Advanced Life Support Interventions Research Articles

Principles and Practice of Palliative Care

The trajectories of serious illness and dying have changed in the last century; in the past, patients lived shorter lives and often died quickly of infectious disease, whereas patients in the 21st century live longer and often with prolonged debility in the advanced stages of illness. As a result, patients with serious illness can suffer undertreated symptoms and often feel poorly prepared for the final stages of disease. With more options for advanced life support and other aggressive interventions at the end of life, patients and families face increasingly complex medical decisions in the terminal phase of illness, and the treatments they receive do not always align with their goals and values. Emerging evidence suggests that integrating palliative care into the treatment of advanced illness can improve outcomes, decrease costs, and improve both patient and family satisfaction. Consequently, patient access to high-quality specialty-level palliative care is becoming standard of care at most academic cancer centers and more available in the community. This chapter describes the practice and principles of specialty-level palliative care and outlines specific "generalist" palliative care competencies essential for all physicians caring for patients with serious illness, including prognostication, patient-centered communication, and the navigation of ethical dilemmas in the field of palliative care. Tables outline the philosophy of palliative care, domains of suffering, location of death of hospice patients, the palliative performance scale, median survival times for cancer syndromes, indicators associated with a poorer prognosis in congestive heart failure, the NURSE mnemonic for accepting and responding to emotion, palliative care communication competencies in the intensive care unit, and the SPIKES mnemonic for breaking bad news. Figures depict causes of death in 1900 versus 2010, palliative care through the trajectory of serious illness, theoretical trajectories of disease, life expectancies for women and men, mortality at 1 year post discharge, and a model for patient-centered communication. This review contains 6 highly rendered figures, 9 tables, and 169 references.

Principles and Practice of Palliative Care

The trajectories of serious illness and dying have changed in the last century; in the past, patients lived shorter lives and often died quickly of infectious disease, whereas patients in the 21st century live longer and often with prolonged debility in the advanced stages of illness. As a result, patients with serious illness can suffer undertreated symptoms and often feel poorly prepared for the final stages of disease. With more options for advanced life support and other aggressive interventions at the end of life, patients and families face increasingly complex medical decisions in the terminal phase of illness, and the treatments they receive do not always align with their goals and values. Emerging evidence suggests that integrating palliative care into the treatment of advanced illness can improve outcomes, decrease costs, and improve both patient and family satisfaction. Consequently, patient access to high-quality specialty-level palliative care is becoming standard of care at most academic cancer centers and more available in the community. This chapter describes the practice and principles of specialty-level palliative care and outlines specific "generalist" palliative care competencies essential for all physicians caring for patients with serious illness, including prognostication, patient-centered communication, and the navigation of ethical dilemmas in the field of palliative care. Tables outline the philosophy of palliative care, domains of suffering, location of death of hospice patients, the palliative performance scale, median survival times for cancer syndromes, indicators associated with a poorer prognosis in congestive heart failure, the NURSE mnemonic for accepting and responding to emotion, palliative care communication competencies in the intensive care unit, and the SPIKES mnemonic for breaking bad news. Figures depict causes of death in 1900 versus 2010, palliative care through the trajectory of serious illness, theoretical trajectories of disease, life expectancies for women and men, mortality at 1 year post discharge, and a model for patient-centered communication. This chapter contains 6 highly rendered figures, 9 tables, 169 references, 1 teaching slide set, and 5 MCQs.

