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Introducción. La resucitación hemostática es una estrategia para compensar la pérdida sanguínea y disminuir el impacto de la coagulación inducida por trauma. Debido a que la disponibilidad de transfundir una razón equilibrada de hemocomponentes es difícil de lograr en el entorno clínico, la sangre total ha reaparecido como una estrategia fisiológica, con ventajas logísticas, que le permiten ser accesible para iniciar tempranamente la resucitación hemostática. El objetivo de este estudio fue evaluar las propiedades celulares, coagulantes y viscoelásticas de la sangre total almacenada por 21 días. Métodos. Las unidades de sangre total fueron obtenidas de 20 donantes voluntarios sanos. Se procesaron mediante un sistema de leucorreducción ahorrador de plaquetas y fueron almacenadas en refrigeración (1-6°C) sin agitación. Se analizaron los días 0, 6, 11 y 21. Las bolsas fueron analizadas para evaluar las líneas celulares, niveles de factores de coagulación y propiedades viscoelásticas mediante tromboelastografía. Resultados. El conteo eritrocitario y la hemoglobina se mantuvieron estables. El conteo de plaquetas tuvo una reducción del 50 % al sexto día, pero se mantuvo estable el resto del seguimiento. Los factores de coagulación II-V-VII-X, fibrinógeno y proteína C se mantuvieron dentro del rango normal. La tromboelastografía mostró una prolongación en el tiempo del inicio de la formación del coágulo, pero sin alterar la formación final de un coágulo estable. Conclusiones. La sangre total leucorreducida y con filtro ahorrador de plaquetas conserva sus propiedades hemostáticas por 21 días. Este es el primer paso en Colombia para la evaluación clínica de esta opción, que permita hacer una realidad universal la resucitación hemostática del paciente con trauma severo.

Flatliners (2017) is a science fiction horror film. Directed by Niels Arden, as a remake of the original from 1990´s film. Starring renowned actors such as Ellen Page, Kiefer Sutherland and Diego Luna. The film shows the life of five medical students and the thrive to study the immediate brain activity after death. To achieve this goal, they stop their heart rate and deprive their brain from oxygen, in the meantime, and with the use of state-of-the-art equipment they are being monitored, seeking for never seen before brain activity. The film to a horror film when, after being brought back from the death they experience paranormal activity, which makes our stars, seek for forgiveness from past experiences in their personal life. During the film we can observe different aspects related to the medical field, different points of view from the medical staff regarding cardiopulmonary reanimation, according to their education and medical guidelines follow thru the medical err and how this affects the daily life of the medical practitioner.

Background: Spontaneous coronary dissection is a disruption of the arterial wall, with clinical manifestations ranging from unstable angina to sudden cardiac death. It is presented a case of an obstetric patient who is successfully resuscitated after a spontaneous coronary dissection. Clinical case: 37-year-old female patient with a 33-week pregnancy and a history of preeclampsia in the previous pregnancy. She consulted for a 30-min chest pain. After her admission, the patient presented loss of consciousness and cardiorespiratory arrest. Basic and advanced life supports were given and then she was transferred to the intensive care unit where a dissection of the right coronary artery was diagnosed. After 14 days, the patient was discharged from the hospital without neurological sequelae. Conclusions: Spontaneous coronary dissection in the obstetric patient corresponds to a medical emergency, in which pharmacological and surgical measures must be implemented early in order to promote the fetal maternal well-being. [ABSTRACT FROM AUTHOR]

The SARCOs2 COVID-19 pandemic has created a challenge in resuscitation efforts requiring primary modifications to existing training guidelines, creating new algorithms to ensure that patients with suspected and COVID-19 carriers present cardiorespiratory arrest (CPR) have the greatest chance of survival without compromising the safety of rescuers who must have all the safety measures and personal protective equipment. The care of intra and extra hospital cardiac arrest of the patient with COVID-19 given its high contagiousness, particularly increased during resuscitation and airway management maneuvers, with repercussions on morbidity and mortality, for the health team. La American Heart Association (AHA), International Liaison Committee on Resuscitation (ILCOR) and the European Resuscitation Council (ERC) recommend prioritizing the use of a high-efficiency filter bag valve mask and securing the airway by endotracheal intubation or supraglottic device or: cricothyroidotomy during advanced CPR maneuvers. [ABSTRACT FROM AUTHOR]

Copyright of Revista de Medicina y Cine / Journal of Medicine & Movies is the property of Ediciones Universidad de Salamanca and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Llull: Revista de la Sociedad Espanola de Historia de las Ciencias y de las Tecnicas is the property of Sociedad Espanola de Historia de las Ciencias y de las Tecnicas and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Ciberrevista Enfermeriadeurgencias.com is the property of Sociedad Espanola de Enfermeria de Urgencias y Emergencias and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Admission to Resuscitation Room could be engendered by many different pathologies, which could appear at any time without regard to sex and age. Nevertheless, in spite of this versatility, there are no investigations that describe the Chilean reality, and the foreign literature is limited. Thus, our study sought to characterize clinically and demographically the patients admitted to RR of the Hospital San Juan de Dios de Los Andes, Chile. Materials and methods: A cross-sectional study was carried out based on an anonymised database. The calculated sample size was at least 1014 subjects (95% confidence interval, 3% accuracy). Convenience sampling was used, including admissions between January of 2013 and June of 2016, obtaining a sample of 1018 patients. Variables studied: sex, age, general diagnosis, specific diagnosis, month and schedule. We worked with Microsoft Excel® using descriptive statistics. Approved by ethical-scientific committee. Results: 58.1% (n=593) of the sample were men; with a 42.5% (n=434) of the whole sample being older than 64 years of age. Most frequent general diagnoses: cardiovascular (50.3%) (n=512), neurological (16.3%) (n=166) and traumatic (11.7%) (n=119). Most frequent specific diagnoses: tachyarrhythmia (15.9%) (n=162) and myocardial infarction (12.6%) (n= 128). The highest amount of admission was registered in January, February and June (average 28), and between 8 P.M. and midnight (22.8%) (n=232). Discussion: There is an apparent predominance of cardiovascular diseases. The distribution by month, sex and age seems to be contingent on the behavior of this group. This is not the case for the distribution by schedules, since cardiovascular diseases usually appear during the morning. In general, our results coincide with the available foreign literature. [ABSTRACT FROM AUTHOR]

