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Life Support (life + support)
Kinds of Life Support Selected AbstractsPALS PEDIATRIC ADVANCED LIFE SUPPORTJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 6 2006Peter Barnett Dr No abstract is available for this article. [source] Emergency weight estimation in Pacific Island and Maori children who are large-for-ageEMERGENCY MEDICINE AUSTRALASIA, Issue 3 2005Lynn Theron Abstract Objective:, Methods to estimate weights of children requiring resuscitation appeared to underestimate the weight of Pacific Island and Maori children. This study sought to quantify differences between real and estimated weights, study links with ethnicity and derive a new estimation method for large-for-age children. Method:, Data were collected prospectively for 3 months. Weights were estimated by formulae described by Shann, Leffler, the Advanced Paediatric Life Support (APLS) formula, the Oakley resuscitation chart and the Broselow tape. Results:, Of the 909 children included, 46% were of Pacific Island and 25% were of Maori origin. Differences between actual and estimated weights were significantly greater (P < 0.05) for the Pacific Island group using all methods of estimation. Maori differences were significantly greater than European differences using Oakley and Broselow methods (P < 0.05). The Broselow tape was the method most likely to underestimate weight in Pacific Island and Maori children. A new formula was derived from non-linear regression analysis, leading to a new chart. Conclusion:, Current emergency methods underestimate weight in Pacific Island and Maori children. We recommend a new chart for these children. [source] Competencies and skills for remote and rural maternity care: a review of the literatureJOURNAL OF ADVANCED NURSING, Issue 2 2007Jillian Ireland Abstract Title. Competencies and skills for remote and rural maternity care: a review of the literature Aim., This paper reports a review of the literature on skills, competencies and continuing professional development necessary for sustainable remote and rural maternity care. Background., There is a general sense that maternity care providers in rural areas need specific skills and competencies. However, how these differ from generic skills and competencies is often unclear. Methods., Approaches used to access the research studies included a comprehensive search in relevant electronic databases using relevant keywords (e.g. ,remote', ,midwifery', ,obstetrics', ,nurse,midwives', education', ,hospitals', ,skills', ,competencies', etc.). Experts were approached for (un-)published literature, and books and journals known to the authors were also used. Key journals were hand searched and references were followed up. The original search was conducted in 2004 and updated in 2006. Findings., Little published literature exists on professional education, training or continuous professional development in maternity care in remote and rural settings. Although we found a large literature on competency, little was specific to competencies for rural practice or for maternity care. ,Hands-on' skills courses such as Advanced Life Support in Obstetrics and the Neonatal Resuscitation Programme increase confidence in practice, but no published evidence of effectiveness of such courses exists. Conclusion., Educators need to be aware of the barriers facing rural practitioners, and there is potential for increasing distant learning facilitated by videoconferencing or Internet access. They should also consider other assessment methods than portfolios. More research is needed on the levels of skills and competencies required for maternity care professionals practising in remote and rural areas. [source] Comparison of Perfusion Quality in Hollow-Fiber Membrane Oxygenators for Neonatal Extracorporeal Life SupportARTIFICIAL ORGANS, Issue 4 2010Jonathan Talor Abstract Perfusion quality is an important issue in extracorporeal life support (ECLS); without adequate perfusion of the brain and other vital organs, multiorgan dysfunction and other deficits can result. The authors tested three different pediatric oxygenators (Medos Hilite 800 LT, Medtronic Minimax Plus, and Capiox Baby RX) to determine which gives the highest quality of perfusion at flow rates of 400, 600, and 800 mL/min using human blood (36°C, 40% hematocrit) under both nonpulsatile and pulsatile flow conditions. Clinically identical equipment and a pseudo-patient were used to mimic operating conditions during neonatal ECLS. Traditionally, the postoxygenator surplus hemodynamic energy value (SHEpost, extra energy obtained through pulsatile flow) is the one relied upon to give a qualitative determination of the amount of perfusion in the patient; the authors also examined SHE retention through the membrane, as well as the contribution of SHEpost to the postoxygenator total hemodynamic energy (THEpost). At each experimental condition, pulsatile flow outperformed nonpulsatile flow for all factors contributing to perfusion quality: the SHEpost values for pulsatile flow were 4.6,7.6 times greater than for nonpulsatile flow, while the THEpost remained nearly constant for pulsatile versus nonpulsatile flow. For both pulsatile and nonpulsatile flow, the Capiox Baby RX oxygenator was found to deliver the highest quality of perfusion, while the Minimax Plus oxygenator delivered the least perfusion. It is the authors' recommendation that the Baby RX oxygenator running under pulsatile flow conditions be used for pediatric ECLS, but further studies need to be done in order to establish its effectiveness beyond the FDA-approved time span. [source] Extracorporeal Life Support as Ultimate Strategy for Refractory Severe Cardiogenic Shock Induced by Tako-tsubo Cardiomyopathy: A New Effective Therapeutic OptionARTIFICIAL ORGANS, Issue 10 2009Massimo Bonacchi Abstract We report a possible new therapeutic strategy, using extracorporeal cardiopulmonary support (ECLS), for severe refractory cardiogenic shock (SRCS) in a patient with Tako-tsubo cardiomyopathy (TC). TC is a syndrome characterized by left ventricular wall motion abnormalities, without coronary artery disease, mimicking the diagnosis of acute coronary syndrome. This ventricular dysfunction can be reversible; however, it can progress into refractory cardiogenic shock with limited therapeutic options available. For the first time in a Tako-tsubo patient with refractory cardiogenic shock, we used ECLS treatment in order to rest the heart, sustain circulation and