Asystolic Cardiac Arrest Research Articles

Resuscitator's perceptions and time for corrective ventilation steps during neonatal resuscitation

BackgroundThe 2010 neonatal resuscitation program (NRP) guidelines incorporate ventilation corrective steps (using the mnemonic – MRSOPA) into the resuscitation algorithm. The perception of neonatal providers, time taken to perform these maneuvers or the effectiveness of these additional steps has not been evaluated. MethodsUsing two simulated clinical scenarios of varying degrees of cardiovascular compromise – perinatal asphyxia with (i) bradycardia (heart rate – 40min–1) and (ii) cardiac arrest, 35 NRP certified providers were evaluated for preference to performing these corrective measures, the time taken for performing these steps and time to onset of chest compressions. ResultsThe average time taken to perform ventilation corrective steps (MRSOPA) was 48.9±21.4s. Providers were less likely to perform corrective steps and proceed directly to endotracheal intubation in the scenario of cardiac arrest as compared to a state of bradycardia. Cardiac compressions were initiated significantly sooner in the scenario of cardiac arrest 89±24s as compared to severe bradycardia 122±23s, p<0.0001. There were no differences in the time taken to initiation of chest compressions between physicians or mid-level care providers or with the level of experience of the provider. ConclusionsEffective ventilation of the lungs with corrective steps using a mask is important in most cases of neonatal resuscitation. Neonatal resuscitators prefer early endotracheal intubation and initiation of chest compressions in the presence of asystolic cardiac arrest. Corrective ventilation steps can potentially postpone initiation of chest compressions and may delay return of spontaneous circulation in the presence of severe cardiovascular compromise.

Presentations to the Emergency Department Following Cannabis use--a Multi-Centre Case Series from Ten European Countries.

Cannabis is the most commonly used illicit drug in Europe, and is generally regarded as having low acute toxicity. We present the findings of the first 6 months of data collection from the Euro-DEN project on presentations related to cannabis use to further understand the acute toxicity related to the use of cannabis. Data was extracted on clinical features, treatment and outcome from the Euro-DEN minimum dataset for all cases of acute recreational drug toxicity reported 1st October 2013 to 31st March 2014 for all cannabis-related presentations. Of 2198 presentations reported by 14 of the 16 Euro-DEN centres, 356 (16.2 %) involved cannabis either alone or together with other drugs/alcohol. There were 36 that involved lone use of cannabis (1.6 % of all presentations). Of the 35 non-fatal lone cannabis presentations, the most commonly reported features were neuro-behavioural (agitation/aggression 8 (22.9 %), psychosis 7 (20.0 %), anxiety 7 (20.0 %)) and vomiting 6 (17.1 %). Most patients (25, 71.4 %) received no treatment and 30 (85.7 %) were discharged/self-discharged from the ED. There was one fatality amongst these lone-cannabis cases: an 18-year-old male collapsed with an asystolic cardiac arrest whilst smoking cannabis and suffered hypoxic brain injury related to prolonged cardiac arrest. THC was detected in a urine sample taken at ED arrival; no other drugs were detected. Lone acute cannabis toxicity was typically associated with neuro-behavioural symptoms and vomiting. Although uncommon, severe toxicity including cardiovascular toxicity and death may be under-recognised, and it is important that Emergency Physicians are aware of this.

Do different anesthesia regimes affect hippocampal apoptosis and neurologic deficits in a rodent cardiac arrest model?

BackgroundDifferent anesthesia regimes are commonly used in experimental models of cardiac arrest, but the effects of various anesthetics on clinical outcome parameters are unknown. We conducted a study in which we subjected rats to cardiac arrest under medetomidine/ketamine or sevoflurane/fentanyl anesthesia.MethodsAsystolic cardiac arrest for 8 minutes was induced in 73 rats with a mixture of potassium chloride and esmolol. Daily behavioral and neurological examination included the open field test (OFT), the tape removal test (TRT) and a neurodeficit score (NDS). Animals were randomized for sacrifice on day 2 or day 5 and brains were harvested for histology in the hippocampus cornus ammonis segment CA1. The inflammatory markers IL-6, TNF-α, MCP-1 and MIP-1α were assessed in cerebrospinal fluid (CSF). Proportions of survival were tested with the Fisher’s exact test, repeated measurements were assessed with the Friedman’s test; the baseline values were tested using Mann–Whitney U test and the difference of results of repeated measures were compared.ResultsIn 31 animals that survived beyond 24 hours neither OFT, TRT nor NDS differed between the groups; histology was similar on day 2. On day 5, significantly more apoptosis in the CA1 segment of the hippocampus was found in the sevoflurane/fentanyl group. MCP-1 was higher on day 5 in the sevoflurane/fentanyl group (p = 0.04). All other cyto- and chemokines were below detection threshold.ConclusionIn our cardiac arrest model neurological function was not influenced by different anesthetic regimes; in contrast, anesthesia with sevoflurane/fentanyl results in increased CSF inflammation and histologic damage at day 5 post cardiac arrest.