Background: Family presence in the emergency department is a reality. However, in some situations, namely emergency situations, family presence is a controversial issue for nurses. Objectives: To identify nurses’ opinions about family presence in emergency situations in adult emergency departments. Methodology: A descriptive exploratory study was conducted using a questionnaire in a convenience sample. The sample con- sisted of 233 nurses from four multipurpose emergency departments in the Lisbon and Tagus Valley region. Results: Most nurses in the study do not agree with family presence in emergency settings. Some of the identified advantages included the provision of clinical information to the team and patient support, whereas the disadvantages related to family anxiety and increased stress for professionals. Conclusion: Nurses have an unfavorable opinion about family presence in emergency situations. It would be important to reflect on the clinical practices in the resuscitation room so that the F for family can be included after the ABCDE approach to emergency care delivery. [ABSTRACT FROM AUTHOR]

JUSTIFICATIVA E OBJETIVOS: As novas diretrizes de ressuscitação cardiopulmonar (RCP) enfatizam a importância das compressões torácicas de alta qualidade e modificam algumas rotinas. Este artigo tem por objetivo revisar as principais alterações na reanimação praticada pelo médico anestesiologista. CONTEÚDO: A ênfase para realização das compressões torácicas de alta qualidade, com frequência e profundidade adequadas, permitindo retorno total do tórax e com interrupção mínima nas compressões, assume posição de destaque nesta atualização. Não se deve levar mais de dez segundos verificando o pulso antes de iniciar a RCP. A relação universal de 30:2 é mantida, modificando-se sua ordem de realização, iniciando-se pelas compressões torácicas, para, em seguida, prosseguir para as vias aéreas e respiração (C-A-B, em vez de A-B-C). O procedimento "ver, ouvir e sentir se há respiração" foi removido do algoritmo e o uso de pressão cricoidea durante as ventilações, em geral, não é mais recomendado. A frequência das compressões foi modificada para um mínimo de cem por minuto, em vez de aproximadamente cem por minuto, sendo sua profundidade em adultos alterada para 5 cm, em lugar da faixa antes recomendada de 4 a 5 cm. Choque único é mantido, devendo ser de 120 a 200 J quando bifásico, ou 360 J quando monofásico. No suporte avançado de vida, o uso de capnografia e capnometria para confirmação da intubação e monitoração da qualidade da RCP é uma recomendação formal. A atropina não é mais recomendada para uso rotineiro no tratamento da atividade elétrica sem pulso ou assistolia. CONCLUSÕES: É importante a atualização quanto às novas diretrizes de RCP, sendo enfatizado o contínuo aprendizado. Isso irá melhorar a qualidade da reanimação e sobrevida de pacientes em parada cardíaca

Tras la publicación de un meta-análisis de los investigadores del grupo PRISM sobre Terapia Guiada por Objetivos en la Resucitación del Shock Séptico, presentamos esta lectura crítica del principal trabajo realizado a nivel europeo. En el estudio PROMISE, no se demostró beneficio del manejo protocolarizado de la sepsis frente a la práctica clínica habitual.

A ressuscitação cardiocerebral (RCC) é uma nova abordagem à ressuscitação de pacientes com parada cardíaca fora do hospital (PCFH). O primeiro componente principal da RCC são as compressões torácicas contínuas (CTC), também chamadas de RCP com compressões torácicas isoladas ou "RCP somente com compressões torácicas" ("Hands-only" CPR), recomendadas como parte da RCC por todos os observadores que testemunhem um colapso súbito de origem presumidamente cardíaco. O segundo componente é um novo algoritmo de tratamento de Suporte Avançado de Vida em Cardiologia (ACLS) para Serviços Médicos de Emergência (SME). Esse algoritmo enfatiza compressões torácicas ininterruptas a despeito de outros procedimentos contínuos como parte do esforço de resgate. Um terceiro componente foi recentemente adicionado à RCC, e é o cuidado agressivo pós-ressuscitação. A RCC tem aumentado a participação de testemunhas e tem melhorado as taxas de sobrevivência em varias comunidades. Essa é a hora para outras comunidades re-examinarem seus próprios desfechos com parada cardíaca e considerar a possibilidade de se juntar a essas cidades e comunidades que dobraram e até mesmo triplicaram as suas taxas de sobrevivência de PCFH.

En este artículo se analizan aspectos éticos de la asistencia a los pacientes terminales; se hace énfasis en la necesidad de que haya una comunicación seria y responsable con ellos y de que se actúe siempre en forma sensible, en el marco de la ética y con miras a proteger sus derechos, en particular su autonomía y dignidad. Se discuten la orden de no resucitar, el suicido ayudado y la eutanasia. Ethical aspects concerning the attendance of terminally-111 patients are analyzed. Emphasis is given to the need of having a serious and responsible communication with them, always acting in a sensitive form and within the framework of ethics. The main goal should be to protect the rights of patients specially their autonomy and dignity. The concepts of do-not resucitate, assisted suicide and euthanasia are considered.

