The Design of the Universe
A 19 minute video on the ‘design’ of the Universe
More like this from the wonderful TED website
External jugular vein a tricky one
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
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
Ionised hypocalcaemia after ROSC
Ionised hypocalcaemia has been observed post-cardiac arrest in previous studies. Investigators in Utah induced VF in a swine model and resuscitated them back to spontaneous circulation1. Ionised hypocalcaemia was associated with hypotension and impaired LV function, and its treatment with a calcium infusion resulted in improved mean arterial pressure and left ventricular stroke work.
Although iv calcium is not recommended as a blind treatment in cardiac arrest, in part due to concerns about exacerbating cellular injury, this study reminds us that the treatment of ionised hypocalcaemia is important, and may be necessary after ROSC.
1. Hypocalcemia following resuscitation from cardiac arrest revisited
Resuscitation 2010 Jan;81:117–122
Therapeutic hypothermia with simple measures
Thirty-eight post-cardiac arrest patients were effectively cooled to the target temperature range of 32-34 celsius using intravenous cold saline and ice packs to groin, axillae, and neck. The ice packs were frozen 250 ml saline bags wrapped in pillow cases. If shivering occurred muscle relaxation with rocuronium was used until the target temperature was reached. Interestingly, rebound hyperthermia occurred in 8/34 patients.
Although a small study, these data reassure those of us who induce therapeutic hypothermia without the use of dedicated cooling equipment.
Cold saline infusion and ice packs alone are effective in inducing and
maintaining therapeutic hypothermia after cardiac arrest
Resuscitation 2010;81:15–19