Molecular Biology Becomes Diagnostic Tool in the Newborn Emergency Department: A Rare Case of Child Idiopathic Arterial Calcification

A Turkish infant of 96 days is accepted to the pediatric emergency room after being carried by their parents because of inconsolable crying, persistent cough, and difficulty in feeding during the previous day. Although she was aware and nor signs nor symptoms was suggestive of an impending MOF, in a few minutes it takes over an asystolic cardiac arrest. It was found the exitus after 75 minutes of resuscitation. The autopsy report indicates as pathological cause of death a rare form of childhood idiopathic calcific arterial disease caused by mutation of the gene encoding the same name EPP1 enzyme.

Is extracorporeal rewarming indicated in avalanche victims with unwitnessed hypothermic cardiorespiratory arrest?

International guidelines recommend using extracorporeal rewarming in all hypothermic avalanche victims with prolonged cardiac arrest if they have patent airways and a plasma potassium level≤12 mmol/L. The aim of this study was to evaluate outcome data to determine if available experience with extracorporeal rewarming of avalanche victims supports this recommendation. At Innsbruck Medical University Hospital, 28 patients with hypothermic cardiac arrest following an avalanche accident were resuscitated using extracorporeal circulation. Of these patients, 25 were extricated from the snow masses with no vital signs and did not survive to hospital discharge. Three patients had witnessed cardiac arrest after extrication and a core temperature of 21.7°C, 22°C, and 24.0°C, two of whom survived long-term with full neurological recovery. A search of the literature revealed only one asystolic avalanche victim with unwitnessed hypothermic cardiac arrest (core temperature 19°C) surviving long-term. All other avalanche victims in the medical literature surviving prolonged hypothermic cardiac arrest suffered witnessed arrest after extrication with a core temperature below 24°C. Our results suggest that prognosis of hypothermic avalanche victims with unwitnessed asystolic cardiac arrest and a core temperature>24°C is extremely poor. Available outcome data do not support the use of extracorporeal rewarming in these patients.

Pheochromocytoma-Induced Inverted Takotsubo-Like Cardiomyopathy Leading to Cardiogenic Shock Successfully Treated With Extracorporeal Membrane Oxygenation

Pheochromocytoma classically displays a variety of rather benign symptoms, such as headache, palpitations, and sweating, although severe cardiac manifestations have been described. We report a case of pheochromocytoma-induced inverted takotsubo-like cardiomyopathy leading to shock and cardiac arrest successfully treated with extracorporeal membrane oxygenation (ECMO) as a bridge to pharmacological therapy and curative adrenalectomy. A previously healthy 46-year-old woman presented to the emergency department with abdominal pain, dyspnea, nausea, and vomiting. Clinical evaluation revealed cardiorespiratory failure with hypoxia and severe metabolic acidosis. Computed tomography (CT) scan showed pulmonary edema and a left adrenal mass. Transthoracic echocardiography (TTE) displayed severe left ventricular dysfunction with inverted takotsubo contractile pattern. Despite mechanical ventilation and inotropic and vasopressor support, asystolic cardiac arrest ensued. The patient was resuscitated using manual chest compressions followed by venoarterial ECMO. Repeated TTEs demonstrated resolution of the cardiomyopathy within a few days. Laboratory results indicated transient renal and hepatic dysfunction, and CT scan of the brain displayed occipital infarctions. Biochemical testing and radionuclide scintigraphy confirmed a pheochromocytoma. Pharmacological adrenergic blockade was instituted prior to delayed adrenalectomy after which the diagnosis was histopathologically verified. The patient recovered after rehabilitation. We conclude that pheochromocytoma should be considered in patients presenting with unexplained cardiovascular compromise, especially if they display (inverted) takotsubo contractile pattern. Timely, adequate management might involve ECMO as a bridge to pharmacological therapy and curative surgery.

Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage

Noncompressible torso hemorrhage is a leading cause of death in trauma, with many patients dying before definitive hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct than can be used to expand the window of salvage in patients with end-stage hemorrhagic shock. The aim of this study was to evaluate the effect of continuous and intermittent REBOA (iREBOA) on mortality using a highly lethal porcine model of noncompressible torso hemorrhage. Male splenectomized pigs (70-90 kg) underwent a laparoscopic liver injury (80% resection of left lobe) followed by a 10-min free-bleed period. Animals were then divided into three groups (n = 8) for a 60-min intervention phase (n = 8): continuous occlusion (cREBOA), iREBOA, or no occlusion (nREBOA). Groups then underwent whole blood resuscitation, damage control surgery, and further critical care. Endpoints were mortality and hemodynamic and circulating measures of shock and resuscitation. Systolic blood pressure (in mmHg) at the end of the free-bleed period for cREBOA, iREBOA, and nREBOA was 31 ± 14, 48 ± 28, and 28 ± 17, respectively (P = 0.125). Following the start of the intervention phase, systolic blood pressure was higher in the iREBOA and cREBOA groups compared with the nREBOA (85 ± 37 and 96 ± 20 vs. 42 ± 4; P < 0.001). Overall mortality for the cREBOA, iREBOA, and nREBOA groups was 25.0%, 37.5%, and 100.0% (P = 0.001). Resuscitative endovascular balloon occlusion of the aorta can temporize exsanguinating hemorrhage and restore life-sustaining perfusion, bridging critical physiology to definitive hemorrhage control. Prospective observational studies of REBOA as a hemorrhage control adjunct should be undertaken in appropriate groups of human trauma patients.

Massive Pulmonary Embolism in a Patient Undergoing Cesarean Delivery

A case of a 40 year old, 86 kg, G7P1 woman with a history of hypercoagulability, at 39.1 weeks' gestation, who presented for elective Cesarean section during spinal anesthesia, is presented. During closure of the uterus, she became unresponsive and went into asystolic cardiac arrest. During resuscitation, clinical signs suggested pulmonary embolism, as confirmed by transesophageal echocardiogram. She was anticoagulated and taken to the Cardiac Catheterization Laboratory; there, clot lysis was performed, resulting in massive bleeding. Embolization of the uterine arteries was attempted and was only partially successful in reducing the bleeding. She then underwent Cesarean hysterectomy to control the bleeding. She had a full recovery and was discharged on the sixth postoperative day.

Abstract 2: PTEN Inhibition Improves Cardiovascular Function and Energy Metabolism While Decreasing Inflammation After Mouse Cardiac Arrest

Introduction: The survival kinase Akt mediates therapeutic hypothermia protection after mouse cardiac arrest (CA). This central kinase affects cardiovascular function, metabolism and inflammation. Phosphatase and tensin homolog deleted on chromosome ten (PTEN) is a primary phosphatase that negatively regulates Akt activity. We hypothesized that the PTEN inhibitor, VO-OHpic (VO), will mimic hypothermia protection by enhancing energy metabolism and cardiac function while reducing inflammation after CA. Methods: C57BL6 mice underwent 8 min of KCl-induced (0.08 mg/g) asystolic CA. VO (10 μg/kg) was administrated IP 30 min before CA. Neurologically intact survival at 72 h after CPR was measured and cardiac function was evaluated by Millar catheter. Blood lactate and glucose were assessed using colorimetric kits, and a cytokine panel using multiplex ELISA. Phosphorylation of Akt, GSK3β and phospholamban in heart and brain were studied by Western blot as markers of Akt activation. Heart cells isolated from 1-2-day old C57BL6 mice and exposed to 30 min ischemia and 90 min reperfusion were used to measure VO effects on contractile function in a cell model of cardiac stunning. Results: VO improved 72 hour survival (90% vs. 50%, p &lt; 0.01). At 30 min after ROSC, VO significantly increased Dp/dt max (5123.4 ± 1026.9 mmHg/s vs. 4033.5 ± 622.4 mmHg/s, p&lt;0.05), and ETCO2 (39.1 ± 2.8 vs. 35.3 ± 1.2 mmHg, p&lt;0.05) with continued benefit seen at 2 hours. VO significantly increased lactate clearance by 4 hours demonstrated by decreased plasma lactate and glucose. The anti-inflammatory cytokine IL10 was increased while VO decreased the pro-inflammatory IL-1β. VO increased the phosphorylation of Akt (Thr308 and Ser473), p-GSK3β and the Akt target phospholamban. In mouse cardiomyocytes, VO (1 μM) improved the contractile velocity (54.6 ± 2.3 % vs. 33.3 ± 3.9 %, p &lt; 0.05), increased total ATP content and the ratio of ATP/ADP during ischemia and enhanced L-type calcium channel recovery. Conclusions: PTEN inhibition improved neurologically intact survival after CA, with improved energy metabolism and cardiac function, and decreased inflammation. Use of PTEN inhibitors such as VO may be a novel strategy with or without cooling for treating the metabolic phase of cardiac arrest.