end-organ perfusion, and promote potential ventricular recovery. ECLS might be the selected treatment for SRCS in patients with TC, and seems to be an effective and useful ultimate therapeutic strategy for preventing death. [source] Extracorporeal Life Support: A Simple and Effective Weapon for Postcardiotomy Right Ventricular FailureARTIFICIAL ORGANS, Issue 7 2009Kuo-Sheng Liu Abstract Postcardiotomy right ventricular (RV) failure develops during the perioperative period following pulmonary hypertensive crisis or acute myocardial infarction. This study reports our institutional experience in treating these patients with extracorporeal life support (ECLS). Between June 2002 and July 2005, 46 adults were treated with ECLS for postcardiotomy shock. Acute RV failure was the cause of support in 14 (30%). Patient mean age was 55.7 ± 15.4 years. Cardiac pathologies were valvular (n = 7), coronary (n = 1), combined coronary and valvular disease (n = 2), complex congenital heart (n = 2), aortic aneurysm (n = 1), and cardiomyopathy post heart transplant (n = 1). The triggers of RV failure were pulmonary hypertension (n = 6), RV infarction (n = 4), and not defined (n = 4). Patients were supported on ECLS for a mean duration of 71 ± 52 h (range, 10,183 h). Major complications included acute renal failure requiring hemodialysis (n = 4), reexploration for bleeding (n = 2), and acute subdural hematoma (n = 1). Nine (64%) patients were successfully weaned from ECLS, and seven (50%) survived to discharge. Preexisting pulmonary hypertension had a favorable tendency for weaning, and acute renal failure requiring hemodialysis correlated with in-hospital mortality. ECLS is beneficial for treating postcardiotomy RV failure when conventional therapy is exhausted. As it can be deployed rapidly and does not require resternotomy for weaning, ECLS could be regarded as the first choice of mechanical support for postcardiotomy RV failure. [source] Venous Pressure Regulation During Pulsatile Extracorporeal Life SupportARTIFICIAL ORGANS, Issue 10 2008Seong Wook Choi Abstract During the use of pulsatile extracorporeal life support (pulsatile-ECLS), the patient's venous pressure near the inlet venous catheter tip must be monitored to maintain sufficient blood flow and to prevent vein collapse. However, direct measurement of the venous pressure and the estimate of suction using measured blood inflow and prepump pressure are not practical because of setup difficulties during emergency treatments and in cardiovascular operations. In this article, we describe a new method for estimating the venous pressure that can be implemented in the controller of the pulsatile-ECLS system, the T-PLS. It uses real-time measurement of the electric current and actuator motion. The current waveform of the T-PLS is used to determine the outflow amount and the volume remaining in the pulsatile pumps. Previously measured values of the pulsatile-ECLS compliance and the hemodynamic resistance along the inflow path are used to evaluate venous pressure with estimated blood flow. Estimated prepump pressure, inflow, and venous pressure were compared to the measured data in a series of in vitro experiments. The estimated venous pressure was used to avoid vein collapse and to increase the reliability in animal experiments. [source] An In Vitro and In Vivo Study of the Detection and Reversal of Venous Collapse During Extracorporeal Life SupportARTIFICIAL ORGANS, Issue 2 2007Antoine P. Simons Abstract:, The objective of this study was to investigate venous collapse (VC) related to venous drainage during the use of an extracorporeal life support circuit. A mock circulation was built containing a centrifugal pump and a collapsible vena cava model to simulate VC under controlled conditions. Animal experiments were performed for in vivo verification. Changing pump speed had a different impact on flow during a collapsed and a distended caval vein in both models. Flow measurement in combination with pump speed interventions allows for the detection and quantitative assessment of the degree of VC. Additionally, it was verified that a quick reversal of a VC situation could be achieved by a two-step pump speed intervention, which also proved to be more effective than a straightforward decrease in pump speed. [source] Ethics Seminars: Withdrawal of Treatment in the Emergency Department,When and How?ACADEMIC EMERGENCY MEDICINE, Issue 12 2006Kelly Bookman MD Abstract Although increasing discussion has occurred within emergency medicine about indications for withholding cardiac life support and other resuscitative interventions, emergency physicians (EPs) may be less familiar with the ethical, legal, and practical issues surrounding withdrawal of life support that has already been initiated. Both physicians and out-of-hospital personnel must act rapidly in critical situations and must assume that the patient has the desire to be resuscitated, unless clear evidence exists to the contrary. Often, only after initial life-saving actions have stabilized the patient is there time to reflect and determine a patient's desires regarding such interventions. When the EP can clearly discern a patient's previously stated wishes during the emergency department (ED) stay, these wishes should be honored in the ED. Respecting a patient's request to avoid unwanted, invasive treatments near death may involve withdrawing interventions that could not be withheld during the first few minutes of care. In this article, the authors use a case of out-of-hospital stabilization of a patient as a springboard to review the ethical and legal framework for withdrawal of life-sustaining care, as well as the practical issues involved with withdrawal of such care in the ED. [source] Comparison of Outcomes of Two Skills-teaching Methods on Lay-rescuers' Acquisition of Infant Basic Life Support SkillsACADEMIC EMERGENCY MEDICINE, Issue 9 2010Itai Shavit MD ACADEMIC EMERGENCY MEDICINE 2010; 17:979,986 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, The objective was to determine if lay-rescuers' acquisition of infant basic life support (BLS) skills would be better when skills teaching consisted of videotaping practice and providing feedback on performances, compared to conventional skills-teaching and feedback methods. Methods:, This pilot-exploratory, single-blind, prospective, controlled, randomized study was conducted on November 12, 2007, at the Rappaport Faculty of Medicine, Technion,Israel Institute of Technology, Haifa, Israel. The population under