Data were collected on 53 episodes of paraldehyde use in tonic-clonic status epilepticus, which showed it appeared to be effective at terminating seizures in 33 of 53 cases. The median dose was 0.79 ml/kg, in keeping with current APLS guidelines (0.4 ml/kg of paraldehyde plus 0.4 ml/kg olive oil given per rectum)
Review of the efficacy of rectal paraldehyde in the management of acute and prolonged tonic-clonic convulsions
Arch Dis Child. 2009 Sep;94(9):720-3
Category Archives: Resus
Life-saving medicine
Best way to insert NG tube in intubated patients
A randomised controlled trial on 200 anaesthetised, tracheally intubated adults compared four methods of nasogastric tube placement, looking at success rates, time to insertion, and complications.
The four groups were: control, using a ureteral guidewire as stylet, a slit endotracheal tube as an introducer, and head flexion with lateral neck pressure. All intervention groups were more successful than the control group. The time necessary to insert the NG tube was significantly longer in the slit endotracheal tube group, which also had the highest bleeding rate. Complications were fewest in the flexion group.
Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study
Anesth Analg. 2009 Sep;109(3):832-5
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
Effect on noradrenaline on tissue oxygen delivery
Some persist in thinking and teaching that the ‘vasopressor’ noradrenaline (norepinephrine) increases mean arterial pressure (MAP) simply by increasing systemic vascular resistance, leading to concerns that it may increase blood pressure at the expense of tissue perfusion. This assertion is contested by many, who now have further support from this study.
In 16 patients with septic shock, various measures of peripheral perfusion were recorded while the dose of noradrenaline was increased to achieve target MAPs. The use of noradrenaline to achieve incremental targets for MAP was associated with increases in global oxygen delivery, cutaneous microvascular flow, and tissue oxygenation in patients with established septic shock; there were no associated changes in the preexisting abnormalities of sublingual microvascular flow. The authors state that these findings suggest that in patients with septic shock, improvements in global hemodynamics and tissue oxygen delivery can be achieved with noradrenaline, without exacerbating microcirculatory flow abnormalities.
The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic shock
Crit Care Med. 2009 Jun;37(6):1961-6
No benefit from drugs in pre-hospital cardiac arrest
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
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
New College of Emergency Medicine Guidelines
New guidelines from the (UK) College of Emergency Medicine are available at http://www.collemergencymed.ac.uk by going to he Clinical Effectiveness Committee page.
Can venous blood gases replace arterial gases?
A comprehensive summary of the literature presented by Professor Anne-Maree Kelly in June 2009 at 4ème SYMPOSIUM INTERNATIONAL BLOOD GASES AND CRITICAL CARE TESTING in France can be viewed on her presentation slides at the link below.
She summarises:
- pH – Close enough agreement for clinical purposes in DKA, isolated metabolic disease; more work needed in shock, mixed disease
- Bicarbonate – Close enough agreement for clinical purposes in most cases; more work needed in shock, mixed disease, calculated vs measured gap
- pCO2 – NOT enough agreement for clinical purposes; potential as a screening test
- Potassium – Insufficient agreement between serum and BG values for clinical purposes
- Base excess – Insufficient data
Can venous blood gas analysis replace arterial in emergency and critical care?
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
Acute medicine guidelines
The Acute Medicine in the Emergency Department Seminar refers to a number of guidelines from different sources.
Go to the Acute Medicine guidelines