Revised Trauma Score, and mechanism of injury, ETI was associated with similar or greater mortality than BVM. ETI patients had longer prehospital times (22.0 vs. 20.1 minutes, p = 0.0241). When corrected for mechanism and severity of anatomic and physiologic injury, ETI confers no survival advantage over BVM and slightly increases prehospital time.
Ref: J Trauma. 2004 Mar;56(3):531-6
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Rapid sequence intubation: The who, where, and what
Emergency rapid sequence intubation (RSI) performed outside the operating room on emergency patients is the cornerstone of emergency airway management. This study conducted by Reid, Chan and Tweeddale includes 208 patients undergoing RSI. All patients were successfully intubated.
Complication rates are comparable between anaesthetists and non-anaesthetists.
Referanser: Emerg Med J. 2004 May;21(3):296-301
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Public-access defibrillation
This prospective, multicenter trial in which participants were randomly assigned to perform either CPR alone or to perform CPR and use AEDs were conducted in 993 community units in North America. No inappropriate shocks were delivered. There were more survivors to hospital discharge in the units assigned to have volunteers trained in CPR plus the use of AEDs (30 survivors among 128 arrests) than there were in the units assigned to have volunteers trained only in CPR. Training and equipping volunteers to attempt early defibrillation can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest. Trained laypersons can use AEDs safely and effectively.
Referanser: N Engl J Med 2004; 351: 37-46
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Albumin vs Saline
No difference exists in 28 day mortality between patients who are resuscitated with albumin and those given saline. This is the finding of a large randomised trial of fluid resuscitation in critically ill patients.
In addition to providing evidence that colloids and crystalloids were equally effective, the study also debunked another myth: the 3:1 ratio.
It had previously been universally accepted that it took three times as much crystalloid volume to resuscitate a patient. But, according to BMJ, Dr Finfer said that the actual ratio was only 1.38 litres of saline to one litre of albumin. "On average, the patients in the study received an average of 1200 ml albumin a day and 1600 ml saline [a day] during the initial four days," he reported.
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Hypoxia and pulse rate reactivity during paramedic rapid sequence intubation
Hypotension and hypoxia have been linked to poor outcomes in head-injury patients. Complete data were available for 54 of 102 patients. 57% of the patients desaturated during RSI. The median duration of desaturation was 160 seconds and the median decrease in oxygen saturation was 22%. These findings cannot be generalized into other services but clarifies that this is an area of treatment, that needs further investigations and debate.
Ann Emerg Med. 2003 Dec;42(6):721-8.
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Bradycardia in acute haemorrhage
Patients with acute haemorrhage may not show the expected initial tachycardic response. Clinicians should consider a diagnosis of acute haemorrhage for patients with hypotension and a normal or low heart rate after surgery.
BMJ 2004;328:451-453 (21 February)
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Surgical MCQ's
This page contains a selection of clinical and basic science multiple choice questions covering all areas of surgical practice. Each question has the answer immediately available with internal links to appropriate revision notes or tutorials.
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X-ray gallery
This site has more than 50 X-rays collected in 12 galleries. Each gallery contains a series of x-rays with accompanying teaching notes and links to related tutorials and revision notes.
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Neonate lifesupport
Useful skills for anyone dealing with emergency medicine!!!
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AED use by bystanders
A prospective observational study in Chicago airports. 50 AED's were placed in the public areas, and rescue personnel were alerted when the AED's were in use.
During a 2-year period, 18 people (1 in 10,000,000) had witnessed cardiac arrest with VF.
1-year survival (with good neurological outcome) was 56% in overall, and 67% in all that were defibrillated within 5 min. The cost per life-year saved was estimated to $7000.
N Engl J Med 2002 Oct 17;347 : 142-7
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Hypertonic saline vs Ringers lactate
A comparison of for fluid resuscitation in the intensive care unit;
Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R; SAFE Study Investigators.
ANZICS CTG, Level 3, 10 Ievers St., Carlton, VIC 3053, Australia.