Principles and Practice of Palliative Care

The trajectories of serious illness and dying have changed in the last century; in the past, patients lived shorter lives and often died quickly of infectious disease, whereas patients in the 21st century live longer and often with prolonged debility in the advanced stages of illness. As a result, patients with serious illness can suffer undertreated symptoms and often feel poorly prepared for the final stages of disease. With more options for advanced life support and other aggressive interventions at the end of life, patients and families face increasingly complex medical decisions in the terminal phase of illness, and the treatments they receive do not always align with their goals and values. Emerging evidence suggests that integrating palliative care into the treatment of advanced illness can improve outcomes, decrease costs, and improve both patient and family satisfaction. Consequently, patient access to high-quality specialty-level palliative care is becoming standard of care at most academic cancer centers and more available in the community. This chapter describes the practice and principles of specialty-level palliative care and outlines specific "generalist" palliative care competencies essential for all physicians caring for patients with serious illness, including prognostication, patient-centered communication, and the navigation of ethical dilemmas in the field of palliative care. Tables outline the philosophy of palliative care, domains of suffering, location of death of hospice patients, the palliative performance scale, median survival times for cancer syndromes, indicators associated with a poorer prognosis in congestive heart failure, the NURSE mnemonic for accepting and responding to emotion, palliative care communication competencies in the intensive care unit, and the SPIKES mnemonic for breaking bad news. Figures depict causes of death in 1900 versus 2010, palliative care through the trajectory of serious illness, theoretical trajectories of disease, life expectancies for women and men, mortality at 1 year post discharge, and a model for patient-centered communication. This chapter contains 6 highly rendered figures, 9 tables, 169 references, 1 teaching slide set, and 5 MCQs.

Principles and Practice of Palliative Care

The trajectories of serious illness and dying have changed in the last century; in the past, patients lived shorter lives and often died quickly of infectious disease, whereas patients in the 21st century live longer and often with prolonged debility in the advanced stages of illness. As a result, patients with serious illness can suffer undertreated symptoms and often feel poorly prepared for the final stages of disease. With more options for advanced life support and other aggressive interventions at the end of life, patients and families face increasingly complex medical decisions in the terminal phase of illness, and the treatments they receive do not always align with their goals and values. Emerging evidence suggests that integrating palliative care into the treatment of advanced illness can improve outcomes, decrease costs, and improve both patient and family satisfaction. Consequently, patient access to high-quality specialty-level palliative care is becoming standard of care at most academic cancer centers and more available in the community. This chapter describes the practice and principles of specialty-level palliative care and outlines specific "generalist" palliative care competencies essential for all physicians caring for patients with serious illness, including prognostication, patient-centered communication, and the navigation of ethical dilemmas in the field of palliative care. Tables outline the philosophy of palliative care, domains of suffering, location of death of hospice patients, the palliative performance scale, median survival times for cancer syndromes, indicators associated with a poorer prognosis in congestive heart failure, the NURSE mnemonic for accepting and responding to emotion, palliative care communication competencies in the intensive care unit, and the SPIKES mnemonic for breaking bad news. Figures depict causes of death in 1900 versus 2010, palliative care through the trajectory of serious illness, theoretical trajectories of disease, life expectancies for women and men, mortality at 1 year post discharge, and a model for patient-centered communication. This review contains 6 highly rendered figures, 9 tables, and 169 references.

Does a mechanical chest compressor (LUCAS2®) disturb the resuscitation interventions?

Purpose: To analyze if the use of a mechanical chest compressor disturbs the main resuscitation interventions during advanced life support (ALS). Describe the time of the ALS interventions in an Emergency Medical System.

How Well Do Emergency Medical Dispatch Codes Predict Prehospital Medication Administration in a Diverse Urban Community?

BackgroundThe Medical Priority Dispatch System (MPDS) is an emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. MPDS is a computer-based EMD system that uses callers' responses to scripted questions to categorize cases into groups and subgroups, based on complaint and perceived acuity. ObjectiveThis study evaluates the ability of MPDS codes to predict prehospital use of medications. MethodsAll transported prehospital patients assigned a subgroup by MPDS from January 1, 2009 to December 31, 2009 in a diverse urban community were matched with their prehospital electronic patient care records. The records of transported patients dispatched through EMD were queried for prehospital interventions and matched to their MPDS classifications. Only MPDS subgroups with 10 or more calls were included in the analysis. ResultsA total of 38,005 patients met inclusion criteria. Patients with chest pain, breathing problems, heart problems, and diabetic problems received the most medications. Medications were administered in 19% of all calls. The individual MPDS subgroup with the highest rate of medication administration was 6E1A (breathing problems, 76%). Higher rates of Advanced Life Support (ALS) interventions in higher-acuity categories (e.g., Alpha, Bravo, Charlie) were seen in several EMD categories, including unconscious/fainting, breathing problems, and abdominal pain; but this was not observed in many other categories, including seizure, sick person, traumatic injury, and hemorrhage/lacerations. ConclusionsMedications were administered in 19% of all calls. There were higher rates of ALS interventions in higher-acuity categories that were not observed in many other categories.

