Initial Resuscitation Efforts Research Articles

Emergent Management of Hypoxic-Ischemic Brain Injury.

This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest. Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings. Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.

Neurologically Intact Survival after Bihemispheric Penetrating Head Trauma: A Case Report

BackgroundPatients with penetrating head trauma that crosses the midline of the brain have a high mortality rate; most die in the prehospital setting or during initial resuscitative efforts. However, surviving patients are often neurologically intact and several factors other than bullet path, including post-resuscitation Glasgow Coma Scale, age, and pupillary abnormalities, must be considered in aggregate when prognosticating patients. Case ReportWe present a case of an 18-year-old man who presented unresponsive after a single gunshot wound to the head that traversed the bilateral hemispheres. The patient was managed with standard care and without surgical intervention. He was discharged from the hospital neurologically intact 2 weeks after his injury. Why Should an Emergency Physician Be Aware of This?Patients with such apparently devastating injuries are at risk of premature termination of aggressive resuscitative efforts based on clinician bias that these efforts are futile and that patients cannot recover to a neurologically meaningful outcome. Our case reminds clinicians that patients with severe injury patterns with bihemispheric involvement can recover with good outcomes, and that bullet path is only one variable among multiple that must be considered to predict clinical outcome.

576 Comparison of Survival Benefit Between Direct Emergency Department Admissions and Inter-hospital Transfers in Burn Victims

IntroductionSevere burn injuries create systemic insults that are life threatening and require immediate stabilization, resuscitation, and, potentially, emergent surgery. Non-burn emergencies, such as stroke, have shown improved survival benefit and outcomes when patients are immediately transferred to specialized facilities. Our objective was to compare the outcomes between burn patients who were transferred to the burn unit from outside hospitals (HT) to controls who were directly admitted from our own emergency department (ED). We hypothesized that HT patients were at increased risk for mortality, wound healing complications, and infectious sequelae relative to the ED cohort.MethodsA matched retrospective cohort study from July 1, 2015 to November 1, 2019 was performed at an ABA-verified burn center. HT patients were identified and matched with ED patients by age and percent total body surface area burned (TBSA). HT and ED cohorts were compared as a whole and then stratified into groups according to % TBSA burned (< 10%, 11-20%, 21-40%, and > 40%). Patient and burn characteristics were recorded. The primary outcome was mortality, and secondary outcomes included total length of stay (LOS), ICU requirement and complications.ResultsA total of 410 HT and 377 ED patients were identified. There were no significant differences in age (P=0.17), burn severity (TBSA: P=0.27; full thickness burns: P=0.13), and inhalation injury (P=0.29). There were no demographic differences when comparing cohorts according to TBSA. For the primary outcome, there were no significant differences in mortality in the cohorts at large (P=0.48) nor between the groups when stratifying for TBSA (< 10% : P=0.35; 11-20% : P=0.44; 21-40% : P=0.30; >40% : P=0.26). For the secondary outcomes at large, there was no significant difference in LOS (P=0.35), ICU requirement (P=0.17), or wound and infectious complications (P=0.14). HT patients at large, however, spent less time in the ICU (P=0.03).ConclusionsThere was no significant difference in overall mortality rates between the HT and ED groups regardless of TBSA. Additionally, there was no difference in hospital course between the cohorts except for longer ICU stays in those admitted directly from the ED. Once the transfer process is initiated, our unit maintains close physician-to-physician communication with the transferring facility throughout the transfer process, including guiding initial resuscitation efforts. This may play a role in the parity of outcomes between groups.

Prenatal Diagnosis of a Lethal Skeletal Dysplasia.

Prenatal Diagnosis of a Lethal Skeletal Dysplasia.

"Playing it SAFE in the NICU" SAFE-R: a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU.