E-mail:
ctg@anzics.com.au
BACKGROUND: It remains uncertain whether the choice of resuscitation fluid for patients in intensive care units (ICUs) affects survival. We conducted a multicenter, randomized, double-blind trial to compare the effect of fluid resuscitation with albumin or saline on mortality in a heterogeneous population of patients in the ICU. METHODS: We randomly assigned patients who had been admitted to the ICU to receive either 4 percent albumin or normal saline for intravascular-fluid resuscitation during the next 28 days. The primary outcome measure was death from any cause during the 28-day period after randomization. RESULTS: Of the 6997 patients who underwent randomization, 3497 were assigned to receive albumin and 3500 to receive saline; the two groups had similar baseline characteristics. There were 726 deaths in the albumin group, as compared with 729 deaths in the saline group (relative risk of death, 0.99; 95 percent confidence interval, 0.91 to 1.09; P=0.87). The proportion of patients with new single-organ and multiple-organ failure was similar in the two groups (P=0.85). There were no significant differences between the groups in the mean (+/-SD) numbers of days spent in the ICU (6.5+/-6.6 in the albumin group and 6.2+/-6.2 in the saline group, P=0.44), days spent in the hospital (15.3+/-9.6 and 15.6+/-9.6, respectively; P=0.30), days of mechanical ventilation (4.5+/-6.1 and 4.3+/-5.7, respectively; P=0.74), or days of renal-replacement therapy (0.5+/-2.3 and 0.4+/-2.0, respectively; P=0.41). CONCLUSIONS: In patients in the ICU, use of either 4 percent albumin or normal saline for fluid resuscitation results in similar outcomes at 28 days. Copyright 2004 Massachusetts Medical Society
PMID: 15163774 [PubMed - in process]
Referanser: N Engl J Med. 2004 May 27;350(22):2247-56
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Morphine for abdominal pain
In a prospective, randomized, double-blind study, hemodynamically stable patient (adults) received either morphine (up to 15 mg) or placebo (mean painscore on VAS scale =7.4). Diagnostic accuracy were not affected by the pain relief.
J Am Coll Surg 2003 Jan; 196:18-31
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Prehospital thrombolysis in northern Norway
This retrospective study by Bredmose et el. reports the experience with prehospital thrombolysis in acute myocardial infarction in northern Norway. A total of 272 patients with cardiac-related diagnoses; 91 were considered to have an acute myocardial infarction. 23 patients were thrombolysed by the rescue anaesthesiologist and four by general practitioners.
58 had contraindications, mainly the duration of chest pain being greater than 6 h.
Twelve of the 23 patients experienced hypotension and arrhythmia after the administration of streptokinase. Prehospital thrombolysis was feasible.
The public should be urged further to make early contact in cases of chest pain.
Eur J Emerg Med. 2003 Sep;10(3):176-9
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Blunt cardiac injury
A single center study that rules out, whether ECG and Troponin I can predict blunt cardiac injury.
Multible rib fractures, pulmonary contusion, hemopneumothorax, sternal fracture, anterior thorasic seatbelt injuries are all injuries that can lead to blunt cardiac injury.
By recording ECG and Troponin I at arrival and 8 hours after admission the risk of blunt cardiac injury can be ruled out, with positive and negative predictive values of 34% and 100%.
J trauma 2003 Jan; 54:45-51
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Optimal Dose of Succinylcholine
The authors reappraised the conventional wisdom that the intubating dose of succinylcholine must be 1.0 mg/kg and attempted to define the lower range of succinylcholine doses that provide acceptable intubation conditions in 95% of patients within 60 s.
Comparable intubating conditions were achieved after 0.3, 0.5, or 1.0 mg/kg succinylcholine. In a rapid-sequence induction, 95% of patients with normal airway anatomy anesthetized with 2 ì g/kg fentanyl and 2 mg/kg propofol should have acceptable intubating conditions at 60 s after 0.56 mg/kg succinylcholine.
Anesthesiology. 2003 Nov;99(5):1045-9
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In memory
On behalf of his many Norwegian friends, collaborators, students, and admirers we would like to extend our deeply felt sorrow and condolences to Peter Safar's family and to his many colleagues in The Safar Resuscitation Research Center in Pittsburgh, Pennsylvania, USA.
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Helicopter vs Ground-ambulance
This report from the Fyn county in Denmark compares the costs and benefits of ground-ambulances (7 mio. Danish krones per year) and helicopters (18 mio. Danish krones per year).
A very thorough report made of Danich specialist in the field of emergency medicine as well as health economi.
Language: Danish
No translations available.
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Good long-term outcome for survivors after rapid defibrillation of out-of-hospital cardiac arrest
The study included 200 patients who received early defibrillation for out-of-hospital ventricular fibrillation in Olmsted County, Minnesota. 145 patients (72 %) survived to hospital admission, 7 died in the emergency department and 9 died after discharge. 79 Patients (40 %) were neurologically intact at discharge.
The survival rate and quality of life were compared with age-, sex-, and disease-matched population. The five-year survival rate was identical to that among age-, sex-,and disease-matched patients who had not had out-of-hospital cardiac arrest. The quality of life among the majority of survivors was similar to that of the general population.
Long-term outcome studies are of great value. This study strengthens the evidence that early defibrillation is worthwhile, and stresses the importance of early-defibrillation program implementation.
New England Journal of Medicine,Vol 348:2626-2633
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Intraosseous Infusion
Intraosseous infusion is one of the quickest ways to establish access for the rapid infusion of fluids, drugs and blood products in emergency situations as well as for resuscitation.