study consisted of all first-year medical students enrolled in the 2007,2008 year. BLS training is part of their mandatory introductory course in emergency medicine. Twenty-three students with previous BLS training were excluded. The remaining 71 were randomized into four and then two groups, with final allocation to an intervention and control group of 18 and 16 students, respectively. All the students participated in infant BLS classroom teaching. Those in the intervention group practiced skills acquisition independently, and four were videotaped while practicing. Tapes were reviewed by the group and feedback was provided. Controls practiced using conventional teaching and feedback methods. After 3 hours, all subjects were videotaped performing an unassisted, lone-rescuer, infant BLS resuscitation scenario. A skills assessment tool was developed. It consisted of 25 checklist items, grouped into four sections: 6 points for "categories" (with specific actions in six categories), 14 points for "scoring" (of accuracy of performance of each action), 4 points for "sequence" (of actions within a category), and 1 point for "order" of resuscitation (complete and well-sequenced categories). Two blinded expert raters were given a workshop on the use of the scoring tool. They further refined it to increase scoring consistency. The main outcome of the study was defined as evidence of better skills acquisition in overall skills in the four sections and in the specific skills sets for actions in any individual category. Data analysis consisted of descriptive statistics. Results:, Means and mean percentages were greater in the intervention group in all four sections compared to controls: categories (5.72 [95.33%] and 4.69 [92.66%]), scoring (10.57 [75.50%] and 7.41 [43.59%]), sequence (2.28 [57.00%] and 1.66 [41.50%]), and order of resuscitation (0.96 [96.00%] and 0.19 [19.00%]). The means and mean percentages of the actions (skill sets) in the intervention group were also larger than those of controls in five out of six categories: assessing responsiveness (1.69 [84.50%] and 1.13 [56.50%]), breathing technique (1.69 [93.00%] and 1.13 [47.20%]), chest compression technique (3.19 [77.50%] and 1.84 [46.00%]), activating emergency medical services (EMS) (3.00 [100.00%] and 2.81 [84.50%]), and resuming cardiopulmonary resuscitation (0.97 [97.00%] and 0.47 [47.00%]). These results demonstrate better performance in the intervention group. Conclusions:, The use of videotaped practice and feedback for the acquisition of overall infant BLS skills and of specific skill sets is effective. Observation and participation in the feedback and assessment of nonexperts attempting infant BLS skills appeared to improve the ability of this group of students to perform the task. [source] Matching Response to Context in Complex Political Emergencies: ,Relief', ,Development', ,Peace-building' or Something In-between?DISASTERS, Issue 4 2000Philip White There is an ongoing debate over the value and pitfalls of the policy and practice of ,linking relief and development' or ,developmental relief' in aid responses to complex political emergencies (CPEs). Driven by concerns about relief creating dependence, sometimes doing harm and failing to address root causes of emergencies despite its high cost, pursuit of both relief and development has become a dominant paradigm among international aid agencies in CPEs as in ,natural' disasters. In CPEs a third objective of ,peace-building' has emerged, along with the logic that development can itself help prevent or resolve conflict and sustain peace. However, this broadening of relief objectives in ongoing CPEs has recently been criticised on a number of counts, central concerns being that it leads to a dilution of commitment to core humanitarian principles and is overly optimistic. This paper addresses these issues in the light of two of the CPEs studied by the COPE project: Eritrea and Somalia/Somaliland. It is argued that the debate has so far suffered from lack of clarity about what we mean by ,relief', ,development' and, for that matter, ,rehabilitation' and ,peace-building'. The wide spectrum of possible aid outcomes does not divide neatly into these categories. The relief,development divide is not always as clear-cut, technically or politically, as the critics claim. Moreover such distinctions, constructed from the point of view of aid programmers, are often of little relevance to the concerns of intended beneficiaries. Second, there has been insufficient attention to context: rather than attempting to generalise within and across CPE cases, a more productive approach would be to examine more closely the conditions under which forms of aid other than basic life support can fruitfully be pursued. This leads to consideration of collective agency capacity to respond effectively to diverse needs in different and changing circumstances. [source] Evaluating the Impact of an Educational Intervention on Documentation of Decision-making Capacity in an Emergency Medical Services SystemACADEMIC EMERGENCY MEDICINE, Issue 7 2004Jennifer Riley MD Abstract Objectives: To compare the documentation of decision-making capacity by advanced life support (ALS) providers and signature acquisition before, one month after, and one year after an educational intervention. Methods:The intervention comprised a one-and-a-half-hour module on assessment and documentation of decision-making capacity. Ambulance call reports were reviewed for all ALS calls occurring during three two-month periods, and refusals of transport were recorded. Provider compliance with documentation of decision-making capacity and signature acquisition were determined from a convenience sample of 75 reports from each period. Reviewers were blinded to study period. Twenty-percent double data entry was undertaken to evaluate accuracy. Ninety-five percent confidence intervals were calculated to compare frequencies of cancelled calls and documentation. Results: From the emergency medical services database, 7,744 calls before the intervention, 7,444 immediately after, and 7,604 one year later were identified. Documentation rates in the second and third periods did not differ from that prior to the intervention (1.3% vs. 0.0% and 0.0% in subsequent periods), nor did the rates of signature acquisition differ (85.3% vs. 85.3% and 78.6%). The accuracy of data entry was 92.6%. However, the frequency of call refusals decreased significantly after the intervention (from 9.0% to 2.0% and 6.6% in the respective