El estado de choque es la urgencia hemodinámica de presentación más frecuente en la práctica clínica y de su manejo adecuado y oportuno depende muchas veces la vida del enfermo, por ello es muy importante que todos los médicos tengan conceptos claros acerca de su tratamiento inicial y aprendan a utilizar los dispositivos de vigilancia mecánicos y electrónicos. Se hace una revisión somera del tema y se dan pautas prácticas relacionadas con el diagnóstico, tratamiento y monitoreo de pacientes en estado de choque.

Copyright of Revista Chilena de Pediatría is the property of Revista Chilena de Pediatria and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Perimortem cesarean section is an emergency procedure of easy and short surgical technique that can be performed by nonobstetrician medical staff with basic training, whose purpose is to improve maternal perfusion, often being a saving measure for the maternal-fetal binomial or for one of the two, as is stated in the literature analyzed for this review. Case: A 16 years old segunfemale with 32 weeks gestation, admitted in cardiac arrest and who after two minutes of unsuccessful resuscitation (8 min stop), a perimortem cesarean is performed by an emergency medical specialist, with excellent neurological outcome for the baby and further evidence of perfusion in the mother. Review: There are reports with variable outcomes for the infant and mother after perimortem cesarean. In 18 years, 38 cases have been found with reports in which they had good results in 89% of surviving infants. In 28% of them, the intervention was conducted in the first five minutes and 98% had a good neurological status after four years of follow up, there are also acceptable results for up to 30 minutes postparo. Conclusion: The perimortem cesarean is an emergency procedure which is performed on a woman with more than 20 weeks of gestation in extremis or cardio respiratory arrest to improve venous return to make a more effective resuscitation and try to save the mother and in some cases, to save only the life of the fetus. [ABSTRACT FROM AUTHOR]

Copyright of Scientia Medica is the property of EDIPUCRS - Editora Universitaria da PUCRS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

La hemorragia posparto es la primera causa de muerte materna en el mundo. Las medidas que se han tomado en muchos países para disminuir su morbimortalidad se han basado principalmente en la prevención. Sin embargo, cuando ocurre de manera imprevista, la aplicación de estrategias como el código rojo ha demostrado resultados positivos. Es poco lo que se sabe sobre el nivel de conocimiento de los profesionales de la salud sobre el código rojo. En este estudio se realizó una encuesta para determinar el nivel de conocimiento sobre el código rojo de los distintos profesionales de la salud que atienden urgencias quirúrgicas de la paciente obstétrica, en cinco instituciones de salud en Bogotá. Se utilizó como instrumento de evaluación un cuestionario de ocho preguntas. La primera pregunta, abierta, evaluó el conocimiento sobre el código rojo; la segunda, el reconocimiento y activación del código rojo; la tercera, quiénes deben integrar el equipo, y del numeral 4 al 8 se evaluó el conocimiento sobre el manejo específico de la hemorragia posparto. Los resultados demuestran la falta de conocimiento sobre el código rojo en los aspectos evaluados en los profesionales encuestados. [ABSTRACT FROM AUTHOR]

The murder of the president John F. Kennedy, on Novermber 22nd of 1963 at 12:30 P. M. has been regarded as the crime of the XX century. An account is presented about the primary care findings at Parkland Memorial as well as the autopsy and radiologic findings described by physicians and published in the JAMA magazine. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: Objective: To analyse the present day characteristics and outcome of cardio-respiratory arrest in children in Spain. Design: An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital cardio-respiratory arrest in children. Patients and methods: Two hundred and eighty-three children between 7 days and 17 years of age with cardio-respiratory arrest. Data were recorded according to the Utstein style. The outcome variables were the sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). Three hundred and eleven cardio-respiratory arrest episodes, composed of 70 respiratory arrests and 241 cardiac arrests in 283 children were studied. Accidents were the most frequent cause of out-of-hospital arrest (40%), and cardiac disease was the leading cause (31%) of in-hospital arrest. Initial survival was 60.2% and 1 year survival was 33.2%. The final survival was higher in patients with respiratory arrest (70%) than in patients with cardiac arrest (21.1%) (P < 0.0001). Although many individual factors correlated with mortality, multivariate logistic regression revealed that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20min (odds ratio: 10.35; 95% CI 4.59–23.32). Conclusions: In Spain, the present mortality from cardio-respiratory arrest in children remains high. Survival after respiratory arrest is significantly higher than after cardiac arrest. The duration of cardiopulmonary resuscitation attempt is the best indicator of mortality of cardio-respiratory arrest in children. [Copyright &y& Elsevier]

Abstract: Although often preventable, drowning remains a leading cause of accidental death, especially in children. New definitions classify drowning as the process of experiencing respiratory impairment from submersion or immersion in a liquid. The key pathophysiological feature in drowning is hypoxia. Accurate neurological prognosis cannot be predicted from the initial clinical presentation, laboratory, radiological, or electrophysiological examinations. Prompt and aggressive resuscitation attempts are crucial for optimal survival. This article reviews the epidemiology, pathophysiology, treatment, and prevention of drowning. [Copyright &y& Elsevier]

