Life-saving Efforts Research Articles

The PULSE initiative: scientific priorities and strategic planning for resuscitation research and life saving therapies.

The Post-resuscitative and initial Utility in Life Saving Efforts (PULSE) Conference represented an initiative by leaders of the international scientific community who sought opportunities for major improvements in clinical outcomes after cardiopulmonary resuscitation and after resuscitation from serious traumatic injury.1 The experts focused on scientific research that would yield major advances in lifesaving care, including measurable increases in survival and functional recovery. However, unless research support is prioritized to address resuscitation, it is highly unlikely that these opportunities would soon be realized. We lose more than 1000 lives each day in the United States from sudden, unexpected death, a fatality rate comparable to the crash of two 747 aircraft without survivors.2–5⇓⇓⇓ Cardiovascular disease is the leading cause of death among individuals aged greater than 65 years, the second leading cause of death among individuals aged 45 to 65 years, and the 5th leading cause of death among individuals aged 1 to 9 years.4,5⇓ Traumatic injuries in the United States were responsible for 147 891 deaths and 2.6 million hospitalizations, costing over $335 000 per death and resulting in 37 million emergency department visits in 1995.6,7⇓ Trauma is the leading cause of death among children and all individuals to age 34 years, the leading cause of loss of productive life-years of any disease, with societal costs (estimated by the National Safety Council) of $469 billion dollars annually, and the third leading cause of death among individuals aged 35 to 54 years. The Conferees anticipated that the availability of new intervention strategies with more effective diagnostic methodologies in the early post-injury time interval would not only save lives but also reduce morbidity.1 Accordingly, the PULSE participants cited current restraints and/or barriers to the delivery of more effective resuscitation interventions and reaffirmed that …

Workshop executive summary report: postresuscitative and initial utility in life-saving efforts (PULSE), June 29-30, 2000, Lansdowne Resort and Conference Center, Leesburg, VA.

Workshop executive summary report: postresuscitative and initial utility in life-saving efforts (PULSE), June 29-30, 2000, Lansdowne Resort and Conference Center, Leesburg, VA.

Workshop Executive Summary Report: Post-Resuscitative and Initial Utility in Life Saving Efforts (PULSE)

The Post-Resuscitative and Initial Utility in Life Saving Efforts (PULSE) workshop was convened in recognition of the estimated loss of >1000 useful lives each day in the United States as a result of poor cardiopulmonary and trauma resuscitation outcomes. The purpose of the workshop was to provide an interdisciplinary forum on promising and novel life-saving therapies in settings of cardiac, hypoxemic, and traumatic arrest and to identify the most promising new directions in cardiopulmonary and trauma resuscitation research. It was organized under a multiagency initiative supported by the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Child Health and Human Development (NICHD), the National Institute of General Medical Sciences (NIGMS), and the National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health, together with the Food and Drug Administration (FDA), each within the Department of Health and Human Services (DHHS) and the Department of Defense (DOD). The workshop, which was held in the Lansdowne Conference Center in Leesburg, Virginia from June 29 to 30, 2000, provided the unique opportunity to convene domestic and international experts to chart a new course for future resuscitation research. Conference participants believed that the world stands at the verge of new therapies and technologies that could save thousands of lives that are currently lost after traumatic injury and circulatory or hypoxemic arrest. Two broad strategies should be aggressively pursued. First, existing therapies known to restore circulation, shorten the period of ischemia, and save lives should be refined to allow more rapid and more widespread deployment. Earlier and better cardiopulmonary resuscitation (CPR), rapid defibrillation, and early control of hemorrhage will lead to immediate improvement in survival. Second, basic and applied research with the goal of identifying new therapies to minimize global ischemic insults should be expanded. Participants were optimistic …

Acute management of complex cardiac injuries.

Injury to the heart has been studied extensively. However, a small group of patients with injuries to the coronary arteries or intracardiac structures may require a different operative approach. Retrospective review of a cardiovascular injury database. Over a 20-year period, 711 cardiac injuries were treated. The mean age of the victims was 31.1 (90% men). Causes were primarily stab wounds (54%) and gunshot wounds (42%). Cardiac chambers injured included the right ventricle (40%), left ventricle (40%), right atrium (24%), and left atrium (3%). The overall mortality was 47%. Sixty complex injuries occurred. Of 21 left anterior descending coronary artery injuries (76.2% mortality), two patients presented with sufficient signs of life to warrant emergent coronary artery bypass (mortality 50%). There were seven circumflex/obtuse marginal coronary artery injuries, all treated with ligation (mortality 71.4%). Eight right/posterior descending coronary artery injuries (mortality 62.5%) were seen, and all but one were treated with ligation. The one patient not treated with ligation underwent coronary bypass and died. Delayed mitral valve replacement was performed for two valvular injuries (mitral). There were a total of 14 intracardiac fistulas (mortality 35.7%). All six of the surviving patients with ventricular septal defect required reoperation. The mortality for complex injuries (coronary, septal, valvular) was 53%. This group was a specific population that self-selected by surviving to operation. Acute operations for complex injuries (beyond cardiorrhaphy) were primarily heroic life-saving efforts. Reoperation for cardiac injuries was most common for septal or valvular injuries. Only 2% of all survivors required reoperation to correct a residual defect.