Confined Space Emergency Response: Assessing Employer and Fire Department Practices

An emergency response plan for industrial permit-required confined space entry is essential for employee safety and is legally required. Maintaining a trained confined space rescue team, however, is costly and technically challenging. Some employers turn to public fire departments to meet their emergency response requirements. The confined space emergency response practices of employers and fire departments have not been previously assessed. We present (1) federal data on the U.S. occurrence between 1992 and 2005 of confined space fatal incidents involving toxic and/or oxygen-deficient atmospheres; (2) survey data from 21 large companies on permit-required confined space emergency response practices; (3) data on fire department arrival times; and (4) estimates by 10 senior fire officers of fire department rescue times for confined space incidents. Between 1992 and 2005, 431 confined space incidents that met the case definition claimed 530 lives, or about 0.63% of the 84,446 all-cause U.S. occupational fatal injuries that occurred during this period. Eighty-seven (20%) incidents resulted in multiple fatalities. Twelve (57%) of 21 surveyed companies reported that they relied on the fire department for permit-required confined space emergency response. Median fire department arrival times were about 5 min for engines and 7 min for technical rescue units. Fire department confined space rescue time estimates ranged from 48 to 123 min and increased to 70 and 173 min when hazardous materials were present. The study illustrates that (1) confined space incidents represent a small but continuing source of fatal occupational injuries in the United States; (2) a sizeable portion of employers may be relying on public fire departments for permit-required confined space emergency response; and (3) in the event of a life-threatening emergency, fire departments usually are not able to effect a confined space rescue in a timely manner. We propose that the appropriate role for the fire department is to support a properly trained and equipped on-site rescue team and to provide advanced life support intervention following extrication and during ambulance transportation.

AP027 Resuscitation in EMS-witnessed prehospital traumatic cardiac arrest

Background: Prehospital traumatic cardiac arrest (TCA) is undoubtedly associated with poor prognosis. The subgroup of patients with detectable vital signs (VS) upon Emergency Medical Services (EMS) arrival and a subsequent EMS-witnessed TCA is of special interest, since it might be associated with better outcome. Materials and Methods: Sixty patients with EMS-witnessed prehospital TCA (Male/Female: 45/15, Mean age: 34.0±21.4 years, Median age: 25 years) were managed by EMS physicians in the area of Thessaloniki during a 10-year period (01.01.1995–31.12.2004). All patients had palpable carotid pulse and organized ECG activity upon EMS arrival and suffered a subsequent, at the scene or during transport, EMS-witnessed TCA. Results: Mean EMS arrival time was 8.3±5.5 min. All patients but one, suffered blunt trauma. Palpable peripheral pulse was detected in 22 (36.67%) cases. Initial median GCS score was 6 (3–15). Pupils were found normal sized in 39 (65.0%) and dilated in 21 (35.0%) patients. Pupillary reflexes were present in 21 (35.0%) patients. During cardiopulmonary resuscitation, all patients received Advanced Life Support interventions by means of endotracheal intubation, fluid resuscitation and chest tube drainage as appropriate. In 25 (41.67%) cases, resuscitation efforts were terminated before arrival at hospital. In total, 35 (58.33%) patients exhibited return of spontaneous circulation. Thirty-two (53.33%) of them died, 12 in the Emergency Department, 17 in the Operating Room and 3 in the Intensive Care Unit. Finally, 3 (5.0%) patients survived to hospital discharge, but only 1 (1.67%) – suffering penetrating neck trauma – with full neurological recovery. Autopsy causes of death revealed severe isolated or multiple organ injuries. Conclusions: The results of our study are in accordance to other similar literature studies and confirm the extremely poor survival rate after TCA. Moreover, resuscitation, even in EMS-witnessed TCA, seems to be in the majority of the cases futility.

The critically ill patient: making the referral to intensive care

Intensive care units are responsible for looking after patients with reversible life-threatening conditions, who need frequent and often invasive monitoring as well as support from mechanized equipment and pharmacological therapies to maintain normal body function and physiological parameters. A previous article highlighted how to recognize and stabilize the sick patient (Elnour and Shankar-Hari, 2011). Some patients may continue to deteriorate despite appropriate and prompt intervention. This article outlines the criteria for advanced life support interventions and hence admission to critical care. The focus of discussion will be patients in need of level 2 to 3 care requiring priority 1 to 2 admissions.

