Difficult Resuscitation Research Articles

Cardiac arrest and cardiopulmonary resuscitation in "hostile" environments: Using automated compression devices to minimize the rescuers' danger.

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual, "hands-on", rescuer-delivered chest compressions. The -theoretical- advantages include high-quality non-stop compressions, thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially "hazardous" victim, or from hazardous and/or difficult resuscitation conditions. Such circumstances involve cardiopulmonary resuscitation (CPR) in the Cardiac Catheterization Laboratory, especially directly under the fluoroscopy panel, where radiation is well known to cause detrimental effects to the rescuer, and CPR during/after land or air transportation of cardiac arrest victims. Lastly, CPR in a coronavirus disease 2019 patient/ward, where the danger of contamination and further serious illness of the health provider is very existent. The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these "hostile" and dangerous settings, while comparing them to manual compressions.

State of the Art: An Update on Adult Burn Resuscitation

Treatment of patients with severe burn injuries is complex, relying on attentive fluid resuscitation, successful management of concomitant injuries, prompt wound assessment and closure, early rehabilitation, and compassionate psychosocial care. The goal of fluid resuscitation is to maintain organ perfusion at the lowest possible physiologic cost. This requires careful, hourly titration of the infusion rate to meet individual patient needs, and no more; the risks of over-resuscitation, such as compartment syndromes, are numerous and life-threatening. Recognizing runaway resuscitations and understanding how to employ adjuncts to crystalloid resuscitation are paramount to preventing morbidity and mortality. This article provides an update on fluid resuscitation techniques in burn patients, to include choosing the initial fluid infusion rate, using alternate endpoints of resuscitation, and responding to the difficult resuscitation.

How are Ambulance Personnel Prepared and Supported to Withhold or Terminate Resuscitation and Manage Patient Death in the Field? A Scoping Review

Introduction Research shows that ambulance personnel can find it challenging to withhold or terminate resuscitation and manage patient death in the field. This scoping review provides a synthesis of published research that has addressed three main questions. Each relates to ambulance personnel enacting decisions to withhold or terminate resuscitation and manage patient death: How are they prepare; what supports and coping strategies are utilised; and what preparation and support needs have been identified? Methods Using Arksey and O'Malley's five-stage scoping review framework this review identifies what is known and what further research is needed in this area. Results Sixteen methodologically heterogenous papers were located. Half of the studies were conducted in the United States, with the remainder in Canada, Singapore, Spain, Sweden and the United Kingdom. Ambulance personnel receive little formal training and feel unprepared to manage situations where resuscitation is unsuccessful or unwarranted, particularly communicating with family, breaking bad news and managing death scenes. These aspects of termination of resuscitation are so challenging that distancing and avoidance are sometimes used as coping strategies, even when medical futility has been established. In addition to formal counselling for personal loss and stressors, ambulance personnel value downtime and informal peer debriefing, following difficult resuscitation decisions and patient deaths. Conclusion Ambulance personnel feel inadequately prepared to withhold or terminate resuscitation and manage patient death in the field. They want more opportunities to learn about death notification, communication with bereaved families and safe, sensitive management of death scenes. More research is needed to determine how best to prepare and support ambulance personnel for the challenges of resuscitation decision-making and patient death.

Precise control of caval and hepatic vessels: Surgical technique to treat level III caval thrombus concomitant to renal cell carcinoma

We investigated the surgical techniques, safety, and prevention of complications of nephrectomy and removal of tumour thrombus for treating level III inferior vena cava (IVC) concomitant to renal cell carcinoma (RCC). We did this by precise controlling IVC and hepatic vessels without a vascular bypass. In this series, we included 5 patients with level III IVC tumour thrombus below the hepatic vein concomitant to RCC. After precisely controlling the IVC and hepatic vessels, we then removed the thrombus en bloc with the renal vein. Blood loss volume, IVC clamping time, hypotension time, resuscitation, cardiocerebrovascular complications, and postoperative organ dysfunction were observed. Surgery was successfully performed without perioperative death. Blood loss volume was 900 to 1500 mL, operation time was 165 to 250 minutes, vascular clamping time was 8 to 12 minutes, and intraoperative hypotension time was 9 to 12 minutes. Serious perioperative complications were not observed. Local recurrence was not observed during the 9 to 24 months of follow-up. One patient exhibited disease-free survival, 3 developed lung or liver metastasis, and 1 died 11 months after surgery. Precise control of IVC and hepatic pedicle vessels, without vascular bypass, is a safe and effective surgical treatment for level III tumor thrombus below the hepatic vein concomitant to RCC. The procedure was conducted without increased risks of intraoperative hypotensive shock, difficult resuscitation, pulmonary embolism, and multiple organ dysfunctions.