Simulation-Based Trial of Surgical-Crisis Checklists

Crises in operating rooms (ORs) require rapid, coordinated care. Checklists have been accepted in other high-risk industries to improve performance during rare and unpredictable critical events. The use of checklists during routine operative care has led to significant reductions in morbidity and mortality. This randomized controlled trial was undertaken to determine the effect of using a crisis checklist during simulations of life-threatening events. Participants were recruited from 1 academic medical center and 2 community hospitals and included teams of anesthesia staff, OR nurses, surgical technologists, and a mock surgeon participant. Each team spent a 6-hour day in a high-fidelity simulated OR where they were presented with crisis scenarios and tested for adherence to 47 key processes derived from evidence-based guidelines. In half the scenarios, the team had access to a set of checklists for crisis events. In the other half, they worked from memory, as usual. The crises included air embolism, anaphylaxis, asystolic cardiac arrest, hemorrhage followed by ventricular fibrillation, malignant hyperthermia, unexplained hypotension and hypoxemia followed by unstable bradycardia, and unstable tachycardia. The checklists were placed adjacent to the anesthesia machine and the circulating nurse’s work area. The primary outcome was failure to adhere to lifesaving processes of care for each crisis. All simulation sessions were recorded, observed, and scored. Study participants were surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. Data were analyzed using SAS software; P < 0.05 was considered significant. Seventeen OR teams, with wide-ranging experience, participated in 106 simulated crisis scenarios. Use of the checklist led to a 75% reduction in failure to adhere to critical steps in management; 6% of steps were missed with checklists available compared with 23% without checklists available (P < 0.001). Results were similar in a multivariate analysis adjusting for institution, scenario, and simulation learning or fatigue. The effect of the checklists did not differ among participants from academic or community hospitals. The significant effect of checklist use was also seen when results were stratified according to scenario. The scenarios were grouped into 3 categories: those directly related to algorithms for advanced cardiac life support, those related to algorithms for advanced cardiac life support and preceded by a precode condition, and other crisis scenarios. In all strata, failure rates were significantly lower in scenarios in which the crisis checklists were used. The effect of the checklist was significant (P < 0.001) in all secondary analyses. Participants reported that the checklists were easy to use and helped them feel better prepared, and they would use the checklists if presented with these operative emergencies in real life. The use of crisis checklists led to a significant improvement in adherence to recommended procedures for common intraoperative emergencies. After participation, 97% of the participants said they would want checklists used if they had an intraoperative crisis as a patient. Events undoubtedly occur in more varied circumstances than possible to simulate, but these results suggest that hospitals and ambulatory surgical centers should consider implementation of checklists to increase the safety of surgical care.

A Most Unusual Passage Per Rectum

Question: A 60-year-old man with acute myelogenous leukemia (AML) in remission relapsed and was admitted for salvage chemotherapy. He received induction with methotrexate, epirubicin and cisplatin. During the course of treatment, he became hypotensive and tachycardic, prompting transfer to the intensive care unit. Septic shock was empirically treated with broad-spectrum antibiotics. His course was further complicated by persistent pancytopenia, atrial fibrillation with rapid ventricular response, disseminated intravascular coagulation and respiratory failure requiring mechanical ventilation. He developed abdominal distension, proximal small bowel dilation, and mesenteric edema by computed tomography without pneumoperitoneum. Subsequent radiographic studies over several days revealed no interval changes; conservative therapy with nasogastric tube suction and methylnaltrexone was given. Five days later, he had an episode of melena accompanied by passage rectally of a 15-cm tubular structure (Figure A). Within hours of this event, he developed multisystem organ failure and hypotension followed by asystolic cardiac arrest. The tubular structure was sent for pathologic review (Figure B). What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Pathologic review revealed necrotic mucosa with cross-section containing luminal debris (black arrow), necrotic epithelium (red arrow), bacterial colonies and calcifications (blue arrow), and underlying superficial muscularis (green arrow). The superficial muscularis was thought to represent either thickened muscularis mucosa or a superficial layer of muscularis propria (Figure B). The final pathologic diagnosis was consistent with a partial thickness colonic cast. Passage of a partial or full thickness colonic cast is an extremely rare event. It was first described by Speakman and Turnbull in 1984 after an abdominal aortic aneurysm resection.1Speakman M.J. Turnbull A.R. Passage of a colon ‘cast’ following resection of an abdominal aortic aneurysm.Br J Surg. 1984; 71: 935Crossref PubMed Scopus (22) Google Scholar Since then, approximately one dozen additional case reports have been published.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar The common theme among most reported cases has been intestinal ischemia after abdominal surgery—usually repair or resection of an abdominal aortic aneurysm.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar Other surgeries that have led to this serious complication include rectal resection, J-pouch formation, and Hartmann pouch reversal.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar Nonsurgical conditions associated with passage of a colonic cast include graft-versus-host-disease,3Al Ashgar H. Peedikayil M. Chaudhri N. et al.Defecation of a “colon cast” as a rare presentation of acute graft-versus-host disease.Ann Saudi Med. 2009; 29: 231-233Crossref PubMed Scopus (35) Google Scholar acute pancreatitis, and now salvage chemotherapy for AML. Appropriate suspicion should arise in critically ill patients who have undergone colorectal or abdominal aneurysm surgery or those with significant intestinal ischemia and critical illness; such settings may rarely herald passage of a colonic cast. Although passage is often a near-terminal event, resection of the ischemic segment in the appropriate clinical setting may be a life-saving measure.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar

Dilated Cardiomyopathy

A 42-year-old woman presented herself to the emergency services in cardiogenic shock. She had a history of progressively worsening breathlessness for the past year; however, no medical evaluation had been performed earlier. At presentation, her pulse rate was 110 beats per minute, regular, and low volume, and her blood pressure was 90/70 mm Hg. On auscultation, third heart sound was present, but no murmurs were heard. Soon after presentation, she had an asystolic cardiac arrest. However, she was resuscitated successfully and mechanically ventilated, and she required inotropic support with dopamine and noradrenaline for maintaining blood pressure. Her ECG showed normal sinus rhythm and nonspecific ST-T changes, and chest radiograph showed cardiomegaly with features of pulmonary venous hypertension (Figure 1). Her echocardiogram showed severe left-ventricular systolic dysfunction with a left-ventricular ejection fraction of 20% (Figure 2). Her routine blood biochemistry, including liver and renal function tests, was within normal limits, except for mild anemia with hemoglobin of 9.5 g/dl. A diagnosis of dilated cardiomyopathy …

Intra‐arrest formation of right‐heart thrombi – a case illustrated by real‐time ultrasonography

The presence of free-floating right-heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free-floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right-heart thrombus formation during a resuscitated cardiac arrest. We present the pre-hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre-hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

Brugada pattern electrocardiogram unmasked with cocaine ingestion.

Cocaine is considered a leading cause of drug-related deaths. This is usually sudden, unwitnessed, and without prodromal features. It has been reported that in-hospital mortality is close to 2%. Cocaine has powerful central nervous system effects1 and acute cocaine overdose has been associated with hyperthermia, agitation, paranoid ideation, status epilepticus, ventricular fibrillation, ventricular tachycardia, and myocardial infarction (MI). The mechanisms of cocaine-related death remain poorly understood. We report a patient who survived massive cocaine ingestion with psychomotor agitation and generalized seizures followed by asystolic cardiac arrest and transient Brugada pattern on electrocardiogram (ECG).

Two cases of asystolic cardiac arrests managed with therapeutic hypothermia

Poor neurological outcome is a common sequel of prolonged cardiac arrest. Although Therapeutic Hypothermia (TH) for neuroprotection has been a subject for research for over Half a century, its use has been limited because of many controversies and lack of clear guidelines. However for over two decades there has been a revival of interest in mild therapeutic hypothermia (32-34°C) for neuroprotection. However its use after primary asystolic cardiac arrest has been questioned.Herein presenting two cases of prolonged asystolic arrest (39 minutes and 25 minutes); where therapeutic hypothermia was successfully used in following prolonged cardio pulmonary resuscitation. On patients who were in deep coma after resuscitation, TH was applied for 24 hours as per institutional protocol with full neurological recovery in both the cases. Therapeutic hypothermia might have a potential role in even in non-shockable arrests and should be considered in every successful cardiopulmonary resuscitation with poor neurological status.