AP028 The impact of delayed transfer to inpatient units for successfully resuscitated out-of-hospital cardiac arrest patients on survival to discharge

Background: Prehospital traumatic cardiac arrest (TCA) is undoubtedly associated with poor prognosis. The subgroup of patients with detectable vital signs (VS) upon Emergency Medical Services (EMS) arrival and a subsequent EMS-witnessed TCA is of special interest, since it might be associated with better outcome. Materials and Methods: Sixty patients with EMS-witnessed prehospital TCA (Male/Female: 45/15, Mean age: 34.0±21.4 years, Median age: 25 years) were managed by EMS physicians in the area of Thessaloniki during a 10-year period (01.01.1995–31.12.2004). All patients had palpable carotid pulse and organized ECG activity upon EMS arrival and suffered a subsequent, at the scene or during transport, EMS-witnessed TCA. Results: Mean EMS arrival time was 8.3±5.5 min. All patients but one, suffered blunt trauma. Palpable peripheral pulse was detected in 22 (36.67%) cases. Initial median GCS score was 6 (3–15). Pupils were found normal sized in 39 (65.0%) and dilated in 21 (35.0%) patients. Pupillary reflexes were present in 21 (35.0%) patients. During cardiopulmonary resuscitation, all patients received Advanced Life Support interventions by means of endotracheal intubation, fluid resuscitation and chest tube drainage as appropriate. In 25 (41.67%) cases, resuscitation efforts were terminated before arrival at hospital. In total, 35 (58.33%) patients exhibited return of spontaneous circulation. Thirty-two (53.33%) of them died, 12 in the Emergency Department, 17 in the Operating Room and 3 in the Intensive Care Unit. Finally, 3 (5.0%) patients survived to hospital discharge, but only 1 (1.67%) – suffering penetrating neck trauma – with full neurological recovery. Autopsy causes of death revealed severe isolated or multiple organ injuries. Conclusions: The results of our study are in accordance to other similar literature studies and confirm the extremely poor survival rate after TCA. Moreover, resuscitation, even in EMS-witnessed TCA, seems to be in the majority of the cases futility.

Decisions to withhold advanced life support treatment (DNR) for patients deceased at the Emergency Department, Karolinska University Hospital Solna, Stockholm, Sweden (KS)

Decisions to withhold advanced life support treatment (DNR) for patients deceased at the Emergency Department, Karolinska University Hospital Solna, Stockholm, Sweden (KS)

Does Emergency Medical Dispatch Priority Predict Delphi Process-Derived Levels of Prehospital Intervention?

The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch system widely used to prioritize 9-1-1 calls and optimize resource allocation. This study evaluates whether the assigned priority predicts a Delphi process-derived level of prehospital intervention in each emergency medical dispatch category. All patients given a MPDS priority in a suburban California county from 2004-2006 were included. A Delphi process of emergency medical services (EMS) professionals in another system developed the following categories of prehospital treatment representing increasing acuity, which were adapted for this study: advanced life support (ALS) intervention, ALS-Stat, and ALS-Critical. The sensitivities and specificities of MPDS priority for level of prehospital intervention were determined for each MPDS category. Likelihood ratios of low and high priority dispatch codes for the level of prehospital intervention also were calculated for each MPDS category. A total of 65,268 patients met inclusion criteria, representing 61% of EMS calls during the study period. The overall sensitivities of high-priority dispatch codes for ALS, ALS-Stat, and ALS-Critical interventions were 83% (95% confidence interval 83-84%), 83% (82-84%), and 94% (92-96%). Overall specificities were: ALS, 32% (31-32%); ALS-Stat, 31% (30-31%); and ALS-Critical 28% (28-29%). Compared to calls assigned to a low priority, calls with high-priority dispatch codes were more likely to receive ALS interventions by 22%, ALS-Stat by 20%, and ALS-Critical by 32%. A low priority dispatch code decreased the likelihood of ALS interventions by 48%, ALS-Stat by 45%, and ALS-Critical by 80%. Among high-priority dispatch codes, the rates of interventions were: ALS 26%, ALS-Stat 22%, and ALS-Critical 1.5%, all of which were significantly greater than low-priority calls (p<0.05) [ALS 13%, ALS-Stat 11%, and ALS-Critical 0.2%]. Major MPDS were categories with high sensitivities (>95%) for ALS interventions included breathing problems, cardiac or respiratory arrest/death, chest pain, stroke, and unconscious/fainting; these categories had an average specificity of 3%. Medical Priority Dispatch System categories such as back pain, unknown problem, and traumatic injury had sensitivities for ALS interventions<15%. The MPDS is moderately sensitive for the Delphi process derived ALS, ALS-Stat, and ALS-Critical intervention levels, but nonspecific. A low MPDS priority is predictive of no prehospital intervention. A high priority, however, is of little predictive value for ALS, ALS-Stat, or ALS-Critical interventions.