Introduction: Cardiac arrest (CA) is associated with poor neurological outcome and is associated with a poor understanding of the cerebral hemodynamic and metabolic changes. The objective of this study was to determine the applicability of near-infrared spectroscopy (NIRS), to observe the changes in cerebral total hemoglobin (T-Hb) reflecting cerebral blood volume, oxygenation state of Hb, oxidized cytochrome oxidase (Cyto-C), and brain water content following CA. Methods: Fourteen rats were subjected to normothermic (37.5 °C) or hypothermic (34 °C) CA induced by 8 min of asphyxiation. Animals were resuscitated with ventilation, cardiopulmonary resuscitation (CPR), and epinephrine (adrenaline). Hypothermia was induced before CA. NIRS was applied to the animal head to measure T-Hb with a wavelength of 808 nm (n = 10) and oxygenated/deoxygenated Hb, Cyto-C, and brain water content with wavelengths of 620–1120 nm (n = 4). Results: There were no technical difficulties in applying NIRS to the animal, and the signals were strong and consistent. Normothermic CA caused post-resuscitation hyperemia followed by hypoperfusion determined by the level of T-Hb. Hypothermic CA blunted post-resuscitation hyperemia and resulted in more prominent post-resuscitation hypoperfusion. Both, normothermic and hypothermic CA resulted in a sharp decrease in oxygenated Hb and Cyto-C, and the level of oxygenated Hb was higher in hypothermic CA after resuscitation. There was a rapid increase in brain water signals following CA. Hypothermic CA attenuated increased water signals in normothermic CA following resuscitation. Conclusion: NIRS can be applied to monitor cerebral blood volume, oxygenation state of Hb, Cyto-C, and water content following CA in rats. [Copyright &y& Elsevier]

Introduction: It has long been observed that CPR skills rapidly decline regardless of the modality used for teaching or criteria used for testing. Uninterrupted chest compression CPR (UCC-CPR) is a proposed alternative to standard single rescuer CPR (STD-CPR) for laypersons in witnessed unexpected cardiac arrest in adults. It delivers substantially more compressions per minute and may be easier to remember and perform than standard CPR. Methods: In this prospective study, 28 medical students were taught STD-CPR and UCC-CPR and then were tested on each method at baseline (0), 6, and 18 months after training. The students’ performance for at least 90 s of CPR was evaluated based on video and Laerdal Skillreporter Resusci Anne recordings. Results: The mean number of correct chest compressions delivered per minute trended down over time in STD-CPR (23±3, 19±4, and 15±3; P = 0.09) but stayed the same in UCC-CPR (43±9, 38±7, and 37±7; P = 0.91) at 0, 6, and 18 months, respectively. The mean percentage of chest compressions delivered correctly fell over time in STD-CPR (54±6%, 35±6%, and 32±6%; P = 0.02) but stayed the same in UCC-CPR (34±5%, 41±7%, and 38±8%) at 0, 6, and 18 months, respectively. The number of chest compressions delivered per minute was higher in UCC-CPR at 0, 6, and 18 months (113 versus 44, P < 0.0001; 94 versus 47, P < 0.0001; and 92 versus 44, P < 0.001). The greater number of chest compressions was due to a mean ventilaroty pause of 13–14 s during STD-CPR at all three time points. Conclusions: Chest compression performance during STD-CPR declined in repeated testing over 18 months whereas there was minimal decline in chest compressions performance on repeated testing of UCC-CPR. In addition, substantially more chest compressions were delivered during UCC-CPR compared to STD-CPR at all time points primarily because of long pauses accompanying rescue breathing. [Copyright &y& Elsevier]

Background: Defibrillation may convert ventricular fibrillation (VF) only to reveal profound mechanical dysfunction. Survival following this dysfunction, known as pulseless electrical activity (PEA) and electromechanical dissociation (EMD), is uncommon. We sought to evaluate an electrical therapy for primary post shock PEA following short duration VF. Methods and results: Forty-eight episodes of VF, lasting 110±25 s, were induced in 16 anesthetized dogs. Following defibrillation, 35 episodes met PEA criteria (ABP≤36 mmHg diastolic and pulse pressure ≤14 mmHg in the first 20 s post shock). These post defibrillation PEA episodes were either Not Treated (NT) or Treated (T) with packets of 4–20 monophasic 0.2 ms 50–100 Hz pulses of 20–60 V applied across the tip and coil of an integrated bipolar transvenous defibrillation lead positioned in the right ventricle. The therapeutic endpoint was return of spontaneous circulation (ROSC; self-sustained ABP≥60 mmHg diastolic and/or ≥100 mmHg systolic) for over 2 min. In the Not Treated group, only 4 of 19 (21%) episodes spontaneously recovered to ROSC in 123±49 s while in the Treated group, 11 of 16 (69%) of the PEA episodes achieved ROSC in 102±92 s. Conclusions: Electrical therapy increased the likelihood of ROSC in primary post defibrillation PEA three-fold (P<0.01). Recovery occurred in the absence of thoracic compression, mechanical ventilation, or adjunctive drug therapy. [Copyright &y& Elsevier]

Objective: This study was conducted to assess the varying attitudes in Europe towards ethical aspects of resuscitation in Europe. Method: The ethics of resuscitation is a key discussion topic in the European Resuscitation Council Advanced Life Support (ALS) course. A questionnaire was sent to all leading ALS course directors in 20 European countries. All completed the questionnaire. The results were compiled in March 2004. Views were sought on the following ethical aspects:Results: The results reveal a considerable variation in the interpretation of ethical dilemmas within European countries. It is interesting to note that the results do not necessarily conform to traditional beliefs in the characteristic differences between Northern and Southern Europe. The Mediterranean countries do not all have the same attitudes, any more than the Nordic or Central European countries share the same views. Conclusions: There remains a widespread divergence of views on ethical aspects of resuscitation with the countries of Europe that are largely unpredictable according to commonly perceived national characteristics. The trend over the past 6 years is towards a more permissive attitude. For many ethical questions there can be no clear and correct didactic answers. [Copyright &y& Elsevier]

