Physicians didn't improve outcome from nontraumatic cardiac arrest

A Norwegian study retrospectively compared outcomes from non-traumatic cardiac arrest between ambulances staffed by physicians (PMA) and non-physician ambulances (non-PMA). There were no differences in any of the clinical outcome measures used in this study of 977 patients, in which 13% (PMA) and 11% (non-PMA) survived to hospital discharge.

Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome

Resuscitation. 2009 Nov;80(11):1248-52

Fluids for cooling post cardiac arrest

Large volume cold fluid resuscitation after return of spontaneous circulation can contribute to effective cooling but does it impair cardiac or respiratory function? A retrospective review of 52 resuscitated cardiac arrest patients suggests that the infusion of large volumes of cold fluid does not cause a further significant reduction in  respiratory function beyond that normally seen after cardiac arrest despite significantly reduced LV function.
Effects of large volume, ice-cold intravenous fluid infusion on respiratory function in cardiac arrest survivors
Resuscitation. 2009 Nov;80(11):1223-8
In the same issue of Resuscitation, a prospective study of cardiac arrest survivors in positive fluid balance from cold fluid cooling showed frequent evidence of hypovolaemia as determined by serial ultrasound assessment.
An accompanying editorial suggests this may be due to the systemic inflammatory response syndrome that follows successful cardiac arrest resuscitation; large volumes are tolerated well and myocardial dysfunction should not lead to restriction of fluids after cardiac arrest.
Assessment of intravascular volume by transthoracic echocardiography during therapeutic hypothermia and rewarming in cardiac arrest survivors
Resuscitation. 2009 Nov;80(11):1234-9

Paediatric gastric tubes

A child with status epilepticus has been stabilised and intubated and is awaiting admission to the paediatric intensive care unit. You decide to insert a nasogastric tube. The nurse asks the following questions:
1. What size gastric tube would you like?

[EXPAND Answer]A general guide is twice the size of the uncuffed tracheal tube.
A four year old for example would usually need a tracheal tube size of 5.0mm internal diameter (age/4 +4), so would need a 10 Fr gastric tube.

2. To what length are you intending to insert it?

[EXPAND Answer]A formula based on height of the child can be used, so get your tape measure or length chart out:
For neonates < 2 weeks and children >8 years 4 months a method called NEMU (nose-ear-midxiphoid-umbilicus measurement) may be used.

3. How will you confirm placement?

[EXPAND Answer]It is very likely this child will get a post-intubation chest radiograph and the gastric tube tip can be visualised on that. However non-radiological tests should be used and pH testing of the aspirate is recommended, looking for pH<6

Further details on these measurements including positive and negative likelihood ratios of pH testing can be found in the evidence-based guideline from Cincinnati Children’s Hospital

Extracorporeal Albumin Dialysis for Acute Liver Failure

NICE has issued guidance on this procedure for patients with acute liver failure.
“The procedure removes toxins bound to albumin in the blood in addition to the water-soluble toxins that can be removed by haemodialysis.”
They state that current evidence on its efficacy is inadequate in quality and quantity, and recommend the procedure “should only be used with special arrangements for clinical governance, consent and audit or research.”
Guidance summary here

Life threatening post partum haemorrhage

A mother may experience life-threatening haemorrhage after delivery of her baby. What can the resuscitation doctor do?
Rosen’s Emergency Medicine describes four main differential diagnoses: uterine atony, genital tract trauma, retained placental tissue, and coagulopathies, or the “four Ts”: tone, trauma, tissue, and thrombin.
As well as resuscitation with fluid and blood products and urgent obstetric and anaesthetic referral, efforts should be made to restore uterine tone with manual and pharmacological means, and consider tamponade of the haemorrhage.
The MOET (Management of Obstetric Emergencies & Trauma) Course outlines the following interventions for major obstetric haemorrhage:

  • Empty uterus: deliver fetus if undelivered / remove placenta or retained products (this may need to be done digitally according to Rosen)
  • Oxytocin / ergometrine / prostaglandin
  • Massage & bimanual compression of uterus
  • Repair genital tract injury
  • Uterine packing or Rusch balloon
  • Compression of aorta
  • Surgical or interventional radiological options: internal iliac or uterine artery ligation, hysterectomy, arterial embolisation

A review of the different balloon tamponade devices available describes the urological Rusch balloon, the dedicated Bakri balloon, a condom sutured to a Foley catheter, multiple Foley catheters, and the Sengstaken-Blakemore tube (SBT). In order for the SBT balloon to reach the uterine fundus, either the tip of the catheter can be cut and the gastric balloon inflated, or the SBT can be folded and the oesophageal balloon inflated. Normal saline is used to inflate the balloon until tamponade is achieved. If the cervix is dilated, vaginal packing may be necessary to prevent migration of the balloon out of the uterus..
The Royal College of Obstetricians and Gynaecologists published 2009 guidelines on PPH. The full text is available here. After commencing resuscitation, summoning help, considering the ‘four T’s’, and examining the patient they recommend:

  • Bimanual uterine compression (rubbing up the fundus) to stimulate contractions.
  • Ensure bladder is empty (Foley catheter, leave in place).
  • Syntocinon 5 units by slow intravenous injection (may have repeat dose).
  • Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension).
  • Syntocinon infusion (40 units in 500 ml Hartmann’s solution at 125 ml/hour) unless fluid restriction is necessary.
  • Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma).
  • Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma), with responsibility of the administering clinician as it is not recommended for intramyometrial use.
  • Misoprostol 1000 micrograms rectally.

Balloon tamponade may then be attempted in cases of uterine atony pending surgical haemostasis if necessary.
As with all life-threatening emergencies, the resuscitation doctor should have a plan, and know his or her options regarding personnel, facilities and equipment. We recommend a closer look at the articles and guidelines referenced above in formulating your own plan as to how you might save a young mother’s life.

Spinal Cord Injury Guidelines

The Paralyzed Veterans of America produce a number of evidence-based guidelines for management of spinal cord injury and its complications that may be useful for the critical care doctor, downloadable from here.
The most relevant to frontline professionals is the Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. A summary of the major recommendations from this document can be found here.