Air Ambulance Transport Times and Advanced Cardiac Life Support Interventions during the Interfacility Transfer of Patients with Acute ST-segment Elevation Myocardial Infarction

Objectives. To characterize transport times for the interfacility air ambulance transport of patients with acute ST-segment elevation myocardial infarction (STEMI), to estimate the proportion of patients at risk of in-transport clinical decompensation, and to explore associated risk factors for such. Methods. The electronic medical records of 35 air ambulance programs in the United States from December 2003 through December 2008 were reviewed. We defined clinical decompensation during transport as the combined outcome of either cardiopulmonary arrest or the receipt of any of a prespecified set of advanced life support (ALS) interventions. Multiple logistic regression employing generalized estimating equations to model autocorrelation of measures within air ambulance programs was used to explore the relationship between time from dispatch to transport and the outcome of interest. Results. Three thousand seven hundred sixty-seven transports of STEMI patients were identified during the period of interest. Eighty-five percent of rotor wing transports (median 80 minutes, interquartile range [IQR] 66–104) and 7% of fixed-wing transports (median 162 minutes, IQR 142–210) attained a total transfer time of ≤2 hours. Clinical decompensation in transport occurred in 182 of 3,767 (4.8%, 95% confidence interval [CI] 4.2–5.6%) transports. The most frequent critical ALS interventions were the administration of antiarrhythmics and the initiation of vasopressors. The odds ratios (ORs) for clinical decompensation comparing higher pretransport time quartiles with the lowest quartile (i.e., Q1: 6–50 minutes) were as follows: Q4: 82–1,500 minutes, OR 2.5 (95% CI 1.3–4.8, p = 0.007); Q3: 64–81 minutes, OR 1.9 (95% CI 1.0–3.6, p = 0.0499); and Q2: 51–63 minutes, OR 1.45 (95% CI 0.7–3.1, p = 0.34). Cardiac arrest or need for an ALS intervention prior to transport and a history of diabetes were also predictive of the outcome of interest. Conclusions. The majority of interfacility rotor-wing air ambulance transfers of patients with STEMI achieved a total transfer time of ≤2 hours. Clinical decompensation requiring ALS treatment occurred in a small percentage of patients. Diabetes, prior arrest or decompensation, and delays to transport were associated with clinical decompensation in the air. Efforts to reduce delays to transport may reduce this risk in transported patients.

Paramedic Intercepts with Basic Life Support Ambulance Services in Rural Minnesota

In rural Minnesota, it is common for paramedics providing advanced life support (ALS) to rendezvous with ambulances providing only basic life support (BLS). These "intercepts" presumably allow for a higher level of care when patients have certain problems or need ALS interventions. The aim of this study was to review and understand the frequency of paramedic intercepts with regard to the actual care rendered and transport urgency (lights and sirens vs. none). All paramedic intercepts occurring between January 2003 and December 2007 for one multi-site emergency medical services (EMS) provider were reviewed for ALS interventions and treatments provided. In addition, the urgency of responses to the dispatch call or "intercept" and transport to a receiving facility were analyzed. During the study period, 1,675 paramedic intercepts occurred and were reviewed. The ALS ambulances responded to the dispatch emergently (lights and sirens) in 97.5% of intercepts (1,633), but emergently transported only 24.2% of the patients (405). Paramedics performed no interventions above BLS levels in 11.6% (194) of the cases. Of the remaining 1,481 patients who received ALS interventions, 955 (64.4%) received no treatment or diagnostic testing other than electrocardiographic monitoring, intravenous access, or both. A significant discrepancy between emergent responses and actual ALS care rendered during intercept calls was demonstrated. Given the significant rate of EMS worker fatalities and transferable patient care costs, further study is needed to determine whether costs and safety are potentially improved by decreasing emergent responses. Future directions include developing or emulating Medical Priority Dispatch System triage protocols for advanced services providing intercepts. In addition, further study of patient outcomes between intercept and non-intercept cases is necessary.