Background: The timing and use of norepinephrine (noradrenaline) (NE) in septic shock remain a matter of controversy. Aim: To study the outcome of septic patients treated with early and exclusive NE. Setting: Tertiary Intensive Care Unit. Patients: 142 patients with septic shock. Intervention: Exclusive NE infusion within 24 hours of admission to ICU. Methods and main results: Retrospective analysis of data from a unit database identified 142 patients. Their median admission simplified acute physiology score (SAPS II) score was 46 [38, 56] with 98 (69%) receiving mechanical ventilation. Mean arterial pressure (MAP) at the start of NE infusion was 60 [58, 68] mmHg. NE infusion was started at a median of 1.3 [0.3, 5.0] h after ICU admission. Restoration and maintenance of target MAP was achieved initially in all patients and, in 61.3%, within 30 min. The median peak dose of NE was 0.28 [0.14, 0.61] μg/(kg min) and the duration of infusion was 88 [42, 175] h. SAPS II predicted mortality was 40.8%, however, only 34.5% (P=0.27) died. Among the most severely ill patients (SAPS II score >56) actual mortality was 50.0% versus 74.7% predicted (P=0.07). Conclusions: Early and exclusive use of NE in hyperdynamic septic shock achieved a stable MAP >75 mmHg in all patients. Survival compared favorably with that predicted by illness severity scores. [Copyright &y& Elsevier]

Objectives: To demonstrate that intraosseous infusions via the calcaneus could deliver fluids to systemic veins and that intraosseous infusions do not require bones with medullary cavities. To demonstrate that intraosseous infusions could be successful in adults. Design: Ten adult cadavers were injected with 16 gauge intraosseous needles and infused with 10 ml of methyl green dye at a concentration of 10 mg/ml. Main outcome measures: Observation of methyl green dye in the great saphenous, medial malleolar and dorsal veins of the foot recorded by digital photography on injection and at 1 min post-injection. Results: Immediate entry of methyl green dye into the superficial veins of the leg was seen in 14 out of the 20 legs trialled and delayed entry was noted in the two legs of another cadaver. No venous entry was seen in one cadaver and intraosseous access failed in one cadaver. Conclusions: Successful intraosseous infusions can be performed via the calcaneus. Intraosseous infusions can be successful in adult populations. While not a substitute for intraosseous infusions in other sites, the calcaneus provides an easily accessible site free of overlying vital structures. [Copyright &y& Elsevier]

Introduction: The outcome after out of hospital cardiac arrest is dismal. Thrombolysis during CPR has been advocated. Our hypothesis was that early administration of bolus thrombolysis could lead to improved survival from out of hospital cardiac arrest.Methods: A prospective, randomised, double blind placebo controlled trial. All victims of out of hospital cardiac arrest brought to the Emergency Department (ED) by the emergency medical system were eligible for inclusion. All patients received standard advanced cardiac life support, except that the first drug the patient received was either tenecteplase 50 mg or placebo. The primary end point was return of spontaneous circulation (ROSC).Results: Of 35 patients enrolled, 19 received tenecteplase and 16 placebo. The tenecteplase group was younger (63 vs 72 years P = 0.04) and had significantly more ventricular fibrillation as the initial rhythm (63% versus 19%, 44% difference, 95% CI 15-73%). There was no difference in rhythm on arrival at the ED. ROSC occurred in 8 (42%) patients receiving tenecteplase and one (6%) placebo (36% difference, 95% CI 11-61%). Two tenecteplase and one placebo patient survived to leave ED, and one in each group survived to hospital discharge. Autopsy results were available on eight patients, five of whom had a thrombotic cause of death.Conclusion: In this pilot study, we found the use of early bolus tenecteplase for OHCA to be feasible, and that it appears to increase the rate of ROSC. Larger studies are required to determine if this translates into a survival benefit. Appropriate patient selection for OHCA studies remains problematic. [ABSTRACT FROM AUTHOR]

Aim: To compare the safety and efficacy of attenuated adult biphasic shocks with standard monophasic weight-based shocks in a piglet model of prolonged prehospital ventricular fibrillation (VF). Background: If attenuated adult shocks are safe and effective for prehospital pediatric VF, automated external defibrillators (AEDs) can be easily adapted for pediatric use. Methods: After 7 min of untreated VF, piglets were randomized to treatment with attenuated adult biphasic shocks or weight-based monophasic shocks. The attenuated adult biphasic group received 200/300/360 J shocks, attenuated by specialized pediatric electrodes to 51/78/81 J and the monophasic weight-based control group received 2/4/4 J/kg shocks. Forty-eight female piglets were studied, 16 in each of three weight categories: 4 kg (neonatal), 14 kg (younger child) and 24 kg (older child). The primary outcome measures of efficacy and safety were 24 h survival with good neurological outcome and post-resuscitation left ventricular ejection fraction (LVEF), respectively. Results: For the 24 kg piglets, attenuated adult biphasic shocks resulted in superior 24 h survival with good neurological outcome (6/8 versus 0/8, P<0.001) and greater LVEF 4 h post-resuscitation (34±4% versus 18±5%, P<0.05). For the 14 and 4 kg piglets, 24 h survival with good neurological outcome occurred in 7/8 versus 5/8 and 7/8 versus 3/8, respectively, and LVEF 4 h post-resuscitation was 30±3% versus 36±6% and 30±3% versus 22±4%, respectively. Conclusions: The escalating attenuated adult biphasic dosage strategy was at least as safe and effective as the standard weight-based monophasic dose over a wide range of weights in this piglet model of prehospital VF. This work supports the concept of using an attenuated adult biphasic dosage in children. [Copyright &y& Elsevier]