periods). Conclusions: An educational intervention resulted in no change in the rate of decision-making capacity documentation or signature acquisition by ALS providers for refusal of transport. There was a temporary increase in the number of transported patients. [source] Can e-learning improve medical students' knowledge and competence in paediatric cardiopulmonary resuscitation?EMERGENCY MEDICINE AUSTRALASIA, Issue 4 2010A prospective before, after study Abstract Objective: To determine whether the use of an e-learning package was able to improve the knowledge and competence of medical students, in a simulated paediatric resuscitation. Methods: A prospective before and after study was performed with medical students at the Children's Hospital at Westmead, Australia. Participants undertook a simulated paediatric resuscitation before and after completing the e-learning. Primary outcome measures were the ability to perform successful basic life support and advanced life support according to published guidelines. Secondary outcome measures were the individual steps in performing the overall resuscitation, the change in pre- and post-e-learning multiple choice question scores and subjective feedback from participants. Results: A total of 28 students were enrolled in the study, with 26 being retested. There was an improvement of 57.7% from 30.8% to 88.5% (P < 0.001, 95% CI 34.9,80.5%) in basic life support competence and an improvement from 0% to 80.0% (P < 0.001, 95% CI 61.8,99.8%) in advanced life support competence. Significant improvements were seen in all secondary outcomes particularly time to rhythm recognition and time to first defibrillation (P < 0.001). Multiple choice question test scores showed a significant improvement of 27.8% or 6.4 marks (95% CI 5.3,7.5, P < 0.001). Conclusion: E-learning does improve both the knowledge and competence of medical students in paediatric cardiopulmonary resuscitation at least in the simulation environment. [source] Out-of-hospital Care of Critical Drug Overdoses Involving Cardiac ArrestACADEMIC EMERGENCY MEDICINE, Issue 1 2004Valentine L. Paredes MD Objectives: Death from acute drug poisoning, also termed drug overdose, is a substantial public health problem. Little is known regarding the role of emergency medical services (EMS) in critical drug poisonings. This study investigates the involvement and potential mortality benefit of EMS for critical drug poisonings, characterized by cardiovascular collapse requiring cardiopulmonary resuscitation (CPR). Methods: The study population was composed of death events caused by acute drug poisoning, defined as poisoning deaths and deaths averted (persons successfully resuscitated from out-of-hospital cardiac arrest by EMS) in King County, Washington, during the year 2000. Results: Eleven persons were successfully resuscitated and 234 persons died from cardiac arrest caused by acute drug poisoning, for a total of 245 cardiac events. The EMS responded to 79.6% (195/245), attempted resuscitation in 34.7% (85/245), and successfully resuscitated 4.5% (11/245) of all events. Among the 85 persons for whom EMS attempted resuscitation, opioids, cocaine, and alcohol were the predominant drugs involved, although over half involved multiple drug classes. Among the 11 persons successfully resuscitated, return of circulation was achieved in six following EMS cardiopulmonary resuscitation alone, in one following CPR and defibrillation, and in the remaining four after additional advanced life support. Conclusions: In this community, EMS was involved in the majority of acute drug poisonings characterized by cardiovascular collapse and may potentially lower total mortality by approximately 4.5%. The results show that, in some survivors, return of spontaneous circulation may be achieved with CPR alone, suggesting a different pathophysiology in drug poisoning compared with cardiac arrest due to heart disease. [source] The Accuracy of Predicting Cardiac Arrest by Emergency Medical Services Dispatchers: The Calling Party EffectACADEMIC EMERGENCY MEDICINE, Issue 9 2003Alex G. Garza MD Abstract Objectives: To analyze the accuracy of paramedic emergency medical services (EMS) dispatchers in predicting cardiac arrest and to assess the effect of the caller party on dispatcher accuracy in an advanced life support, public utility model EMS system, with greater than 90,000 calls and greater than 60,000 transports per year. Methods: This was a retrospective analysis from January 1, 2000, through June 30, 2000, of 911 calls with dispatcher-assigned presumptive patient condition (PPC) or field diagnosis of cardiac arrest. Sensitivity and positive predictive value (PPV) of the PPC code for cardiac arrest by calling parties were calculated. Homogeneity of sensitivity and PPV of the PPC code for cardiac arrest by calling parties was studied with chi-square analysis. Relevant proportions, relative risk ratios, and associated 95% confidence intervals (95% CIs) were calculated. Student's t-test was used to compare quality assurance scores between calling parties. Results: There were 506 patients included in the study. Overall sensitivity for dispatcher-assigned PPC of cardiac arrest was 68.3% (95% CI = 63.3% to 73.0%) with a PPV of 65.0% (95% CI = 60.0% to 69.7%). There was a significant difference in the PPV for the EMS dispatcher diagnosis of cardiac arrest depending on the type of caller (,2= 17.34, p < 0.001). Conclusions: A higher level of medical training may improve dispatch accuracy for predicting cardiac arrest. The type of calling party influenced the PPV of dispatcher-assigned condition. [source] Can First Responders Be Sent to Selected 9-1-1 Emergency Medical Services Calls without an Ambulance?ACADEMIC EMERGENCY MEDICINE, Issue 4 2003Craig B. Key MD Objectives: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). Methods: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. Results: For ALERTs (n= 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n= 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. Conclusions: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents. [source] Amiodarone Attenuates Fluoride-induced Hyperkalemia in VitroACADEMIC EMERGENCY MEDICINE, Issue 2 2003Mark Su MD Abstract Poisoning by hydrofluoric acid or fluoride salts results in hypocalcemia, hypomagnesemia, and hyperkalemia with subsequent cardiac dysrhythmias. In previous studies, quinidine attenuated fluoride-induced hyperkalemia in vitro, and enhanced survival in animals. Like quinidine, amiodarone