Emergency medicine residents and paramedics cannulated patients who were anaesthetised. The external jugular vein (EJV) took longer to cannulate and had a higher failure rate than an antecubital vein. More than a quarter of the paramedics and a third of the doctors failed to cannulate the EJV.
Is external jugular vein cannulation feasible in emergency care? A randomised study in open heart surgery patients
Resuscitation. 2009 Dec;80(12):1361-4
Category Archives: PHARM
Prehospital and Retrieval Medicine
IO in OI
A case report describes three failed attempts to flush or secure an intraosseous needle placed using the EZ-IO drill during cardiac arrest of an adult patient subsequently noted to have osteogenesis imperfecta (OI) type III. While not listed as a contraindication to EZ-IO use by the manufacturer, one should consider that OI may result in procedural failure.
Intraosseous access in osteogenesis imperfecta (IO in OI)
Resuscitation. 2009 Dec;80(12):1442-3
HEMS paramedic intubation success
All medical out of hospital cardiac arrests attended by the Warwickshire and Northamptonshire Air Ambulance (WNAA) over a 64-month period were reviewed. There were no significant differences in self-reported intubation failure rate, morbidity or clinical outcome between doctor-led and paramedic-led cases. The authors conclude that experienced paramedics regularly operating with physicians have a low tracheal intubation failure rate at out of hospital cardiac arrests, whether practicing independently or as part of a doctor-led team, and that this is likely due to increased and regular clinical exposure.
Can experienced paramedics perform tracheal intubation at cardiac arrests? Five years experience of a regional air ambulance service in the UK
Resuscitation. 2009 Dec;80(12):1342-5
DC shock? I want my blankie!
A blanket made of nonconducting material was used to allow CPR to continue during defibrillation of arrested swine. Coronary perfusion pressure was maintained when the blanket was used
but fell when there was a hands-off interruption for defibrillation. Also, the defibrillation threshold was significantly lower when the blanket was used. A good idea, although even the authors point out that “Thus far, medical literature has not reported any rescuer or bystander serious injury from receiving an inadvertent shock while in direct or indirect contact with a patient while performing CPR“
The resuscitation blanket: A useful tool for “hands-on” defibrillation
Resuscitation. 2010 Feb;81(2):230-23
Precordial thump
The precordial thump is recommended for witnessed and monitored ventricular fibrillation/ventricular tachycardia (VF/VT) cardiac arrest when a defibrillator is not immediately available.
Haman et al investigated the precordial thump in patients in whom VT or VF was initiated during an electrophysiological study, applying a single thump after initiation of ventricular arrhythmia in 155 patients. This terminated the tachycardia in two (1.3%) patients.
Pellis et al investigated the precordial thump as an initial measure by paramedics in 144 patients in out-of-hospital cardiac arrest, irrespective of the initial rhythm. Three patients had return of spontaneous circulation and two were discharged alive.
Precordial thump efficacy in termination of induced ventricular arrhythmias
Resuscitation 2009;80:14–6
Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study
Resuscitation 2009;80:17–23
Naloxone in cardiac arrest
Previous case reports and animal studies have suggested a possible role for naloxone in cardiac arrest even in the absence of opioid overdose.
Possible mechanisms include reducing the myocardial depressant effect of endogenous opioids, stimulating catecholamine release, and providing antiarryhthmic effects through an effect on cardiomyocyte ion channels.
A retrospective review of 32,544 out of hospital cardiac arrests over 5 years revealed 36 to have received pre-hospital naloxone. Of these, only one survived to hospital discharge, who tested positive for opiates in a urine toxicology screen in the emergency department.
No need to change the guidelines yet then.
Naloxone in cardiac arrest with suspected opioid overdoses
Resuscitation. 2010 Jan;81(1):42-6
Thoracostomy in blunt traumatic arrest
37 patients with blunt traumatic cardiac arrest underwent attempted resuscitation by a HEMS crew over a four year period. Chest decompression was performed in 18 cases (17 thoracostomy, one needle decompression). The procedure revealed evidence of chest injury in 10 cases (pneumothorax, haemothorax, massive air leak) and resulted in return of circulation and survival to hospital in four cases. All four cases died of associated major head injury, although one became a heart beating organ donor. Only half of the cases found to have pneumothorax demonstrated clinical signs of one prior to chest decompression.
The authors state: ‘Relying on clinical signs of the thorax alone will not identify all patients with these injuries, and our data support extending the practice into all patients with a suitable mechanism of injury together with external evidence of chest injury.’
Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest
Emerg Med J. 2009 Oct;26(10):738-40
Not such a B.I.G. success in the field?
Success rates with the bone injection gun were 71% (10 out of 14) in children <16 years and 73% (19 out of 26) in adults. Less encouraging data than that seen with the EZ-IO device, and consistent with the experience of some other services.
Prehospital Intraosseus Access With the Bone Injection Gun by a Helicopter-Transported Emergency Medical Team
J Trauma. 2009 Jun;66(6):1739-41
Ballistic penetrating neck injury and the risk of immobilisation
British military physicians reported the outcomes of patients sustaining penetrating neck injury from the Iraq and Afghanistan conflicts. Three quarters were injured in explosions, one quarter from gunshots.
Of 90 patients, only 1 of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. The authors conclude that penetrating ballistic trauma to the neck is associated with a high mortality rate, and their data suggest that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk, and cervical collars may hide potential life-threatening conditions.
Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma
Injury. 2009 Dec;40(12):1342-5
Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury
Patients admitted to a level 1 trauma centre with traumatic brain injury whose end-tidal CO2 was kept with the Brain Trauma Foundation recommended limits of 30-35 mmHg (3.9-4.6 kPa) had a lower mortality than those whose CO2 was outside this range. The group in which the target was not achieved had a greater injury severity, which may have contribute to the difficulty in optimising ETCO2.
Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury
J Trauma. 2009 Jun;66(6):1577-82