This articles gives an update on the technique.
Key Points
- Intraosseous infusion is a temporary emergency measure
- Indicated in life-threatening situations when intravenous access fails (3 attempts or >90 seconds)
- Use the anteromedial aspect of the tibia
- Insert pointing caudal to avoid the epiphyseal growth plate
- Use an aseptic technique
- Crystalloids, colloids, blood products and drugs can be infused
- Remove as soon as the child has been resuscitated and intravenous access has been established
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Troponin T a predictor of severity in pulmonary embolism?
136 patients with confirmed pulmonary embolism (PE) by computed tomography or scintigraphy were included in the study. The severity of PE was graded by the grading system by Grosser.
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Ambulance transport is not a negligible risk for pedestrians
The National Highway Traffic Safety Administration (NHTSA) Fatality Analysis Reporting System (FARS) reported in the period 1991-2002 that 275 pedestrians and 82 ambulance occupants died in ambulance-related crash injuries in the U.S. Of the 82 ambulance occupants who died 27 persons were on-duty EMS workers. Fifteen (56%) of the EMS workers who died were unrestrained.
The report does not tell anything about the total number of ambulance transports during this period (which most be many millions). But the results stresses that ambulance transport is a potentially risk for EMS workers, patients and especially pedestrians. Ambulance speeding should only be done when necessary.
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Changing Incidence of Out-of-Hospital Ventricular Fibrillation
Recent reports from 2 European cities and an earlier observation from Seattle, Wash, suggest that the number of patients treated for out-of-hospital ventricular fibrillation (VF) has declined. The adjusted annual incidence of cardiac arrest with VF as the first identified rhythm decreased by about 56% from 1980 to 2000.
JAMA. 2002;288:3008-3013.
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ECG in Hypothermia
Hypothermia is known to adversely affect the electrocardiogram (ECG) in many
cases. This study set out to determine the incidence of defined cardiac
dysrhythmias through a multicenter study.
Wilderness Environ Med 2001 Winter;12(4):232-5
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Missed injuries of the cervical spine
Medical records were evaluated for 569 patients with neurologic deficits
secondary to traumatic spinal cord injury. 9.1 % of the diagnosis (52 instances)
were missed out on the initial evaluation of the patient. 34 patients were
mismanaged.
Most of the injuries were at level C3 to C6.
J Trauma 2002 Aug;53(2):314-20
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Noradrenaline for septic shock??
Noradrenaline has been considered deleterious because of its vasoconstrictive
effects and dopamine has been the pressor of choice.
One study (by Martin et al), which includes 97 adult patients in septic shock (prospective, non-randomized, observational design) concludes that noradrenaline may potentiate end-organ perfusion.
Another study by Reinhart et al takes gives an overview of various drugs used for the treatment of septic shock, from volume resuscitation, cathecholamines, phosphodiesterase inhibitors, prostacyclines and N-acetyl cystein.
He concludes that no negative effects has been seen with the use of noradrenaline and challenges the use of dobutamine.
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The systemic inflammatory response after major trauma
Clinical Aspects of Prehospital Tube Thoracostomy
Dr. Charles D. Deakin, MA MD MB BChir MRCP FRCA , er «Consultant Anaesthetist» ved Southampton General Hospital i England. Videre er han Honarary Anaesthetist ved den verdensberømte Helicopter Emergency Medical Service lokalisert i London.
Annual European deaths from road traffic accidents now been in excess of 50,000 for most of the past decade (1). Of these deaths, about half occur before the patient reaches hospital. Historically, pre-hospital deaths were viewed as an inevitable result of the primary injury, but several studies have shown that a significant proportion of these deaths maybe related to poor prehospital diagnosis and treatment.
The systemic inflammatory response after major trauma.
Ugeskr Læger 2003;165: 669-72.
Few investigations have elucidated the acute inflammatory response after accidental trauma before the patients were anesthetized and treated with analgetics and intravenous fluid. The cellular immunological response seems to be characterized by an initial activation followed by suppression.
In major tissue trauma, the granulocytes are the major effector cells. Activated granulocytes are redistributed from the peripheral blood into the tissues, where release of proteolytic enzymes and oxygen-free radicals participate in the development of systemic inflammation and organ dysfunction.
High concentrations of proinflammatory and antiinflammatory cytokines can be measured locally in the injured tissue.
Abstract is not yet available
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IV fibrinolytic therapy approved for treatment of Stroke patients in the EU
EMEA has made stroke an indication for thrombolysis. It is obligate for centres
using this therapy to enter the Internet based monitoring study SITS-MOST under
the period 2003-2005. After this period EMEA will decide if stroke thrombolysis
will be definitively approved.
Three monts after EU approval the first patient was included in SITS-MOST.