is a potassium channel blocker, although amiodarone is more familiar to clinicians due to its recent inclusion in advanced cardiac life support (ACLS) protocols. Objectives: This in-vitro study of human erythrocytes was designed to determine whether amiodarone could attenuate fluoride-induced hyperkalemia. Methods: Six healthy volunteers each donated 60 mL of blood on three occasions. Each specimen was divided into 12 tubes, incubated at 37°C, and oxygenated with room air. An aqueous sodium fluoride (F,) solution was added to tubes 1,9. Incremental amounts of quinidine were added to tubes 1,4 (Q1,Q4) to attain calculated concentrations of 0.73 ,g/mL, 1.45 ,g/mL, 2.9 ,g/mL, and 5.8 ,g/mL, respectively. Incremental amounts of amiodarone were added to tubes 5,8 (A1,A4) to attain calculated concentrations of 0.38 ,g/mL, 0.75 ,g/mL, 1.5 ,g/mL, and 3.0 ,g/mL, respectively. Tubes 9,12 were controls for each of F,, amiodarone, quinidine alone, and no additive, respectively. Extracellular potassium concentration ([K+]) was followed, and an objective endpoint was defined as the rise in potassium concentration at 6 hours. Results: Fluoride produced a significant change in [K+] by 6 hours in all samples. Quinidine produced a J-shaped curve in its ability to attenuate the rise in [K+], with only one concentration, Q3, demonstrating significance versus tube 9 (control). Amiodarone also demonstrated a J-shaped dose,response effect, with statistical significance at A1, A2, and A3 versus tube 9 (control). There was no significant difference among the effective concentrations (Q3, A1, A2, and A3) of both drugs. Conclusions: In this in-vitro model using human blood, amiodarone and quinidine both attenuated F, -induced hyperkalemia. Further study is indicated to determine whether amiodarone enhances survival in F, -poisoned animals. [source] On the Future of Reanimatology,ACADEMIC EMERGENCY MEDICINE, Issue 1 2000Peter Safar MD Abstract: This article is adapted from a presentation given at the 1999 SAEM annual meeting by Dr. Peter Safar. Dr. Safar has been involved in resuscitation research for 44 years, and is a distinguished professor and past initiating chairman of the Department of Anesthesiology and Critical Care Medicine at the University of Pittsburgh. He is the founder and director of the Safar Center for Resuscitation Research at the University of Pittsburgh, and has been the research mentor of many critical care and emergency medicine research fellows. Here he presents a brief history of past accomplishments, recent findings, and future potentials for resuscitation research. Additional advances in resuscitation, from acute terminal states and clinical death, will build upon the lessons learned from the history of reanimatology, including optimal delivery by emergency medical services of already documented cardiopulmonary cerebral resuscitation, basic-advanced,prolonged life support, and future scientific breakthroughs. Current controversies, such as how to best educate the public in life-supporting first aid, how to restore normotensive spontaneous circulation after cardiac arrest, how to rapidly induce mild hypothermia for cerebral protection, and how to minimize secondary insult after cerebral ischemia, are discussed, and must be resolved if advances are to be made. Dr. Safar also summarizes future technologies already under preliminary investigation, such as ultra-advanced life support for reversing prolonged cardiac arrest, extending the "golden hour" of shock tolerance, and suspended animation for delayed resuscitation. [source] Out-of-hospital Cardiac Arrest in Denver, Colorado: Epidemiology and OutcomesACADEMIC EMERGENCY MEDICINE, Issue 4 2010Jason S. Haukoos MD Abstract Objectives:, The annual incidence of out-of-hospital cardiac arrest (OOHCA) in the United States is approximately 6 per 10,000 population and survival remains low. Relatively little is known about the performance characteristics of a two-tiered emergency medical services (EMS) system split between fire-based basic life support (BLS) dispersed from fixed locations and hospital-based advanced life support (ALS) dispersed from nonfixed locations. The objectives of this study were to describe the incidence of OOHCA in Denver, Colorado, and to define the prevalence of survival with good neurologic function in the context of this particular EMS system. Methods:, This was a retrospective cohort study using standardized abstraction methodology. A two-tiered hospital-based EMS system for the County of Denver and 10 receiving hospitals were studied. Consecutive adult patients who experienced nontraumatic OOHCA from January 1, 2003, through December 31, 2004, were enrolled. Demographic, prehospital arrest characteristics, treatment data, and survival data using the Utstein template were collected. Good neurologic survival was defined by a Cerebral Performance Categories (CPC) score of 1 or 2. Results:, During the study period, 1,985 arrests occurred. Of these, 715 (36%) had attempted resuscitation by paramedics and constitute our study sample. The median age was 65 years (interquartile range = 52,78 years), 69% were male, 41% had witnessed arrest, 25% had bystander cardiopulmonary resuscitation (CPR) performed, and 30% had ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as their initial rhythm. Of the 715 patients, 545 (76%) were transported to a hospital, 223 (31%) had return of spontaneous circulation (ROSC), 175 (25%) survived to hospital admission, 58 (8%) survived to hospital discharge, and 42 (6%, 95% confidence interval [CI] = 4% to 8%) had a good neurologic outcome. Conclusions:, Out-of-hospital cardiac arrest survival in Denver, Colorado, is similar to that of other United States communities. This finding provides the basis for future epidemiologic and health services research in the out-of-hospital and ED settings in our community. ACADEMIC EMERGENCY MEDICINE,2010; 17:391,398 © 2010 by the Society for Academic Emergency Medicine [source] Extramedullary granulocytic sarcoma of the skin, mediastinum, and pericardiumINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 3 2008Mohammad Diab MD A 27-year-old man, with a past history of developmental delay, presented on 18 November 2005 for the evaluation of an acute onset of multiple red,violaceous nodules on the head, neck, and trunk of 5 days' duration. The patient had no associated fever, chills, weight loss, night sweats, chest pain, dyspnea, lymphadenopathy, or organomegaly. He had no previous history of malignancies. A