Pediatric Out-of-Hospital Critical Procedures in the United States.

Regular clinical application is important for maintenance of difficult resuscitation skills. Although emergency medical services must provide life-saving care for critically ill and injured children, the frequency with which these procedures are performed is unknown. We sought to characterize critical pediatric procedures performed by emergency medical service personnel in the United States. We performed a retrospective, descriptive study of emergency medical service responses. We included patients less than 18 years old in the 2011 National Emergency Medical Services Information Systems national data set. We identified emergency medical service cases receiving critical procedures, including intubation, cricothyroidotomy, cardiac pacing, cardioversion, defibrillation, needle decompression, pericardiocentesis, and intraosseous or central venous catheter placement. None. We analyzed the data to determine the number and prevalence of procedures, success rates, and factors associated with success. Of the 14,371,941 emergency medical service responses, 865,591 (6.8%) involved children. Emergency medical service responses to pediatric patients most often involved traumatic injuries (35.7%) or respiratory complications (13.2%). Emergency medical service performed a total of 616,913 procedures on 246,016 pediatric cases. Critical procedures were infrequently performed (n = 11,026, 10 per 1,000 pediatric cases). The most common critical procedures performed were intubation (n = 3,599, 6.7 per 1,000 pediatric cases) and intraosseous access (n = 2,618, 5 per 1,000 pediatric cases). Overall, 81% of critical procedures were successful. Increasing age and interfacility transfers were associated with greater odds of procedural success (p < 0.01). Despite the broad range of pediatric conditions seen in the prehospital setting, pediatric critical procedures are infrequently performed. These data highlight factors that are associated with successful completion of critical pediatric procedures.

Clinical Features of Neonates with Hydrops Fetalis.

The objective of this study was to evaluate the clinical characteristics of neonates with hydrops fetalis to improve recognition of the disease. The clinical data of 10 neonates with hydrops fetalis were retrospectively studied. Prenatal characteristics, causes, clinical features, and prognosis were explored. Eight neonates presenting abnormal nonstress test suffered from severe neonatal asphyxia at birth and were resuscitated by endotracheal intubation. Nine had skin edema, eight had pleural effusions with one unilateral and seven bilateral. Six had ascites, eight had polyhydramnios, one had multiple malformations and one had chromosome abnormalities. One survived and nine died. Six died due to resuscitation failure in delivery room, two died due to giving up after 1 day and one died due to the treatment failure after 6 months. Causes of hydrops fetalis were a congenital diaphragmatic hemangioma, recurrent atrial premature beats, genetic syndrome suspicious, Down syndrome, congenital pulmonary lymphangiectasia, anemia, paroxysmal supraventricular tachycardia, placental chorioangioma, and idiopathic edema. The prognosis varied because of different etiologies of hydrops fetalis. Severe cases frequently had skin edema and high rate of asphyxia at birth and difficult resuscitation. Timely intrauterine interventions were helpful for successful resuscitation. A well-prepared resuscitation team and the effectiveness of resuscitation could correlate to increasing survival rate.

Intraosseous access – A classical method for vascular access that regains an important role as resuscitation tool

75-80% of life threatening situations, with unexpected arrest, are documented out of hospital (1). This situation generates frequently a difficult resuscitation. Main cause for failure is delay in gaining vascular access for fluid and drug delivery (2). Intraosseous access (IO) is used for treatment in patients without a previously placed intravenous line that experience abrupt-onset life threatening situations (3). Authors revisit data from initial development of this method and document the role of IO access as a valuable tool during resuscitation according to European Resuscitation Council Guidelines 2010 (4). Particular aspects of technique, improvisations and real life trouble shooting issues are presented from a single pediatric Emergency Department experience.