Rapid diagnosis of sudden, unexpected, and potentially fatal complications in the neonatal intensive care unit (NICU) is essential for the initiation of prompt and life-saving management. Point-of-care ultrasound (POCUS) protocols are widely used in adult emergency situations to diagnose and guide treatment, but none has been specifically developed for the neonate. We propose a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU for rapid screening for the most common life-threatening complications needing immediate attention. We integrated current knowledge on the use of POCUS for diagnosis of the most critical neonatal complications into the “SAFE-R protocol” (Sonographic Assessment of liFe-threatening Emergencies — Revised). The ultrasound algorithm was evaluated at the bedside for suitability and ease of use. Main features of SAFE-R are the use of standardized ultrasound points and a simple one-probe rule-in/rule-out approach. The flowchart is designed by order of urgency and priority is given to treatable causes. Hence, ruling out cardiac tamponade is the first step in the decision tree, followed by pneumothorax, pleural effusion, then acute critical aortic occlusion, acute abdominal complications, and severe intraventricular hemorrhage.Conclusion: SAFE-R is the first ultrasound algorithm specifically conceived for use in the NICU to screen for the most common urgent neonatal complications leading to sudden deterioration, thereby providing critical information within minutes. The simplified and rapid approach is designed for the neonatologist and is easy to learn and quick to perform. What is Known:• The fields of neonatal and pediatric critical care are undergoing a transformation with the adoption of POCUS and the recent publication of the first international guidelines on POCUS for critically ill children and neonates.• Targeted emergency ultrasound protocols are widely used in adult emergency and critical care medicine, but specific and adapted ultrasound algorithms are lacking for the pediatric and neonatal population.What is New:• We propose the first targeted ultrasound protocol specifically designed for the suddenly decompensating infant in the NICU for rapid screening of the most common life-threatening complications needing immediate attention.• The SAFE-R ultrasound algorithm integrates current knowledge on ultrasound diagnosis of the most critical neonatal complications into a simple and easy-to-perform emergency scanning protocol aimed to guide initial management and resuscitation efforts.

A randomised trial of laryngeal mask airway in neonatal resuscitation.

Birth asphyxia is the leading cause of neonatal mortality in low-income countries.1 Improving resuscitation and outcomes from neonatal resuscitation at birth are crucial.2 Asphyxiated newborns often require bag-mask ventilation (BMV) as part of their initial resuscitation. When this fails, intubation is necessary. However, intubation is a difficult skill to practice especially for non-doctor staff present at delivery in low-income countries.2 Thus, improving the effectiveness of initial efforts to provide ventilation in asphyxiated newborn may decrease the need for extensive resuscitation and improve neonatal outcomes. Previous studies have shown an LMA is effective in providing positive pressure ventilation (PPV) ventilation at delivery,3 while other benefits of an LMA include ease of placement, minimal trauma, less air leak and improved seal.4 In this study, Pejovic et al. tested whether PPV provided in low-income countries by midwives using an LMA was superior to BMV. This large, RCT demonstrated that using an LMA to provide PPV at birth by midwives in neonates with asphyxia did not decrease mortality and morbidity when compared with facemask ventilation at birth. Although the current study did not show a benefit of using an LMA for initial resuscitative efforts when compared with facemask ventilation, it still may have a role in providing PPV at birth in low-income countries. The current phase three trial was done at a high volume delivery hospital in Uganda. Whether conducting the study in a hospital with low volume where midwives are less familiar with traditional BMV would have a different result is unknown. Furthermore, access to foetal monitoring would have increased the pre-test probability of birth asphyxia and potentially increased the ability of the study to detect a therapeutic effect. Previous studies have shown an LMA can be used in place of intubation for advanced airway management; it would be interesting to know if the transition from initial resuscitation to advanced resuscitation was improved with use of an LMA. Additional studies are needed to determine effectiveness of an LMA ventilation in infants with asphyxia with different study design, including foetal monitoring, patient selection, resuscitative steps and selection of hospital. This study shows an LMA can be used safely by midwives for providing ventilation at birth as measured by these short-term in-hospital experience. Along with these short-term morbidity and mortality data, assessment of long-term outcomes is needed. Furthermore, it would be interesting to know whether additional studies of an LMA vs facemask ventilation at birth would demonstrate a beneficial role for an LMA in neonatal resuscitation. Finally, although an LMA ventilation provided by midwives at birth in neonates with asphyxia while not superior to facemask ventilation with regard to in-hospital morbidity and mortality in low-income countries, it was shown to be safe, which opens the door to future study of an LMA in neonatal resuscitation in low-income countries. https://ebneo.org/laryngeal-mask-airway None.