biopsy indicated a diagnosis of leukemia cutis (Fig. 1). His initial complete blood count (CBC) was within normal limits. The 2-week follow-up revealed enlargement of the previous lesions and the development of new lesions (Fig. 2). By the third week, the patient had developed dyspnea, but with normal breath sounds and oxygen saturation. Chest computed tomography demonstrated a mediastinal mass measuring 16 × 5.2 cm and pericardial thickening (Fig. 3). The diagnosis of granulocytic sarcoma of the skin lesion and mediastinal mass was established on the basis of immunohistochemical stains, with positivity to CD43 and Leder's preparation and negativity to CD3, CD4, CD5, CD8, CD10, CD20, CD23, CD30, CD34, CD56, bcl-1, terminal deoxynucleotidyl transferase (TdT), and granzyme. The bone marrow was negative for malignant cells. CBC and chemistry panel were all normal. Nevertheless, the patient experienced increased dyspnea and developed a pericardial effusion which required a pericardial window. Cytology of the pericardial fluid was consistent with granulocytic sarcoma. Once the diagnosis of granulocytic sarcoma was established, the patient started a regimen of cytarabine, daunorubicin, and etoposide. Despite this, the skin lesions and mediastinal mass showed minimal response. Repeat computed tomography showed a mediastinal mass measuring 14.5 × 4.4 cm. The patient's respiratory status required intubation and, 2 weeks later, his family requested that he be withdrawn from life support. Figure 1. Immature myelocytic infiltrate in the dermis (hematoxylin and eosin, ×4) Figure 2. Clinical image of granulocytic sarcoma Figure 3. Computed tomography of the chest illustrating mediastinal pericardial involvement [source] Cardiocerebral Resuscitation Is Associated With Improved Survival and Neurologic Outcome from Out-of-hospital Cardiac Arrest in EldersACADEMIC EMERGENCY MEDICINE, Issue 3 2010Jarrod Mosier MD Abstract Background:, Recent studies have shown that a new emergency medical services (EMS) protocol for treating patients who suffer out-of-hospital cardiac arrest (OHCA), cardiocerebral resuscitation (CCR), significantly improves survival compared to standard advanced life support (ALS). However, due to their different physiology, it is unclear if all elders, or any subsets of elders who are OHCA victims, would benefit from the CCR protocol. Objectives:, The objectives of this analysis were to compare survival by age group for patients receiving CCR and ALS, to evaluate their neurologic outcome, and to determine what other factors affect survival in the subset of patients who do receive CCR. Methods:, An analysis was performed of 3,515 OHCAs occurring between January 2005 and September 2008 in the Save Hearts in Arizona Registry. A total of 1,024 of these patients received CCR. Pediatric patients and arrests due to drowning, respiratory, or traumatic causes were excluded. The registry included data from 62 EMS agencies, some of which instituted CCR. Outcome measures included survival to hospital discharge and cerebral performance category (CPC) scores. Logistic regression evaluated outcomes in patients who received CCR versus standard ALS across age groups, adjusted for known potential confounders, including bystander cardiopulmonary resuscitation (CPR), witnessed arrest, EMS dispatch-to-arrival time, ventricular fibrillation (Vfib), and agonal respirations on EMS arrival. Predictors of survival evaluated included age, sex, location, bystander CPR, witnessed arrest, Vfib/ventricular tachycardia (Vtach), response time, and agonal breathing, based on bivariate results. Backward stepwise selection was used to confirm predictors of survival. These predictors were then analyzed with logistic regression by age category per 10 years of age. Results:, Individuals who received CCR had better outcomes across age groups. The increase in survival for the subgroup with a witnessed Vfib was most prominent on those <40 years of age (3.7% for standard ALS patients vs. 19% for CCR patients, odds ratio [OR] = 5.94, 95% confidence interval [CI] = 1.82 to 19.26). This mortality benefit declined with age until the ,80 years age group, which regained the benefit (1.8% vs. 4.6%, OR = 2.56, 95% CI = 1.10 to 5.97). Neurologic outcomes were also better in the patients who received CCR (OR = 6.64, 95% CI = 1.31 to 32.8). Within the subgroup that received CCR, the factors most predictive of improved survival included witnessed arrest, initial rhythm of Vfib/Vtach, agonal respirations upon arrival, EMS response time, and age. Neurologic outcome was not adversely affected by age. Conclusions:, Cardiocerebral resuscitation is associated with better survival from OHCA in most age groups. The majority of patients in all age groups who survived to hospital discharge and who could be reached for follow-up had good neurologic outcome. Among patients receiving CCR for OHCA, witnessed arrest, Vfib/Vtach, agonal respirations, and early response time are significant predictors of survival, and these do not change significantly based on age. ACADEMIC EMERGENCY MEDICINE 2010; 17:269,275 © 2010 by the Society for Academic Emergency Medicine [source] Influence of Sex on the Out-of-hospital Management of Chest PainACADEMIC EMERGENCY MEDICINE, Issue 1 2010Zachary F. Meisel MD Abstract Background:, Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out-of-hospital (OOH) care for chest pain is protocol-driven and may be less likely to demonstrate differences between men and women. Objectives:, The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex. Methods:, A 1-year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured. Results:, A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI). Conclusions:, For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk. ACADEMIC EMERGENCY MEDICINE 2010; 17:80,87 © 2010 by the Society for Academic Emergency Medicine [source] ABO-incompatible deceased donor liver transplantation in the United States: A national registry analysis,LIVER TRANSPLANTATION, Issue 8 2009Zoe A. Stewart In the United States, ABO-incompatible liver transplantation (ILT) is limited to emergent situations when ABO-compatible liver transplantation (CLT) is unavailable. We analyzed the United Network for Organ Sharing database of ILT performed from 1990-2006 to assess ILT outcomes for infant (0-1 years; N = 156), pediatric (2-17 years; N = 170), and adult (> 17 years; N = 667) patients. Since 2000, the number of ILT has decreased annually, and there has been decreased use of blood