Intracranial haemorrhage has to be excluded by CT scan and treatment initiated before 3 hours of symptom onset.
For more information visit the website http://www.acutestroke.org/
Will fibrinolytic therapy be the future treatment of acute stroke patients ? If this is so the whole "stroke chain of recovery" has to be changed. This indeed includes the prehospital care. North America has several years experience of this treatment, read about the prehospital aspects:
Emergency Medicine Clinics of North America Nov; 20(4):877-86
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Public access defibrillators
This study from the Scottish Ambulance Service includes 15 189 cardiac
arrests.
What is already known on this topic
Three quarters of all deaths from acute coronary events occur before the patient reaches a hospital
Defibrillation is an independent predictor of survival from out of hospital cardiac arrest
The probability of a rhythm being amenable to defibrillation declines with time
Interest in providing public access defibrillators to reduce the time to defibrillation has been growing, but their potential impact on overall survival is unknown
What this study adds
Most arrests occur in sites unsuitable for locating public access defibrillators
Arrests that occur in sites suitable for locating defibrillators already have the best profile in terms of ambulance response time, use of defibrillation, and survival of the patient
Public access defibrillators are less likely to increase survival than expansion of first responder defibrillation or bystander cardiopulmonary resuscitation
BMJ 2002 Sep 7;325(7363):515
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Volume resuscitation - an overview
The question of volume resuscitation or not is still not solved....
This overview made by Professor Kenneth L Mattox from Houston, Texax, USA is probably one of the best ones. Gives a comprehensive insight into this complex question.
A must read.....
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Pulse oximetry in discharge decision-making
Young children present to emergency departments every day with respiratory
illnesses, and emergency physicians must decide whether or not to hospitalize
them. One data point used in this decision-making process is the pulse oximeter
reading.
Although many factors enter into the decision to hospitalize a young child, as a general principle, hypoxic children should be hospitalized and others may be considered for discharge.
This article take up the discussion whether or not we can use the ulse oximeter in the Emergency Room.
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Quality of cardiac massage
How do we perform the best cardiac massage ??
This study questions whether the ratio of 5/1 is better than the ratio of 15/2.
Better management of cardiac arrest suggested by an increase in a number of compressions with a ratio of 15/2 could be attenuated by cardiac compressions of lesser quality.
The discussion has just begun...
Resuscitation 2002 Dec;55(3):263-7
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Clinical Aspects of Prehospital Tube Thoracostomy
Annual European deaths from road traffic accidents now been in excess of 50,000 for most of the past decade (1). Of these deaths, about half occur before the patient reaches hospital. Historically, pre-hospital deaths were viewed as an inevitable result of the primary injury, but several studies have shown that a significant proportion of these deaths maybe related to poor prehospital diagnosis and treatment.
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Should family be present during resuscitation in the emergency department?
We are used not to have the families present during resuscitation. The articles discusses this very controversal issue.
The literature indicates that family benefit from being present during
resuscitation. But there are many aspects in this discussion.
Ann Emerg Med 2002 Aug;40(2):193-205
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Prehospital advanced life support (ALS) provided by specially trained physicians
Is there a benefit of the use of prehospitally trained doctors?
This study takes a closer look.........
The benefit of prehospital advanced life support by an anesthesiologist is
evaluated in Scandinavian settings with a modified Delphi technique. For every 14th patient treated life years are gained.
Acta Anaesthesiol Scand 2002 Aug;46(7):771-8
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Bleeding after crystalloid infusions
A Danish group has now shown that coagulopathy induced by haemodilution with either HES 200/0.5, HES 130/0.4, and dextran 70 may be improved by fibrinogen supplementation
Br J Anaesth. 2004 Dec 17
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Kobe earthquake in Japan
The authors reviewed autopsy data in the Kobe earthquake of 1995.
The authors analyzed 5,411 fatalities. More than 80% of these patients died within three hours.
Thirteen percent of victims experienced a protracted death, which could have been prevented with earlier medical or surgical intervention.
Survival analysis revealed a significant population of potentially salvageable patients if more timely and appropriate medical intervention had been available immediately after the earthquake.
Prehosp Emerg Care. 2004 Apr-Jun;8(2):217-22.
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Public-access defibrillation
This prospective, multicenter trial in which participants were randomly assigned
to perform either CPR alone or to perform CPR and use AEDs were conducted in 993
community units in North America.
No inappropriate shocks were delivered. There were more survivors to hospital discharge in the units assigned to have volunteers trained in CPR plus the use of AEDs (30 survivors among 128 arrests) than there were in the units assigned to have volunteers trained only in CPR
Training and equipping volunteers to attempt early defibrillation can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest.
Trained laypersons can use AEDs safely and effectively.
Referanser: N Engl J Med 2004; 351: 37-46
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The London Bombings 7 July
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