Haemorrhage in pre-existing adrenal masses. A case series

IntroductionAdrenal haemorrhage in the context of a pre-existing adrenal mass is a rare, underestimated and potentially fatal surgical emergency. It is a rare cause of acute abdominal pain. Presentation of casesData from 13 patients with adrenal haemorrhage in a pre-existing adrenal mass were prospectively collected during a 9 year period from a single institution. All patients underwent CT imaging which formed the basis of diagnosis and a complete endocrinological evaluation. Seven out of 13 patients underwent an elective surgical procedure and 2 patients underwent emergency laparotomy. Five out of 13 patients were diagnosed with metastatic disease. One patient was diagnosed with pheochromocytoma. DiscussionThe likelihood of an undiagnosed pheochromocytoma renders emergency surgery extremely precarious. Complete patient evaluation includes testing for hormonally active adrenal tumors and malignancy. Emergency surgery is reserved for cases where conservative management fails. ConclusionHaemorrhage of an adrenal mass constitutes a diagnostic and therapeutic challenge. Most patients respond well to initial resuscitation efforts. When feasible, patients should undergo a complete hormonal and oncologic evaluation before surgical intervention is considered.

Massive, Spontaneous Ruptured Renal Subcapsular Haematoma Following Thrombolytic Therapy in Acute ST-Elevation Myocardial Infarction

Background: Thrombolytic therapy remains widely used in majority of developing countries, where delivery of primary percutaneous coronary intervention (PCI) remains a challenge. Unfortunately, complications following such therapy remains prominent, predominantly bleeding-related problems. We present a rare case of massive renal subcapsular haemorrhage and hematoma following thrombolytic therapy. Case Report: A 61-year old gentleman presented following an episode of chest pain due to acute ST-elevation myocardial infarction. Due to potential delays in obtaining PCI, the patient was counselled for thrombolysis using streptokinase which he had consented to. Unfortunately, within 36 hours of admission, he developed abdominal pain, haematuria, hypotension and altered mental status, associated with acute drops in haemoglobin levels. Following initial resuscitation efforts, a Computed Tomography scan of the abdomen was performed revealing a massive renal subcapsular hematoma, likely secondary to previous thrombolysis. Discussion: Renal subcapsular hematoma can either be spontaneous or iatrogenic, the latter often due to coexisting renal-based neoplasm or vasculitidies. Iatrogenic causes include trauma, following renal biopsies or anticoagulation therapy amongst a few others. Iatrogenic renal subcapsular haemorrhage and hematoma formation are rare following thrombolysis. Our literature search revealed only one other similar case, although this was following administration of recombinant Tissue Plasminogen Activator in a case of acute ischaemic cerebrovascular accident. Conclusion: This case highlights the complexity in management, following the findings in terms of need for cessation of dual antiplatelet therapy and timing for PCI and stent selection.

In the ICU - delirium post cardiac arrest.

The present review aims to describe the clinical impact and assessment tools capable of identifying delirium in cardiac arrest survivors and providing strategies aimed at preventing and treating delirium. Patient factors leading to a cardiac arrest, initial resuscitation efforts, and postresuscitation management all influence the potential for recovery and the risk for development of delirium. Data suggest that delirium in cardiac arrest survivors is an independent risk factor for morbidity and mortality. Recognizing delirium in postcardiac arrest patients can be challenging; however, detection is not only achievable, but important as it may aid in predicting adverse outcomes. Serial neurologic examinations and delirium assessments, targeting light sedation when possible, limiting psychoactive medications, and initiating patient care bundles are important care aspects for not only allowing early identification of primary and secondary brain injury, but in improving patient morbidity and mortality. Developing delirium after cardiac arrest is associated with increased morbidity and mortality. The importance of addressing modifiable risk factors, recognizing symptoms early, and initiating coordinated treatment strategies can help to improve outcomes within this high risk population.