The Value of Life: Editor's Introduction

Issues pertaining to the value of life involve some of the most fundamental concepts in the area of risk and uncertainty. Individual perceptions of mortality risks have long served as the reference point for assessing how people think about risk. Since the time of Adam Smith economists have focused on market choices involving fatality risks, particularly those on the job, in order to assess how reliably individuals make choices in risk contexts and how markets respond to their expressed risk preferences. More recently, the value of life has become an explicit issue in policy debates. In the United States government, agencies have been explicitly valuing statistical lives using appropriate value-of-life methodologies for over a decade. The policy issues are intertwined with a wide variety of concerns pertaining to how people think about risk and how they make decisions involving mortality risk. These policy concepts raise other pertinent concerns as well. Life-saving efforts do not confer immortality, but extend life probabilistically. How should the framers of government policy incorporate recognition of the duration of life lost and the quality of those life years? Timing also enters in other ways as lives saved now may have a different value than lives saved in the future. The first part of the special issue on the value of life appeared in the Journal of Risk and Uncertainty in Volume 14, Number 3, and the second segment of papers appears in this issue. Whereas the previous issue is more wide-ranging in focus, this issue focuses almost exclusively on timing and duration issues. The first of the value-of-life journal issues began with a paper by Viscusi, Hakes, and Carlin. Their catalog of the risks of death by cause was distinctive in that it distinguished not only overall mortality risks but the duration of life lost as well. Doing so increases the relative importance of accidents as compared to deferred illnesses. Using these estimates, the authors showed that many well-known perceptional biases can be traced to a failure to adjust for the duration of life lost. The paper estimated the implicit rate of discount that people use in assessing the discounted expected life-years lost to various causes of death, which they find to be between 3.3 and 12.4 percent. Their calculations of the cost effectiveness of regulatory policies are in terms of the cost per discounted life-year saved, decreasing the relative efficacy of regulations affecting health as compared to those affecting safety. The paper by Jenni and Loewenstein explores the “identifiable victim effect.” It has long been observed that people are willing to pay more for saving an identified life than saving a statistical life. The classic example in the literature pertains to the amount society would pay to save a trapped girl in a well. Is this attachment to identified lives irrational, or is the lower value attached to statistical lives a reflection of people’s failure to think

On the history of modern resuscitation

The development of modern cardiopulmonary-cerebral resuscitation (CPCR) has given every person the ability to challenge death anywhere. Despite sparks of knowledge and occasional applications of possibly effective lifesaving efforts since antiquity, the possibility to reverse acute terminal states or clinical death by modern, physiologically sound, and effective measures did not come about until around 1900 inside hospitals, and around 1960 outside hospitals. Additional potentially effective cerebral resuscitation, research since around 1970, may be taken to clinical trials before the year 2000. The history of resuscitation medicine around 1900, when many opportunities to assemble existing bits of knowledge into an effective system were missed, should be a warning for those individuals who will lead CPCR beyond the year 2000. History has shown the need for continuing communication and collaboration among investigators of different countries, and between laboratory researchers, clinicians of various disciplines, and prehospital rescuers. The lessons learned from history, for research challenges in the near future, include: a) the development of ultra-advanced life support to be initiated outside the hospital, to bridge cardiopulmonary resuscitation (CPR)-resistant cases to definitive cardiac procedures in the hospital; and b) cerebral resuscitation to complete recovery after 10 to 15 mins of normothermic cardiac arrest without blood flow. Both challenges above will require research projects at multiple levels--from the molecular and cellular levels, to the use of small and large animal models (with organs' and organisms' process and outcome evaluations), to studies of patients and communities. Beyond the year 2000, resuscitation research might become more challenging and cost-effective in the area of multiple trauma, which concerns the young and fit. Research challenges concerning brain trauma, uncontrolled hemorrhagic shock, and "suspended animation" for delayed resuscitation have their own histories, and are not covered here. The author apologizes for not having recognized many important contributors to the history of CPCR because of space constraints or lack of knowledge about such contributions. Input on this subject from readers of this paper is hereby invited.