Objectives: To survey current practice and to compare the opinion of paediatricians and anaesthesiologists regarding laryngeal mask airway (LMA) in neonatal resuscitation. Design: A structured postal questionnaire on the use of the laryngeal mask airway in neonatal resuscitation was sent to the heads of department of the paediatric and anaesthesiology services. Setting: Forty-three hospitals in the Veneto Region, Italy. Results: During the year 2000, 1526 out of 33708 (4.5%) neonates in our region needed resuscitation. Of these cases, 101 (6.6%) were ventilated using the LMA. Laryngeal mask airway availability was significantly greater in the anaesthesiology department compared to the paediatric department (90% versus 50%; P=0.002). However, 52% of anaesthesiologists and 72% of paediatricians had never used the laryngeal mask airway in their practice. The laryngeal mask airway was considered as an essential device more frequently by the anaesthesiologists than by the paediatricians (27% versus 5%; P=0.015); both groups considered the laryngeal mask airway particularly useful in specific situations. Interestingly, while 16% of the paediatricians described the laryngeal mask airway as having no value, none of the anaesthesiologists did (P=0.002). Staff competence was considered low by 70% of anaesthesiology heads of department compared with 90% of their pediatric colleagues. In both specialties, use of the laryngeal mask airway was limited to medical staff. With regard to training, 35% of anaesthesiologists and 22.5% of paediatricians had attended a course on laryngeal mask airway use. Conclusions: Laryngeal mask airway availability and perceived value were higher amongst anaesthesiologists than their paediatric colleagues. However, educational level, competence and utilization rates of the LMA in neonatal resuscitation were low in both groups. [Copyright &y& Elsevier]

Successful outcome following cardiac arrest have been reported in the range of 13–59%. It is well established that the time from the onset of a ventricular arrhythmia to successful defibrillation predicts outcome. Recent out of hospital arrest protocols minimizing time to defibrillation have reported significant improvement in outcomes. The Bethesda conference and American Heart Association (AHA) both set standards for defibrillation time for in hospital codes but do not set standards for other interventions. In February 2000, the Brooke Army Medical Center (BAMC) cardiopulmonary resuscitation committee published time guidelines for the initiation of CPR, emergency team arrival, first defibrillation and first medication. We sought to evaluate resuscitation outcomes before and after this intervention. Methods: Data on each response time was prospectively collected as was etiology for the event, emergency location, patient age, gender, and emergency outcome for the 7 months prior to the guideline introduction and 15 months afterwards. Results: The mean response times (in minutes) for initiation of CPR (1.3 vs. 0.4), emergency team arrival (1.6 vs. 1.2), first defibrillation (7.8 vs. 6.6) and first medication (4.1 vs. 3.8) demonstrated trends toward improvement. Compliance with the time standards also increased (67–91, 85–95, 67–71 and 93–86%, respectively). Emergency survival trended toward improvement (47 vs. 57%) while discharge survival significantly increased from 3 to 24% (P=0.017). Conclusions: Setting time guidelines for Advanced Cardiac Life Support (ACLS) improved initiation of CPR, emergency team arrival, first defibrillation, and first medication administration. These time reductions were accompanied by improved event survival and a statistically improved survival to discharge. [Copyright &y& Elsevier]

A 42-year-old man presented with shortness of breath, weakness, and diaphoresis, and developed a new left bundle branch block while under evaluation in the Emergency Department. At emergency cardiac catheterization, he was found to have only insignificant coronary disease, and a hyperdynamic ventricle. Despite these findings, he subsequently developed profound bradycardia and hypotension, which were refractory to standard therapies including pressors, calcium, and transvenous pacing. He gradually improved over several days and made a full recovery, after which he admitted to taking multiple calcium channel blockers (CCBs) in an attempt to self-medicate for symptoms he related to his lifelong paroxysmal supraventricular tachycardia. This is the first report of a CCB overdose mimicking an acute myocardial infarction, and highlights the fact that CCB overdose must be considered in the differential diagnosis of some patients who present with apparent acute myocardial infarction. [Copyright &y& Elsevier]

Background: Automated external defibrillators (AEDs) have become increasingly available outside of the Emergency Medical Systems (EMS) community to treat sudden cardiac arrest (SCA). We sought to study the use of AEDs in the home, businesses and other public settings by minimally trained first responders. The frequency of AED use, type of training offered to first responders, and outcomes of AED use were investigated. In addition, minimally trained responders were asked if they had encountered any safety problems associated with the AED.Methods: We conducted a telephone survey of businesses and public facilities (2683) and homes (145) owning at least one AED for at least 12 months. Use was defined as an AED taken to a medical emergency thought to be a SCA, regardless of whether the AED was applied to the patient or identified a shockable rhythm.Results: Of owners that participated in the survey, 13% (209/1581) of businesses and 5% (4/73) of homes had responded with the AED to a suspected cardiac arrest. Ninety-five percent of the businesses/public facilities offered training that specifically covered AED use. The rate of use for the AEDs was highest in residential buildings, public places, malls and recreational facilities with an overall usage rate of 11.6% per year. In-depth interviews were conducted with lay responders who had used the AED in a suspected cardiac arrest. In the four cases where the AED was used solely by a lay responder, all four patients survived to hospital admission and two were known to be discharged from the hospital. There were no reports of injury or harm.Conclusions: This survey demonstrates that AEDs purchased by businesses and homes were frequently taken to suspected cardiac arrests. Lay responders were able to successfully use the AEDs in emergency situations. Further, there were no reports of harm or injury to the operators, bystanders or patients from lay responder use of the AEDs. [ABSTRACT FROM AUTHOR]