Out-of-hospital cardiac arrest outcomes with “pit crew” resuscitation and scripted initiation of mechanical CPR

ObjectiveTo compare OHCA outcomes in patients managed with mechanical versus manual CPR in an EMS system with a “pit crew” approach to resuscitation and a scripted sequence for the initiation of mechanical CPR. MethodsThrough a year-long quality improvement effort we standardized the initial resuscitative efforts for OHCA, prioritizing a “pit crew” approach to high quality manual CPR, early defibrillation and basic airway management ahead of a scripted sequence for initiating mechanical CPR. We then analyzed outcomes for adult, non-traumatic OHCA attended in the following year (2016). We used a propensity score matched analysis to compare ROSC, survival to discharge, and neurologic status among patients managed with manual versus mechanical CPR while controlling for patient demographics and arrest characteristics. ResultsOf 444 eligible OHCAs, 217 received manual and 227 received mechanical CPR. Crude ROSC (39.2% vs. 29.1%) and survival to discharge (13.8% vs. 5.7%) were higher with manual CPR. In the propensity matched analysis (n = 176 manual CPR; 176 mechanical CPR), both ROSC (38.6% vs. 28.4%; difference: 10.2%; CI: 0.4% to 20.0%) and survival to discharge (13.6% vs. 6.8%; difference: 6.8%; CI: 0.5% to 13.3%) remained significantly higher for patients receiving manual CPR. ConclusionsIn this EMS system with a standardized, “pit crew” approach to OHCA that prioritized initial high-quality initial resuscitative efforts and scripted the sequence for initiating mechanical CPR, use of mechanical CPR was associated with decreased ROSC and decreased survival to discharge.

Chronic Intestinal Idiopathic Pseudo-obstruction (CIIPO) Complicated by Sigmoid Volvulus

A 17-year-old male patient with chronic intestinal idiopathic pseudo-obstruction was admitted to the emergency department clinically deteriorated due to sigmoid volvulus. Initial resuscitative efforts followed by endoscopy failed to detorse and decompress the bowel. At the followed emergency laparotomy the volvulus was derotated and a Hartmann’s procedure with left hemicolectomy was performed. The patient after 3 months underwent stoma closure. At one-year follow-up the patient showed clinical improvement.

Prehospital Intubation Does Not Decrease Complications in the Penetrating Trauma Patient

Intubation in the prehospital setting does not result in a survival benefit in penetrating trauma. However, the effect of prehospital intubation (PHI) on the development of in-hospital complications has yet to be determined. The goal of this study was to determine if PHI in patients with penetrating trauma results in reduced mortality and in-hospital complications. Patient records for all Category 1 trauma activations as a result of penetrating injury admitted to our institution from 2006 to 2010 were reviewed. There were 1615 Category 1 trauma activations with 152 (9.8%) intubated in the field. A total of 1311 survived initial resuscitative efforts to permit hospital admission with 55 (4.2%) being intubated in the field. For patients surviving to admission, prehospital intubation was associated with increased mortality (hazard ratio, 8.266; 95% confidence interval [CI, 4.336 to 15.758; P < 0.001). After correcting for Injury Severity Score, PHI was not protective against pulmonary complications (odds ratio [OR], 0.724; 95% CI, 0.229 to 2.289; P = 0.582), deep vein thrombosis/pulmonary embolus (OR, 0.838; 95% CI, 0.281 to 2.494; P = 0.750), sepsis (OR, 0.572; 95% CI, 0.201 to 1.633; P = 0.297), wound infections (OR, 1.739; 95% CI, 0.630 to 4.782; P = 0.286), or complications of any kind (OR, 1.020; 95% CI, 0.480 to 2.166; P = 0.959). For victims of penetrating trauma, immediate transportation by emergency medical personnel may result in improved outcomes.

Cardiogenic shock as the initial presentation of neonatal systemic hypertension

Neonatal systemic hypertension is an underappreciated etiology of cardiac failure. We present a series of three neonates who presented in cardiogenic shock secondary to severe hypertension, recognized after initial resuscitation efforts. Although the underlying etiology of the hypertension varied, all three patients had improved hemodynamics after their blood pressure was controlled. These cases suggest that neonates presenting in cardiogenic shock with hypertension, and without structural heart disease, may benefit from a thorough renal evaluation and institution of anti-hypertensive therapy.