Nosocomial and community-acquired infection rates of patients treated by prehospital advanced life support compared with other admitted patients

Objectives Nosocomial infections are a large burden to both patients and health care organizations, causing hospitals to take measures in an attempt to reduce microorganism transmission. Patients treated by emergency medical services are one population that has not been studied regarding infection rates. This study examines admitted patients treated by advanced life support (ALS) and their likelihood of having community-acquired and nosocomial infections. Methods A retrospective cohort study was conducted of 154 318 admitted patients between 2003 and 2007. Subjects identified as having either community-acquired or nosocomial infections were grouped based on infection type and ALS treatment. The proportion of infected patients among total hospital admissions in each of these groups was calculated and compared using odds ratios (ORs). Results A total of 5418 patients had at least 1 infection while admitted (3653 nosocomial, 1765 community). The probability of an ALS patient getting a nosocomial infection was 3.20% versus 2.28% for non-ALS patients (OR, 1.42; 95% confidence interval [CI], 1.28-1.57). There was no significant difference in community-acquired infections between ALS and non–ALS-treated groups (1.22% vs 1.14%; OR, 1.08; 95% CI, 0.92-1.26). Conclusions Despite having similar rates of community-acquired infections, patients admitted after ALS treatment had significantly greater risk for nosocomial infections. Because causality is not established, it remains unknown whether paramedic interventions contributed to the increased rate. Quite possibly, these patients are more susceptible to virulent organisms; however, prospective research is needed to identify causal relationships. Thus, treatment by ALS can be used as an identifier of patients at an increased risk of acquiring nosocomial infections.

Effect of Crew Size on Objective Measures of Resuscitation for Out-of-Hospital Cardiac Arrest

Background. There is no consensus among emergency medical services (EMS) systems as to the optimal numbers and training of EMS providers who respond to the scene of prehospital cardiac arrests. Increased numbers of providers may improve the performance of cardiopulmonary resuscitation (CPR), but this has not been studied as part of a comprehensive resuscitation scenario. Objective. To compare different all-paramedic crew size configurations on objective measures of patient resuscitation using a high-fidelity human simulator. Methods. We compared two-, three-, and four-person all-paramedic crew configurations in the effectiveness and timeliness of performing basic life support (BLS) and advanced life support (ALS) skills during the first 8 minutes of a simulated cardiac arrest scenario. Crews were compared to determine differences in no-flow fraction (NFF) as a measure of effectiveness of CPR and time to defibrillation, endotracheal intubation, establishment of intravenous access, and medication administration. Results. There was no significant difference in mean NFF among the two-, three-, and four-provider crew configurations (0.32, 0.26, and 0.27, respectively; p == 0.105). More three- and four-person groups completed ALS procedures during the scenario, but there was no significant difference in time to performance of BLS or ALS procedures among the crew size configurations for completed procedures. There was a trend toward lower time to intubation with increasing group size, though this was not significant using a Bonferroni-corrected p-value of 0.01 (379, 316, and 263 seconds, respectively; p == 0.018). Conclusion. This study found no significant difference in effectiveness of CPR or in time to performance of BLS or ALS procedures among crew size configurations, though there was a trend toward decreased time to intubation with increased crew size. Effectiveness of CPR may be hindered by distractions related to the performance of ALS procedures with increasing group size, particularly with an all-paramedic provider model. We suggest a renewed emphasis on the provision of effective CPR by designated providers independent of any ALS interventions being performed.

Surviving Cardiac Arrest

Surviving cardiac arrest requires high-quality cardiopulmonary resuscitation, advanced life support interventions, and optimal post-cardiac arrest care. After return of spontaneous circulation and stabilization of airway, breathing, and circulation, the focus shifts to the treatment of post-cardiac arrest syndrome. Research indicates this unique and complex syndrome requires specific treatment strategies.