Ex Utero Intrapartum Therapy

The Ex Utero Intrapartum Therapy (EXIT) procedure was initially developed to secure the airway in fetuses at delivery after they had undergone in utero tracheal occlusion for congenital diaphragmatic hernia. Indications for the EXIT procedure have been expanded to include any delivery in which prenatal diagnosis is concerned for neonatal airway compromise, such as large neck masses and Congenital High Airway Obstruction Syndrome, or when a difficult resuscitation is anticipated such as with large lung lesions. Uteroplacental blood flow and gas exchange are maintained through the use of inhalational anesthetics to allow optimal uterine relaxation with partial delivery of the fetus and amnioinfusion to sustain uterine distension. Using the EXIT procedure, sufficient time is provided on placental bypass to perform life-saving procedures such as bronchoscopy, laryngoscopy, endotracheal intubation, tracheostomy, cannulation for extracorporeal membrane oxygenation, and resection of lung masses or resection of neck masses in a controlled setting, thus avoiding a potential catastrophe.

In Situ Simulation Training for Paediatric Cardiorespiratory Arrest: Initial Observations and Identification of Latent Errors

In response to a successful, although difficult resuscitation in one of our paediatric wards, we developed and implemented an educational program to improve the resuscitation skills, teamwork and safety climate in our multidisciplinary acute-care paediatric service. The program is ongoing and consists of didactic presentations, high-fidelity in situ simulation and facilitated debriefing to encourage reflective learning. The underlying goal, to provide this training to all staff over a two-year period, should be achieved by late 2011. In this preliminary report we describe teamwork difficulties that are commonly found during such training. These included inconsistent leadership behaviours, inadequate delegation of areas of responsibility, failure to communicate problems during the execution of technical tasks (such as difficulty opening the resuscitation trolley) and failure to challenge inadequate or inappropriate therapy (such as poor chest expansion during bag-mask ventilation). In addition, we unexpectedly discovered seven latent errors in our clinical environment during the first nine months of course delivery. The most disturbing of these was that participants repeatedly struggled to identify and overcome the locking-mechanism and tamper-proof device on a newly introduced resuscitation trolley.

Procedural experience with out-of-hospital endotracheal intubation*

Out-of-hospital rescuers likely need regular clinical experience to perform endotracheal intubation (ETI) in a safe and effective manner. We sought to determine the frequency of ETI performed by individual out-of-hospital rescuers. Analysis of an administrative database of all emergency medical services (EMS) patient care reports in Pennsylvania. Commonwealth of Pennsylvania from January 1 to December 31, 2003. EMS advanced life support rescuers (paramedics, prehospital nurses, and EMS physicians) who reported at least one patient contact during the study period. None. We calculated individual rescuer ETI frequency and opportunity. We evaluated relationships between ETI frequency and the number of patient contacts. We also examined the relationship with practice setting (air medical vs. ground rescuers and urban vs. rural rescuers). In 1,544,791 patient care reports, 11,484 ETIs were reported by 5,245 out-of-hospital rescuers. The median ETI frequency was one (interquartile range, 0-3; range, 0-23). Of 5,245 rescuers, >67% (3,551) performed two or fewer ETIs, and >39% (2,054) rescuers did not perform any ETIs. The median number of ETI opportunities was three (interquartile range, 0-6; range, 0-76). ETI frequency was associated with patient volume (Spearman's rho = 0.67) and was higher for air medical (p = .006) and urban (p < .0001) rescuers. ETI frequency was not associated with response (Spearman's rho = -0.01) or transport (Spearman's rho = -0.06) times. Out-of-hospital ETI, an important and difficult resuscitation intervention, is an uncommon event for most rescuers.