Initial predictors associated with outcome in injured multiple traumatic limb amputations: A Kandahar-based combat hospital experience

IntroductionImprovised explosive devices (IEDs) are the defining mechanism of injury during Operation Enduring Freedom. This is a retrospective analysis of initial management for IED blast injuries presenting with bilateral, traumatic, lower-extremity (LE) amputations with and without pelvic and perineal involvement. MethodsA database of trauma admissions presenting to a North Atlantic Treaty Organization (NATO) Role 3 combat hospital in southern Afghanistan over a 7-month period was created to evaluate the care of this particular injury pattern. Patients were included if they were received from point of injury with at least bilateral traumatic LE amputations and had vital signs with initial resuscitation efforts. ResultsThirty-two presented with double LE amputations (36%) and nine with triple amputations (10%). After excluding 10 patients who failed to meet the inclusion criteria, 22 patients were analysed. The mean age was 29 years, and the average ISS and admission haemoglobin were 22 and 11.3mgl−1, respectively. Patients received an average of 54 units of blood products and underwent 1.6 operations with a mean operative time of 142.5min. The pattern of injury was associated with an increase in the total blood products required for resuscitation (pelvis n=12, p=0.028, gastrointestinal tract (GI) n=14, p=0.02, perineal n=15, p=0.036). There was no relationship between ISS or admission haemoglobin and the need for massive transfusion. Low Glasgow Coma Scale (GCS) was associated with increased 30-day mortality. Hollow viscus injury and operative hemipelvectomy were also associated with mortality. ConclusionsEarly 30-day follow-up demonstrated that IED injuries with bilateral LE amputations with and without pelvic and perineal involvement are survivable injuries. Standard measures of injury and predictors of survival bore little relationship to observed outcomes and may need to be re-evaluated. Long-term follow-up is needed to assess the extent of functional recovery and overall morbidity and mortality.

Abstract 98: Initiation of Large-Volume, Ice-Cold Saline Infusion During Initial Resuscitation Attempts for Out-of-Hospital Cardiac Arrest Results in Near-Target Temperatures for Therapeutic Hypothermia Upon Emergency Department Arrival

Background: New York City Project Hypothermia is a collaborative effort involving the Fire Department of New York (FDNY), Greater New York Hospital Association, Health and Hospitals Corporation, the Regional Emergency Medical Advisory Committee, and the New York State Department of Health. As part of this effort, the FDNY implemented a pilot protocol in the New York City 9-1-1 System on August 1, 2010 that introduced the induction of therapeutic hypothermia during initial resuscitation efforts via large-volume, pressure infused, ice-cold saline administration. Purpose: We sought to assess the effects of the intra-arrest initiation of an infusion of up to 30cc/kg of ice-cold saline on core body temperature for out-of-hospital cardiac arrest (OOHCA). Methods: A convenience sample of out-of-hospital cardiac arrest patients for whom core temperature monitoring via esophageal temperature probes was available were analyzed. Results: There were a total of 78 patients for whom core temperature (esophageal) data was available both at the time hypothermia induction and upon ED arrival. Eight patients (10.3%) were reported to have developed clinical signs of pulmonary edema during the infusion and were excluded from this analysis due to the discontinuation of the large-volume infusion. Among the remaining 70 patients, an average of 1,361mls of ice-cold saline was administered prior to emergency department arrival. The average initial temperature for these patients at the time hypothermia induction was 35.1 o C (range 32.7-38.0 o C). The average temperature reduction as a result of the large-volume, ice-cold saline infusion was -0.92 o C, with an average core temperature upon emergency department arrival of 34.2 o C. Conclusion: Large volume, ice-cold saline infusion during initial resuscitation efforts allows patients to arrive in the emergency department with a core temperature near the target range for therapeutic hypothermia. Further study is needed to assess the effects of early induction of hypothermia on immediate and long-term survival.

Abstract 242: Incidence and Relevance of Pulmonary Edema as a Result of Large-Volume, Ice-Cold Saline Infusion for the Induction of Hypothermia During Out-of-Hospital Cardiopulmonary Resuscitation