Background: The importance of the defibrillation waveform on the evolving post-shock cardiac rhythm is uncertain. The primary objective of this study was to evaluate cardiac rhythms following the first defibrillation shock, comparing biphasic truncated exponential (BTE), monophasic damped sinusoidal (MDS), and monophasic truncated exponential (MTE) waveforms in patients experiencing out-of-hospital ventricular fibrillation cardiac arrest (OHCA). Methods: We reviewed the automated external defibrillator (AED) and emergency medical services (EMS) records of 366 patients who suffered OHCA and were treated with defibrillation shocks by first-tier emergency responders between 1 January 1999 and 31 August 2002 in King County, Washington. The post first shock rhythms were determined at 5, 10, 20, 30, and 60 s and compared according to defibrillation waveform. Results: The MDS and BTE waveforms were associated with significantly higher frequency of defibrillation than the MTE waveform, though only the BTE association persisted to 30 and 60 s. No difference in defibrillation rates was detected between MDS and BTE waveforms. By 60 s, an organized rhythm was present in a greater proportion for BTE (40.0%) compared with MDS (25.4%, P=0.01) or MTE (26.5%, P=0.07). Conclusion: In this retrospective cohort investigation, MDS and BTE waveforms had higher first shock defibrillation rates than the MTE waveform, while patients treated with the BTE waveform were more likely to develop an organized rhythm within 60 s of the initial shock. The results of this investigation, however, do not provide evidence that these surrogate advantages are important for improving survival. Additional investigation is needed to improve the understanding of the role of waveform and its potential interaction with other clinical factors in order to optimize survival in OHCA. [Copyright &y& Elsevier]

The present study was designed to investigate the protective effects of calcitonin gene-related peptide (CGRP) in a porcine model of cardiopulmonary resuscitation (CPR). Twelve pigs were anesthetized, paralyzed, mechanically ventilated with oxygen, and were monitored for electrocardiograph (ECG), arterial pressure, right atrial pressure, airway pressure. Ventricular fibrillation (VF) was induced in all animals by the application of 30 V of alternating current (60 Hz) across the heart, and remained untreated for 3 min, followed by conventional CPR with pneumatic piston device (Thumper) for 15 min. At 18 min of VF a single dose of vasopressin was given, and followed by defibrillation attempts. Two groups were studied. Group 1: Six pigs were used as saline control. Group 2: 0.3 nmol/kg CGRP was given 15 min prior to induction of VF. All animals in the CGRP pretreated group achieved a return of spontaneous circulation (ROSC) and survived more than 2 h (100%), whereas none of the saline control animals achieved ROSC. Blood gases were not significantly different between the groups. However, CGRP group had significantly higher arterial blood pressure and coronary perfusion pressure than control group during CPR. Pretreatment with CGRP affords a cardioprotective effect in this model of whole body ischemia. [Copyright &y& Elsevier]

Prolongation of the QT interval is a known risk factor for syncope, seizures and sudden cardiac death. Most patients with QT prolongation have an acquired cause, but congenital forms of QT prolongation are being increasingly recognized. However, existing advanced cardiac life support (ACLS) treatment algorithms for prolonged QT mediated ventricular fibrillation pertains to acquired long-QT syndrome (LQTS). Here, a young patient with out-of-hospital cardiac arrest secondary to congenital LQTS illustrates critical exceptions to the current ACLS treatment algorithms for ventricular fibrillation and unstable ventricular tachycardia when QT prolongation is congenital in origin. A clarified ACLS algorithm is proposed. [Copyright &y& Elsevier]

We investigate the effects of the tyrosine kinase inhibitor, tyrphostin AG126 on the organ injury and dysfunction (kidney, liver, pancreas, muscle and or brain) associated with haemorrhagic shock in the anaesthetised rat. Haemorrhage (sufficient to lower mean arterial blood pressure to 45 mmHg for 90 min) and subsequent resuscitation with the shed blood resulted (within 4 h after resuscitation) in expression of inducible nitric oxide synthase inhibitor (iNOS), positive staining for nitrotyrosine (liver), renal, liver and pancreatic injury, and injury to the muscle and brain. Pre-treatment (30 min prior to the onset of haemorrhage) with the tyrosine kinase inhibitor tyrphostin AG126 reduced the iNOS expression, nitrotyrosine formation, hepatic, brain or muscular injury, and to a lesser extent, the renal injury caused by haemorrhage and resuscitation. Selective inhibition of iNOS activity with N-(3-(aminomethyl)benzyl) acetamidine (1400 W, 10 mg kg−1 i.v., 5 min prior to the onset of resuscitation), also attenuated nitrotyrosine formation, renal dysfunction, liver injury and brain or muscular injury associated with haemorrhagic shock. The expression of iNOS protein was unaffected by 1400 W. We propose that the activation of tyrosine kinases and the induction of iNOS contribute to the multiple organ injury caused by severe haemorrhage and resuscitation. [Copyright &y& Elsevier]

Background: The Advanced Life Support (ALS) Provider Course trains healthcare professionals in a standardised approach to the management of a cardiac arrest. In the setting of limited resources for healthcare training, it is important that courses are fit for purpose in addressing the needs of both the individual and healthcare system. This study investigated the use of ALS skills in clinical practice after training on an ALS course amongst members of the cardiac arrest team compared to first responders.Methods: Questionnaires measuring skill use after an ALS course were distributed to 130 doctors and nurses.Results: 91 replies were returned. Basic life support, basic airway management, manual defibrillation, rhythm recognition, drug administration, team leadership, peri- and post-arrest management and resuscitation in special circumstances were used significantly more often by cardiac arrest team members than first responders. There was no difference in skill use between medically and nursing qualified first responders or arrest team members.Conclusion: We believe that the ALS course is more appropriately targeted to members of a cardiac arrest team. In our opinion the recently launched Immediate Life Support course, in parallel with training in the recognition and intervention in the early stages of critical illness, are more appropriate for the occasional or first responder to a cardiac arrest. [ABSTRACT FROM AUTHOR]