type B donors and increased use of blood type A donors. Furthermore, ILT graft survival has improved for all age groups in recent years, beyond the improved graft survival attributable to era effect based on comparison to respective age group CLT. On matched control analysis, graft survival was significantly worse for adult ILT as compared to adult CLT. However, infant and pediatric ILTs did not have worse graft survival versus age-matched CLT. Adjusted analyses identified age-specific characteristics impacting ILT graft loss. For infants, transplant after 2000 and donor age < 9 years were associated with reduced risk of ILT graft loss. For pediatric patients, female recipient sex and donor age > 50 years were associated with increased risk of ILT graft loss. For adults, life support, repeat transplant, split grafts, and hepatocellular carcinoma were associated with increased risk of ILT graft loss. The current study identifies important trends in ILT in the United States in the modern immunosuppression era, as well as specific recipient, donor, and graft characteristics impacting ILT graft survival that could be utilized to guide ILT organ allocation in exigent circumstances. Liver Transpl 15:883,893, 2009. © 2009 AASLD. [source] Graft and patient survival after adult live donor liver transplantation compared to a matched cohort who received a deceased donor transplantationLIVER TRANSPLANTATION, Issue 10 2004Paul J. Thuluvath Live donor liver transplantation (LDLT) has become increasingly common in the United States and around the world. In this study, we compared the outcome of 764 patients who received LDLT in the United States and compared the results with a matched population that received deceased donor transplantation (DDLT) using the United Network for Organ Sharing (UNOS) database. For each LDLT recipient (n = 764), two DDLT recipients (n = 1,470), matched for age, gender, race, diagnosis, and year of transplantation, were selected from the UNOS data after excluding multiple organ transplantation or retransplantation, children, and those with incomplete data. Despite our matching, recipients of LDLT had more stable liver disease, as shown by fewer patients with UNOS status 1 or 2A, in an intensive care unit, or on life support. Creatinine and cold ischemia time were also lower in the LDLT group. Primary graft nonfunction, hyperacute rejection rates, and patient survival by Kaplan-Meier analysis were similar in both groups (2-year survival was 79.0% in LDLT vs. 80.7% in case-controls; P = .5), but graft survival was significantly lower in LDLT (2-year graft survival was 64.4% vs. 73.3%; P < .001). Cox regression (after adjusting for confounding variables) analysis showed that LDLT recipients were 60% more likely to lose their graft compared to DDLT recipients (hazard ratio [HR] 1.6; confidence interval 1.1-2.5). Among hepatitis C virus (HCV) patients, LDLT recipients showed lower graft survival when compared to those who received DDLT. In conclusion, short-term patient survival in LDLT is similar to that in the DDLT group, but graft survival is significantly lower in LDLT recipients. LDLT is a reasonable option for patients who are unlikely to receive DDLT in a timely fashion. (Liver Transpl 2004;10:1263,1268.) [source] Cardiopulmonary resuscitation training for undergraduate medical students: a five-year studyMEDICAL EDUCATION, Issue 3 2002Colin A Graham Background Cardiopulmonary resuscitation (CPR) training for undergraduate medical students and junior doctors has been noted to be poor in the past. Attempts have been made over the last decade to improve CPR training for all health professionals. Aim This study aimed to determine if CPR training for undergraduate medical students in a single institution improved after initial concerns in 1992, and to observe trends in CPR training over five years. Methods Prospective single centre observational cohort survey by means of a 2-page self completed questionnaire to final year undergraduate medical students at the University of Glasgow (1993,97 inclusive). Results Mean annual response rate 58% (range 48% , 67%). 99% of responders had been trained in basic life support during undergraduate training. The use of simulated arrests for training increased significantly. CPR training was concentrated in the first and final years. Training in all aspects of advanced life support increased, as did the students' confidence in these techniques. Student satisfaction with the amount of basic life support training increased very significantly and there was a small, but significant increase in student satisfaction with advanced life support training. Overall confidence at the prospect of being a member of the resuscitation team on qualification did not increase. Conclusions There has been a sustained improvement in CPR training at this institution since 1993. Improvements in the training of specific advanced life support techniques does not lead to improved overall confidence in using these skills on qualification. Advanced life support training requires further expansion. [source] Gaps in Procedural Experience and Competency in Medical School GraduatesACADEMIC EMERGENCY MEDICINE, Issue 2009Susan B. Promes MD Abstract Objectives:, The goal of undergraduate medical education is to prepare medical students for residency training. Active learning approaches remain important elements of the curriculum. Active learning of technical procedures in medical schools is particularly important, because residency training time is increasingly at a premium because of changes in the Accreditation Council for Graduate Medical Education duty hour rules. Better preparation in medical school could result in higher levels of confidence in conducting procedures earlier in graduate medical education training. The hypothesis of this study was that more procedural training opportunities in medical school are associated with higher first-year resident self-reported competency with common medical procedures at the beginning of residency training. Methods:, A survey was developed to assess self-reported experience and competency with common medical procedures. The survey was administered to incoming first-year residents at three U.S. training sites. Data regarding experience, competency, and methods of medical school procedure training were collected. Overall satisfaction and confidence with procedural education were also assessed. Results:, There were 256 respondents to the procedures survey. Forty-four percent self-reported that