Background: New York City Project Hypothermia is a collaborative effort involving the Fire Department of New York (FDNY), Greater New York Hospital Association, Health and Hospitals Corporation, the Regional Emergency Medical Advisory Committee, and the New York State Department of Health. As part of this effort, the FDNY implemented a pilot protocol that introduced the induction of therapeutic hypothermia during initial resuscitation efforts for nontraumatic adult cardiac arrests. Purpose: We sought to measure the incidence of pulmonary edema among patients receiving large-volume, ice-cold saline during initial resuscitation efforts and to assess the impact of this condition on immediate outcomes. Methods: Out-of-hospital cardiac arrest data was analyzed for the following periods: August 1, 2009 - May 31, 2010 (historical control group) and August 1, 2010 - May 31, 2011 (study group). Pulmonary edema was defined as having occurred if clinical signs and symptoms were reported by the on-scene paramedics during a standardized post-resuscitation interview. Data were analyzed using Fisher's exact test, and a p &lt;0.05 was considered significant. Results: There were 5,582 resuscitations during the control period and 4,727 resuscitations in the study period. Return of spontaneous circulation (ROSC) and sustained ROSC occurred among 29.0% and 21.9% of the control group and 31.7% and 24.1% of the study group, respectively. A total of 361/4,727 patients (7.6%) in the study period were experienced pulmonary edema. The ROSC and sustained ROSC rates for this population were 37.1% and 25.2%, respectively. These outcomes were significantly improved as compared to both the control group and the remainder of the study group (all p &lt;0.01). Conclusion: Clinical signs of pulmonary edema develop in some out-of-hospital cardiac arrest patients receiving large volume, ice-cold saline infusion for the purpose of initiating therapeutic hypothermia. Given the improved immediate outcomes among these patients, the clinical relevance of this clinical condition is of uncertain significance.

Abstract 97: Intra-arrest Induction of Therapeutic Hypothermia via Large-Volume, Ice-Cold Saline Infusion Results in Improved Outcomes Among Out-of-Hospital Cardiac Arrests of Cardiac Etiology

Background: New York City Project Hypothermia is a collaborative effort involving the Fire Department of New York (FDNY), Greater New York Hospital Association, Health and Hospitals Corporation, the Regional Emergency Medical Advisory Committee, and the New York State Department of Health. As part of this effort, the FDNY implemented a new pilot protocol in the New York City 9-1-1 System that introduced the induction of therapeutic hypothermia during initial resuscitation efforts via large-volume ice-cold saline infusion. Purpose: We sought to assess the effects of this protocol on immediate survival end-points following out-of-hospital cardiac arrest (OOHCA) of cardiac etiology. Methods: OOHCA data was analyzed for the following periods: August 1, 2009 - May 31, 2010 (historicalcontrol group) and August 1, 2010 - May 31, 2011 (study group). Except for the intra-arrest induction of hypothermia, no other aspect of the regional resuscitation protocols differed between the two periods. Standard Utstein definitions were utilized. Fisher's exact test was utilized, and a p &lt;0.05 was considered significant. Results: 4,459 / 5,582 (79.9%) of resuscitations during the control period and 3,581 / 4,727 (75.8%) of resuscitations during the study period were of cardiac etiology. The groups did not differ with respect to age, gender, race, response time, bystander witnessed status, or frequency of bystander CPR. Patients in the study period were less likely to have an EMS-witnessed arrest (6.5% vs 7.8%, p=0.03). Return of spontaneous circulation (ROSC) and sustained ROSC were improved in the study group as compared to the control group: 31.1% vs 26.8% (p&lt;0.0001) and 23.6% vs 19.9% (p&lt;0.0001), respectively. Conclusion: The initiation of therapeutic hypothermia via large volume, ice-cold saline infusion improves immediate survival for non-traumatic out-of-hospital cardiac arrest of cardiac etiology. Further study is required to identify specific populations for whom this therapy is most appropriate.

Abstract 2: Intra-arrest Induction of Therapeutic Hypothermia via Large-Volume Ice-Cold Saline Infusion Improves Immediate Outcomes for Out-of-Hospital Cardiac Arrest

