A Norwegian randomised controlled trial over five years compared out-of-hospital nontraumatic cardiac arrest outcomes between ACLS protocols with and without access to intravenous drugs (epinephrine/adrenaline, atropine, amiodarone).
Patients randomised to the drug group had a higher rate of hospital admission with return of spontaneous circulation, but there was no significant difference in survival to discharge, survival with favourable neurological outcome, or one year survival.
Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest
JAMA. 2009 Nov 25;302(20):2222-9
Category Archives: PHARM
Prehospital and Retrieval Medicine
Characteristic ECG signs of LAD occlusion without ST elevation
In a single centre observational study over 10 years of patients undergoing acute PCI of the left anterior descending (LAD) artery, 35 of 1890 (2%) had a distinct non-ST elevation ECG pattern.
The ECG showed ST-segment depression at the J-point of at least 1 mm in the precordial leads with upsloping ST-segments continuing into tall, symmetrical T-waves. Patients also showed a mean J-point elevation of approximately 0.5 mm in lead aVR.
This novel ECG pattern resolved after reperfusion in all included patients.
The authors caution that these electrocardiographic changes may be missed or misdiagnosed as reversible ischaemia, which might substantially delay the transportation to a PCI centre or the start of reperfusion therapy
The authors conclude: “It is important for cardiologists and emergency care physicians to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy.”
Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion
Heart. 2009 Oct;95(20):1701-6
Is cervical spine protection always necessary following penetrating neck injury?
This short cut review in the Best Bets format attempted to answer the question: “is cervical spine protection always necessary following penetrating neck injury?”
From the available evidence they draw the following conclusions:
- In stab wounds to the neck (with or without neurological deficit) an unstable spinal injury is very unlikely and c-spine immobilisation is not needed
- In gunshot wounds the value of cspine immobilisation is limited: for gunshot wounds without neurological deficit no immobilisation is required, while in cases of gunshot wounds with neurological deficit, or where the diagnosis cannot be made (ie, altered mental status), a collar or sandbag is advised once ABCs are stable, with close observation and intermittent removal to inspect and reassess.
- In the rare event of penetrating injury with combined blunt force trauma, a collar or sandbag is advised if possible, once ABCs are stable, with intermittent removal to reassess.
Emerg Med J. 2009 Dec;26(12):883-7
Full text at BestBets.org
Spinal imaging and immobilisation may be unnecessary in many GSW patients
A retrospective review of 4204 patients sustaining gunshot wounds (GSW) to the head, neck or torso examined the incidence of spinal cord injury and bony spinal column injury required operative spinal intervention. None of the patients demonstrated spinal instability requiring operative intervention, and only 2/327 (0.6%) required any form of operative intervention for decompression. The authors concluded that spinal instability following GSW with spine injury is very rare, and that routine spinal imaging and immobilisation is unwarranted in examinable patients without symptoms consistent with spinal injury following GSW to the head, neck or torso.
The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds
Injury. 2009 Aug;40(8):860-3
Cuffed tracheal tubes for children
In a prospective randomised controlled multi-centre trial, cuffed tracheal tubes were compared with uncuffed tubes in 2246 children aged from birth to five years undergoing general anaesthesia. There was no significant difference in post-extubation stridor but the need for tube exchange was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001).
From the resuscitation point of view, there remain few if any arguments for using an uncuffed tube.
Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children
Br J Anaesth. 2009 Dec;103(6):867-73
First Aid for Burns
A review of burn first aid treatments highlights the paucity of evidence on which to make firm recommendations. The authors recommend using cold running tap water (between 2 and 15 degrees C) and to avoid ice or alternative therapies. The optimum duration of first aid application and the delay after the injury for which first aid can still be effective are two areas of research which need further exploration.
A review of first aid treatments for burn injuries
Burns. 2009 Sep;35(6):768-75
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
Pre-hospital intubation for head injury: ?no benefit
A systematic review of pre-hospital intubation for head injured patients failed to show evidence of benefit of tracheal intubation or invasive ventilation. The authors acknowledge the lack of methodological quality in the studies reviewed and the predominance of US paramedic-delivered intubations without the use of anaesthetic drugs.
Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence
Br J Anaesth. 2009 Sep;103(3):371-86
Pre-hospital intubation 'success' at a US centre
Of 203 patients attending a US Level 1 trauma centre who had pre-hospital airway management, 25 (12%) had unrecognised oesophageal intubations.
Patients were treated in the field by fire rescue personnel of various municipalities and with different experience levels. Patients transported by air were significantly more likely to be successfully intubated than those transported by ground, perhaps due to both increased experience and the use by air crews of succinylcholine. The authors in their discussion contrast these results with those of European studies which report higher success rates with pre-hospital systems that employ emergency physicians and anaesthetists.
Prehospital intubations and mortality: a level 1 trauma center perspective
Anesth Analg. 2009 Aug;109(2):489-93