Simulated rescue airway use by laypersons with scripted telephonic instruction

Background The King LT-D is a supraglottic airway with the potential for use by trained first responders in settings where access to advanced life support interventions by a physician or Emergency Medical Services may be delayed. Objectives To determine the success rate of novice users in the telephone-directed placement of the King LT-D airway during a simulated respiratory arrest in order to establish the feasibility of conducting further study into use of the device by first responders after minimal training. Methods We conducted a prospective study using 30 undergraduate students without medical training and a high-fidelity simulator. Subjects were instructed using a telephone-directed protocol to assess the airway, place the King LT-D and ventilate the simulator. Subjects were assessed on the successful placement of the King LT-D, time to placement, and perceived ease of use of the device. A Likert scale was used to identify the participant's perceptions. Subjects with CPR/AED certification were compared to those without such training. Data were analyzed using descriptive statistics and a t-test. Results The King airway was successfully placed in 80% (95% CI: 65; 95) of attempts. Success rate did not differ with prior CPR training. The median time to successful placement was 1 min 50 s (95% CI: 1 min 6 s; 2 min 39 s). The participants perceived the King LT-D to be easy to place in 90% (27/30) of cases. Conclusion The King LT-D is simple enough to use, that it can be successfully placed by novice users with minimal telephonic instruction. This suggests that further studies could be conducted to determine the effect of King LT-D use on quality of airway management in scenarios depicting management of cardiac arrest by first responders in areas with delayed access to ALS interventions.

Enfermería de cuidados intensivos y terapias continuas de reemplazo renal

Continuous renal replacement therapy (CRRT) has evolved within the space of a few years and is currently as widely used in intensive care units as, for example, mechanical ventilation. However, for this treatment to be useful to the critically ill patient, the nurse must have the knowledge required to solve the complications that may arise when this technique is used in order to achieve the desired objectives and to avoid complications arising from its misuse. In some units and countries, this has led to conflict about the nurses best qualified to apply these therapies. However, advances in technology have simplified the machines used. The purpose of this article was firstly, to provide a basic approximation to knowledge of the continuous extrarenal purification system and, secondly, to describe the nursing care, which can be divided into three parts: catheter care, care of the circuit, and patient care for the appropriate use of CRRT. Nurses initially perceive CRRT as being difficult to apply but with proper training these treatments become one more therapy within the framework of advanced life support treatment of critically the ill.

Management of Prehospital Seizure Patients by Paramedics

Background. Seizure patients are frequently encountered in the prehospital environment andhave the potential to need advanced interventions, though the utility of advanced life support (ALS) interventions in many of these patients has not been proven. Objective. Our goals were to assess the management of prehospital seizure patients by paramedics in an urban EMS system with an existing ALS-based prehospital seizure protocol andto assess characteristics andshort-term outcomes that may aid in addressing the utility of specific ALS interventions. Methods. This was a retrospective study of 97 EMS cases with the chief complaint of seizure. Prehospital records were reviewed for patient andevent characteristics, including past seizure history, seizure timing, level of consciousness, on-scene andtransport times, andEMS interventions. Emergency department (ED) records were reviewed for recurrence of seizure activity, ED evaluation, anddisposition. Data were analyzed using descriptive statistics andStudent t-test. Results. Of 87 patients meeting the protocol inclusion criteria for all ALS interventions, 11 (12.6%) received cardiac monitoring, 55 (63.2%) had intravenous (IV) access attempted, and56 (64.4%) had blood glucose determination. Average on-scene time was 5.9 minutes longer if IV access was attempted (p = 0.001), though transport times were not significantly different (11.6 versus 11.3 minutes, respectively; p = 0.851). Additional seizure activity occurred in the prehospital and/or ED settings in 28 patients (28.9% of all cases), including 17 in the prehospital setting and15 in the ED. Diazepam was administered by EMS for half of the eight (8.2%) patients who had seizures lasting more than 1 minute, while the remainder had seizures that were focal or spontaneously resolved. Conclusion. This study showed a lower-than-anticipated level of compliance with an ALS-based prehospital seizure protocol, though patient-specific care appeared appropriate. Prehospital seizure patients have the potential for seizure recurrence andmay benefit from focused ALS interventions, but their heterogeneity makes uniform protocols difficult to develop andfollow.