Massive pulmonary embolism in a patient undergoing Cesarean delivery

A case of a 40 year old, 86 kg, G7P1 woman with a history of hypercoagulability, at 39.1 weeks’ gestation, who presented for elective Cesarean section during spinal anesthesia, is presented. During closure of the uterus, she became unresponsive and went into asystolic cardiac arrest. During resuscitation, clinical signs suggested pulmonary embolism, as confirmed by transesophageal echocardiogram. She was anticoagulated and taken to the Cardiac Catheterization Laboratory; there, clot lysis was performed, resulting in massive bleeding. Embolization of the uterine arteries was attempted and was only partially successful in reducing the bleeding. She then underwent Cesarean hysterectomy to control the bleeding. She had a full recovery and was discharged on the sixth postoperative day.

Thumbs Up Sign in Brain Death

Spinal reflexes can be seen in the setting of brain death. We present a new spinal reflex. We also review spinal movements in pediatric brain death and provide suggestions to distinguish them from movements generated by the brain. We report a five-year old girl admitted after an asystolic cardiac arrest and was soon declared brain death as a result of bilateral cerebellar hematoma. She had spinal movements including a "Thumbs up sign". These findings delayed organ procurement. "Thumbs up sign" should be added to the list of spinal reflexes seen with brain death. Spinal reflexes in brain death can be clinically recognized and should explained to all involved parties to avoid unnecessary testing, confusion for family members, and delay or refusal of organ donation.

CHLORAMPHENICOL WITH FLUID AND ELECTROLYTE THERAPY CURES TERMINALLY ILL GREEN TREE FROGS (LITORIA CAERULEA) WITH CHYTRIDIOMYCOSIS

Terminal changes in frogs infected with the amphibian fungal pathogen Batrachochytrium dendrobatidis (Bd) include epidermal degeneration leading to inhibited epidermal electrolyte transport, systemic electrolyte disturbances, and asystolic cardiac arrest. There are few reports of successful treatment of chytridiomycosis and none that include curing amphibians with severe disease. Three terminally ill green tree frogs (Litoria caerulea) with heavy Bd infections were cured using a combination of continuous shallow immersion in 20 mg/L chloramphenicol solution for 14 days, parenteral isotonic electrolyte fluid therapy for 6 days, and increased ambient temperature to 28 degrees C for 14 days. All terminally ill frogs recovered rapidly to normal activity levels and appetite within 5 days of commencing treatment. In contrast, five untreated terminally ill L. caerulea with heavy Bd infections died within 24-48 hr of becoming moribund. Subclinical infections in 15 experimentally infected L. caerulea were cured within 28 days by continuous shallow immersion in 20 mg/L chloramphenicol solution without adverse effects. This is the first known report of a clinical treatment protocol for curing terminally ill Bd-infected frogs.

Continuous Mechanical Chest Compression Using the LUCAS-2 Device as a Bridge to Emergency Aortic Valve Surgery

A 44-year-old woman diagnosed with infective endocarditis was transferred to a tertiary-level hospital for further evaluation and treatment. During transport, she was fully conscious, hemodynamically stable, and spontaneously breathing with supplied nasal oxygen. On arrival at the tertiary hospital, she suffered asystolic cardiac arrest while being transferred from a stretcher to a bed. Immediate cardiopulmonary resuscitation (CPR) was initiated with manual chest compressions. Advanced cardiac life support was continued for 10 minutes using the algorithm of nonshockable rhythms.

I-gel Has High Success for Elective Intubations

In this large study, the i-gel was associated with a 93% first-attempt success rate and few complications. Researchers prospectively evaluated 2049 i-gel supraglottic airway device insertions in elective surgery patients at 5 Swiss hospitals over a 24-month period. After induction of anesthesia, operators recorded data on operator specialty and experience, patient characteristics, airway assessment, anesthesia management, and perioperative complications. The first-attempt i-gel success rate was 93%, and the overall success rate was 96%. Risk factors for first-attempt i-gel failure were male sex, older age, poor dentition, and impaired mandibular subluxation. Mean airway leak pressure was 26 cm H2O. Providers classified 92% of insertions as easy or very easy. Complications included mucosal injury (3%), sore throat (2%), laryngospasm or bronchospasm (1%), nerve injury (2 patients), and glottic hematoma (1 patient). One patient suffered an asystolic cardiac arrest but had return of spontaneous circulation 1 minute later. Comment: Although this study is subject to selection bias, the large number of insertions shows that the i-gel is associated with high success (>93%) and relatively minor complications in an elective surgery population. The leak pressure is comparable to that for a standard laryngeal mask airway. Based on these results, the i-gel is a reasonable choice for emergency airway management in patients without a predicted difficult airway.