The use of automated external defibrillators (AED) by lay people has the potential to markedly increase survival from community cardiac arrest. Wider public use of AEDs requires units that can be operated safely and effectively by people with minimal or no training. This study compares the use of three AEDs by untrained lay people regarding ease-of-use, safety, pad positioning and time to defibrillation. 24 subjects with no prior exposure to the use of AEDs were asked to perform simulated defibrillation on a manikin using three defibrillators: Zoll AEDPlus, Medtronic Physio-Control LifePak CR Plus and Philips/Laerdal HeartStart OnSite Defibrillator. Subjects’ performance were videotaped and reviewed for time to defibrillate, pad positioning and safety. Subjects were asked to rate the three units in terms of ease-of-use. Average times to first shock were 74.8 s for the Physio-Control, 83.0 s for the Laerdal and 153.4 s for the Zoll defibrillator. Pad positioning was scored as correct in 23/24 Laerdal trials, 19/24 Physio-Control trials and 14/24 Zoll trials. 23 out of the 24 subjects rated the Zoll most difficult to use. All subjects safely stayed clear of the unit when required. The majority of subjects safely and effectively delivered defibrillating shocks without any prior training and within quite acceptable times. Untrained subjects find the Physio-Control and Laerdal Defibrillator easier to use than the Zoll device. Features of AED design that improved ease of use are discussed. [Copyright &y& Elsevier]

Background: The administration of oxygen at a high-inspired concentration is often required in medicine, particularly in resuscitation of critically ill patients. However, there is a lack of evidence-based guidance on how to achieve this using currently available apparatus. The aim of this study was to assess how maximum inspired oxygen concentrations can be delivered using existing equipment. Methods: Ten healthy female volunteers breathed oxygen through two types of Hudson non-rebreathing mask with reservoir bag, one with a safety vent in the mask body and the other with a valve replacing this safety vent (3-valve mask). Oxygen flow was adjusted to either 10 or 15 l min−1 and the masks were fitted to the face either loosely or tightly. The expired oxygen concentration was measured using an oxygen analyzer. Findings: By using the Hudson non-rebreathing mask with three valves, increasing the oxygen flow to 15 l min−1, and fitting the mask tightly to the face the average expired oxygen fraction could be raised to 0.85. This equates to an average inspired oxygen fraction of 0.97 in these subjects. Interpretation: The three simple measures mentioned above result in a significant improvement in the performance of the Hudson non-rebreathing mask. Together they allow the delivery of an inspired oxygen concentration close to maximum. [Copyright &y& Elsevier]

Oxygen deficiency during critical illness may cause profound changes in cellular metabolism and subsequent tissue and organ dysfunction. Clinical treatment in these cases targets rapid reoxygenation to avoid a prolonged impaired synthesis of cellular high-energy phosphates (ATP). However, the effect of this therapeutic intervention on tissue metabolism has not been determined yet. Thus the present study was designed to determine the effects of hypoxia and reoxygenation with either room air or 100% oxygen on variables of interstitial metabolism in different tissues using in vivo microdialysis. Twenty-seven adult, male CD-rats (407–487 g; Ivanovas, Kisslegg, Germany) were studied during general anesthesia. Following preparation and randomization, rats were normoventilated for 45 min (FiO2 0.21), followed by induction of hypoxia (FiO2 0.1, 40 min) and reoxygenated for 50 min either with FiO2 1.0 (group 1, n=10) or FiO2 0.21 (group 2, n=10). Control animals (n=7) were ventilated with 21% oxygen during the observation period. Additional to invasive haemodynamic parameters, biochemical tissue monitoring was performed using CMA 20 microdialysis probes, inserted into muscle, subcutaneous space, liver, and the peritoneal cavity allowing analyses of lactate and pyruvate at short intervals. Hypoxia induced a significant reduction in mean arterial pressure (MAP) in group 1 and 2 compared with the control group (P<0.05) without any significant differences between both treatment groups. This was accompanied by a significant increase in blood lactate (10.5±3.1 mM (group 1) and 12.3±4.1 mM (group 2) vs. 1.5±0.3 mM (control); P<0.05) and severe metabolic acidosis (base excess (BE): −18.3±5 mM (1) and −17.3±7 mM (2) vs. −2.6±1.8 mM (control), P<0.05). During hypoxia, the interstitital lacate/pyruvate ratio in groups 1 and 2 increased to 455±199% (muscle), 468±148% (intraperitoneal), 770±218% (hepatic) and 855±432% (subcutaneous) (P<0.05 vs. control, respectively). No significant inter-organ or inter-group differences in interstitial dialysates were observed in the treatment groups, neither during hypoxia nor during reoxygenation. Our data suggest, that hypoxia induces comparable metabolic alterations in various tissues and that reoxygenation with 100% oxygen is not superior to 21% oxygen in restoring tissue metabolism after critical hypoxia. [Copyright &y& Elsevier]

Background: The aim of this research is to evaluate quality of out-of-hospital medical services in our country, using performance indicators and a new computerised database. Methods: (a) Experimental design: Data were collected prospectively in three emergency dispatch centres for 90 days. Follow-up was evaluated at 1 day and 1 month after the event. This paper presents data on the cardiac arrest cohort only. (b) Setting: Three emergency dispatch centres in Lombardia. (c) Patients: One hundred and seventy-eight patients in non-traumatic cardiac arrest were enrolled. (d) Interventions: None. The study was observational only. Results: Mean interval between phone call and arrival on scene was 8.5±3.5 min. BLS manoeuvres were carried out from bystanders only in 15% of the cohort; this was associated with significant mortality reduction (85.7 versus 95.8%, χ2 P<0.05). One hundred and thirty-three patients (75%) received assistance from BLS crews while only 45 patients (25%) were assisted by ALS medical personel, with a significant mortality reduction (ALS deaths 86.7%, BLS deaths 97%). Total 24 h survival was 9% and survival at 1 month declined to 6.17%. Conclusions: Quality monitoring produces objective information on interventions and outcomes. Only with this information, is it possible to implement improvement programmes that are planned according to the data presented. [Copyright &y& Elsevier]