Background: New York City Project Hypothermia is a collaborative effort involving the Fire Department of New York (FDNY), Greater New York Hospital Association, Health and Hospitals Corporation, the Regional Emergency Medical Advisory Committee, and the New York State Department of Health. As part of this effort, the FDNY implemented a pilot protocol in the New York City 9-1-1 System on August 1, 2010 that introduced the induction of therapeutic hypothermia during initial resuscitation efforts via large-volume ice-cold saline infusion. Purpose: We sought to assess the effects of this protocol on immediate survival end-points following out-of-hospital cardiac arrest (OOHCA). Methods: OOHCA data was analyzed for the following periods: August 1, 2009 - May 31, 2010 (historicalcontrol group) and August 1, 2010 - May 31, 2011 (study group). Except for the intra-arrest induction of hypothermia, no other aspect of the regional resuscitation protocols differed between the two periods. Standard Utstein definitions were utilized. Due to the large sample sizes, Chi-square analyses without Yates' correction were utilized, and a p &lt;0.05 was considered significant. Results: 5,582 resuscitations for nontraumatic adult cardiac arrests during the control period were compared to 4,727 resuscitations in the study period that included the intra-arrest induction of hypothermia. The groups did not differ with respect to age, response time, bystander witnessed status, or frequency of bystander CPR. Patients in the study period were less likely to be male (52.3% vs 54.6%, p = 0.019), less likely to be white (32.8% vs 35.1%, p = 0.013), and less likely to have an EMS-witnessed arrest (8.3% vs 9.5%, p=0.026). Return of spontaneous circulation (ROSC) and sustained ROSC were improved in the study group as compared to the control group: 31.7% vs 29.0% (p=0.003) and 24.1% vs 21.9% (p=0.0014), respectively. Conclusion: The initiation of therapeutic hypothermia via large volume, ice-cold saline infusion results in improved immediate survival for non-traumatic out-of-hospital cardiac arrest. To our knowledge, this is the first report to describe the use of intra-arrest hypothermia in humans and to demonstrate such an effect.

Emergency angio-embolisation in the operating theatre for trauma patients using the C-Arm digital subtraction angiography

Background and aims: Angio-embolisation in trauma is a relatively new technique that is gaining popularity and recognition in identifying and arresting bleeding in trauma patients. We studied the possibility whether angio-embolisation using the Digital Subtraction Angiography (DSA), in the operating theatre (OT) could achieve successful haemostasis in trauma patients. We further studied the feasibility of using this technique as part of trauma resuscitation/damage control. Methods: A retrospective study of trauma patients, with Injury Severity Score (ISS≥9), admitted to Tan Tock Seng Hospital (TTSH) from January 2004 to December 2008 was done. Patients who had received angio-embolisation in the OT or angiography suite were evaluated in terms of age, gender, ISS, the site and type of angioembolisation used. The primary end point was to assess the success rate of angioembolisation using the C-Arm DSA in the OT, and whether there were any complications necessitating a repeat procedure or surgical intervention. The secondary end points of the study were aimed at studying the cost effectiveness of this technique, logistical feasibility and evaluating this technique as part of the initial trauma resuscitative efforts. Results: A total of 43 trauma patients received angioembolisation. 32 patients had the angio-embolisation done using the C-Arm DSA in the OT (n=32). None of the patients who received angioembolisation in the operating theatre (n=32) had any re-bleeding. 15 out of 32 survived. There were no complications related to the angio-embolisation procedure. The majority of angio-embolisations done were for pelvic fractures. Conclusion: The success of angio-embolisation in the OT using the C-Arm DSA for a trauma patient and its complication rates are similar to that done in a dedicated angio-graphic suite. We conclude that angio-embolisation in the operating theatre using the C-Arm DSA is feasible, cost effective and can be a modality in the initial trauma resuscitation/damage control in any lead lined operating theatre. We believe that we are the first to describe this method of angio-embolisation using the C-Arm DSA in a conventional lead lined trauma operating theatre and its use as a feasible option in a trauma resuscitation/damage control algorithm.

Cardiac Surgery Resuscitation: Time for a New Standard?

ardiac arrest in someone who hasundergone heart surgery is quitedifferent than other patient popula-tions. While it seems obvious that apatient who has undergone a sterno-tomy, induced asystole, cardiopulmo-nary bypass, aortic cross-clamping,and hypothermia has uniquely differ-ent reasons for arrest (and methods tocorrect it) than others, little has beenwritten about this important issue. Upto 5000 cardiac surgery patients expe-rience a postoperative arrest situationannually in the United States andstandard resuscitation algorithms, de-signed primarily for those experiencingout-of-hospital events, have proven tobe inadequate and potentially harmful.With a greater appreciation ofimportant distinctions between thesepatients vs others, comes a new way ofthinking about their optimal arrestmanagement that is long overdue.CHEST COMPRESSIONSAdvanced cardiac life support (ACLS)has become a standard of care foremergency response in the acute caresetting. These algorithms advocateexternal cardiac compressions (ECC)as an essential component of initialresuscitation efforts for virtually all ar-rest situations, and healthcare workersare well conditioned to perform ECCupon finding an arrest victim.