they were marginally or not adequately prepared to perform common procedures. Incoming first-year residents reported the most procedural experience with suturing, Foley catheter placement, venipuncture, and vaginal delivery. The least experience was reported with thoracentesis, central venous access, and splinting. Most first-year residents had not provided basic life support, and more than one-third had not performed cardiopulmonary resuscitation (CPR). Participation in a targeted procedures course during medical school and increasing the number of procedures performed as a medical student were significantly associated with self-assessed competency at the beginning of residency training. Conclusions:, Recent medical school graduates report lack of self-confidence in their ability to perform common procedures upon entering residency training. Implementation of a medical school procedure course to increase exposure to procedures may address this challenge. [source] Bridge to Thoracic Organ Transplantation in Patients with Pulmonary Arterial Hypertension Using a Pumpless Lung Assist DeviceAMERICAN JOURNAL OF TRANSPLANTATION, Issue 4 2009M. Strueber We describe a novel technique of pumpless extracorporeal life support in four patients with cardiogenic shock due to end-stage pulmonary hypertension (PH) including patients with veno-occlusive disease (PVOD) using a pumpless lung assist device (LAD). The device was connected via the pulmonary arterial main trunk and the left atrium, thereby creating a septostomy-like shunt with the unique addition of gas exchange abilities in parallel to the lung. Using this approach, all four patients were successfully bridged to bilateral lung transplantation and combined heart,lung transplantation, respectively. Although all patients presented in cardiogenic shock, hemodynamic unloading of the right ventricle using the low-resistance LAD stabilized the hemodynamic situation immediately so that no pump support was subsequently required. [source] Primary Nonfunction (PNF) in the MELD Era: An SRTR Database AnalysisAMERICAN JOURNAL OF TRANSPLANTATION, Issue 4 2007S.R. Johnson PNF following liver transplantation (LT) is an infrequent but life-threatening complication. Liver allocation under MELD is based upon recipient severity of illness, a known risk factor for the occurrence of PNF. The incidence of PNF since the application of MELD has not previously been reported. The SRTR database was studied since inception of MELD until September 2004 for all adult recipients of deceased donor LT. PNF was defined as graft loss or death within 14 days of LT secondary to PNF or without defined cause. A total of 10545 transplants met inclusion criteria and PNF occurred in 613 (5.81%) of recipients. Univariate analysis demonstrated donor age, serum creatinine >1.5 mg/mL, hypertension and CVA as risk factors for PNF. Recipient factors included life support, mechanical ventilation, use of inotropes, hemodialysis, initial status 1 and use of a shared transplant. In the multivariate model only donor age and recipient serum creatinine, bilirubin, on life support and status 1 at transplant were significant risk factors for PNF. In this analysis of PNF in the MELD era the incidence of PNF does not appear to have increased from prior reports. Risk factors for PNF are related to donor age and severity of recipient illness. [source] An assessment of the validity of SOFA score based triage in H1N1 critically ill patients during an influenza pandemicANAESTHESIA, Issue 12 2009Z. Khan Summary Sequential Organ Failure Assessment (SOFA) score based triage of influenza A H1N1 critically ill patients has been proposed for surge capacity management as a guide for clinical decision making. We conducted a retrospective records review and SOFA scoring of critically ill patients with influenza A H1N1 in a mixed medical-surgical intensive care unit in an urban hospital. Eight critically ill patients with influenza A H1N1 were admitted to the intensive care unit. Their mean (range) age was 39 (26,52) years with a length of stay of 11 (3,17) days. All patients met SOFA score based triage admission criteria with a modal SOFA score of five. Five patients required invasive ventilation for a mean (range) of 5 (4,11) days. Five patients would have been considered for withdrawal of treatment using SOFA scoring guidelines at 48 h. All patients survived. We conclude that SOFA score based triage could lead to withdrawal of life support in critically ill patients who could survive with an acceptably low length of stay in the intensive care unit. [source] Comparison of Perfusion Quality in Hollow-Fiber Membrane Oxygenators for Neonatal Extracorporeal Life SupportARTIFICIAL ORGANS, Issue 4 2010Jonathan Talor Abstract Perfusion quality is an important issue in extracorporeal life support (ECLS); without adequate perfusion of the brain and other vital organs, multiorgan dysfunction and other deficits can result. The authors tested three different pediatric oxygenators (Medos Hilite 800 LT, Medtronic Minimax Plus, and Capiox Baby RX) to determine which gives the highest quality of perfusion at flow rates of 400, 600, and 800 mL/min using human blood (36°C, 40% hematocrit) under both nonpulsatile and pulsatile flow conditions. Clinically identical equipment and a pseudo-patient were used to mimic operating conditions during neonatal ECLS. Traditionally, the postoxygenator surplus hemodynamic energy value (SHEpost, extra energy obtained through pulsatile flow) is the one relied upon to give a qualitative determination of the amount of perfusion in the patient; the authors also examined SHE retention through the membrane, as well as the contribution of SHEpost to the postoxygenator total hemodynamic energy (THEpost). At each experimental condition, pulsatile flow outperformed nonpulsatile flow for all factors contributing to perfusion quality: the SHEpost values for pulsatile flow were 4.6,7.6 times greater than for nonpulsatile flow, while the THEpost remained nearly constant for pulsatile versus nonpulsatile flow. For both pulsatile and nonpulsatile flow, the Capiox Baby RX oxygenator was found to deliver the highest quality of perfusion, while the Minimax Plus oxygenator delivered the least perfusion. It is the authors' recommendation that the Baby RX oxygenator running under pulsatile flow conditions be used for pediatric ECLS, but further studies need to be done in order to establish its effectiveness beyond the FDA-approved time span. [source] | ||||||||||||||||||||||