Septicaemia after burn injury: a comparative study

Seventy-nine (8.4%) patients during June 1992–May 1996 (Group-1) and 68 (7.2%) patients from June 1996 to May 2000 (Group-2) who developed septicaemia at the burns unit of Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, were retrospectively studied and compared. The mean age of 26 years, male predominance, flame burns as main aetiology and mean burn percentage of ≥40% was observed in both the groups. Both groups revealed extensive flame burn, inhalation injury, intubation and difficult resuscitation as the risk factors. The proportion of satisfactory resuscitation increased significantly ( P<0.001) in Group-2. The septicaemia commonly occurred within 2 weeks postburn but the number of episodes during 5 days postburn was less in Group-2. The surface wound was found to be the likely source of entry of the organisms into the blood stream in both the groups. The gram positive organisms were dominant aetiologic factor in both groups but an increase frequency of Acnetobacter was found in Group-2. The proportion of MRSE and Pseudomonas septicaemia was significantly higher ( P<0.01) in the Group-1. The rate of survivors, in both the groups was higher among operated patients but it was significantly higher ( P<0.001) in the Group-1. A mortality rate 20.6% in Group-2 decreased against Group-1, which can be attributed to better resuscitation, nutritional care, early detection of septicaemia, appropriate antibiotics and early wound excision and skin grafting. MOF was the cause of death of 60.9% in Group-1 and 85.7% in Group-2. There was no role of prophylactic antibiotic in burn patients in the incidence of septicaemia and mortality.

Pseudomonas aeruginosa septicaemia in burns

Out of 1415 patients treated as inpatients at Al-Babtain Center for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait spanning over a period of 6 years from June 1992 to June 1998, 102 developed clinically and microbiologically proven septicaemia. Only 15 out of them had either single or multiple episodes of septicaemia due to Pseudomonas aeruginosa and were studied during their stay in the hospital. Five of them were males and 10 females, with a mean age of 26 years (range 3–51 years) and mean total body surface area of burns (TBSA) of 66% (range 25–90%). All of them had flame burns and resuscitation was found to be difficult in eight patients either due to delayed hospitalization or accompanied inhalation injury. Seven patients were intubated, four due to inhalation injury and three for septicaemic complications. Among the 15 patients under study, a total of 36 septicaemic episodes were detected of which 21 were due to P. aeruginosa. This organism was found in the first episodes in nine patients, in second episodes in six, in third episodes in three and fourth, fifth and sixth episodes in one patient, each at a variable postburn day. Ten patients had 38 sessions of excision and skin grafting, six of them survived. Nine of the 15 patients under study died due to septicaemia, but only six of them had P. aeruginosa as the last isolate. Except for one, all patients had >40% TBSA burn, two had difficult resuscitation and four were intubated. The day of death varied between 3 to 52 days postburn (mean 19 days). This study showed that females with flame burns are susceptible to P. aeruginosa septicaemia. Difficult resuscitation and intubation also proved to be important risk factors. Septicaemia could occur quite early in the postburn days and the mortality due to this organism was quite high. Early excision and grafting with other effective management may result in a better outcome.

Resuscitation decision making by New Mexico emergency medical technicians

The extent to which Emergency Medical Service personnel are placed in situations in which difficult cardiopulmonary resuscitation decisions must be made has been poorly explored. Further, it is not known whether this kind of decision making is troubling to emergency medical technicians. Although it is likely that emergency medical service systems handle with-holding cardiopulmonary resuscitation in a variety of ways, the authors chose to examine a cross-section of New Mexico emergency medical technicians. Using a survey instrument, emergency medical technicians of all tralning levels, representing several emergency medical service systems around the state were asked how many times in their career they had been in a situation in which cardiopulmonary resuscitation had been withheld without a direct physician order. Of 310 individuals surveyed, 211 (66.8%) responded that this had occurred at least once. When asked whether they had been troubled by one of these situations, 86 of 211 (41%) individuals responded “yes.” When a variety of demographic factors were evaluated, only training to the paramedic level was identified as being an independent predictor of those who were troubled ( P = .019). Emergency medical technician training, protocols, and do not resuscitate programs may need to be expanded to give furthe guidance to prehospital personnel when making difficult resuscitation decisions.