ON THE HISTORY OF MODERN RESUSCITATION

The development of modern cardiopulmonary-cerebral resuscitation (CPCR) has given every person the ability to challenge death anywhere. Despite sparks of knowledge and occasional applications of possibly effective lifesaving efforts since antiquity, the possibility to reverse acute terminal states or clinical death by modern, physiologically sound, and effective measures did not come about until around 1900 inside hospitals, and around 1960 outside hospitals. Additional potentially effective cerebral resuscitation, research since around 1970, may be taken to clinical trials before the year 2000. The history of resuscitation medicine around 1900, when many opportunities to assemble existing bits of knowledge into an effective system were missed, should be a warning for those individuals who will lead CPCR beyond the year 2000. History has shown the need for continuing communication and collaboration among investigators of different countries, and between laboratory researchers, clinicians of various disciplines, and prehospital rescuers. The lessons learned from history, for research challenges in the near future, include: a) the development of ultra-advanced life support to be initiated outside the hospital, to bridge cardiopulmonary resuscitation (CPR)-resistant cases to definitive cardiac procedures in the hospital; and b) cerebral resuscitation to complete recovery after 10 to 15 mins of normothermic cardiac arrest without blood flow. Both challenges above will require research projects at multiple levels--from the molecular and cellular levels, to the use of small and large animal models (with organs' and organisms' process and outcome evaluations), to studies of patients and communities. Beyond the year 2000, resuscitation research might become more challenging and cost-effective in the area of multiple trauma, which concerns the young and fit. Research challenges concerning brain trauma, uncontrolled hemorrhagic shock, and suspended animation for delayed resuscitation have their own histories, and are not covered here. The author apologizes for not having recognized many important contributors to the history of CPCR because of space constraints or lack of knowledge about such contributions. Input on this subject from readers of this paper is hereby invited.

Carotid artery trauma: A review of contemporary trauma center experiences

Many issues surrounding the management and outcome of carotid artery injuries remain controversial. The purpose of this study was to review a large contemporary experience with such injuries in the setting of designated trauma centers. A statewide computerized trauma registry was used to identify all patients with injuries to the common or internal carotid arteries from October 1987 to June 1993. The records of 82 such patients were retrieved and analyzed. Overall mortality and stroke rates were 17% and 28%, respectively. Patients presenting with coma or shock had a particularly bad prognosis (50% and 41% mortality, respectively). Internal carotid injuries resulted in mortality and stroke rates of 21% and 41%, respectively, compared with 11% each for common carotid injuries. Patients with blunt injuries had a much higher stroke rate (56% vs 15%) but had lower mortality (7% vs 22%) than did patients with penetrating injuries. Airway compromise and associated injuries did not affect prognosis. Operative repair and percutaneous balloon occlusion had the best survival and functional outcomes. Operative repair offers the best chances for recovery in all categories of patients regardless of injury mechanism. Ligation is useful only as a last-resort lifesaving effort. Shock and neurologic impairment are poor prognostic factors but should not negate repair.

Topic: Committee Consultation to Prolong or Stop Extreme Care Measures

In response to increased public fear that life-saving efforts of the hospital might be pursued to the detriment rather than help of the patients, a committee was formed to study and advise about treat

Let's save ourselves

I noticed in an electric-utility business seminar in New York City recently that many of the participants were bemoaning the fact that without federal relief many of this nation's investor-owned electric utilities will not be able to survive their current financial trauma. Federal subsidy was one of the ways suggested for this life-saving effort. The alternative, of course, is, you guessed it, energy shortages for the rest of the decade. These utilities, of course, are not alone in their cry for government assistance. We've been subjected to quite a few recently—Pan Am, Grumman, Lockheed, and Franklin National Bank, to name just a few. The cited cause of Pan Am's financial distress is the high cost of fuel and a steadily decreasing number of passengers, but there is a much more important and fundamental reason for the present state of affairs—too many poor managerial decisions. Pan Am was overaggressive in its push to build bigger, faster ...

Statistics Are Still Fragile

A July 24, 1972, JAMA editorial entitled Be Careful With Statistics—They're Fragile urged physicians to be especially alert to myths and half-truths that have greatly delayed life-saving efforts. It pointed out that we cannot logically attack the problems in medicine or anywhere else if we handle or interpret statistics carelessly. A situation has arisen recently that we believe calls for reemphasizing the ideas expressed in that editorial. Because of the energy shortage, a nationwide 55-mph speed limit was introduced early this year. Almost immediately, the number of fatalities on our highways dropped dramatically. In January of this year, for instance, there were 853 fewer deaths as compared to January 1973. Pennsylvania's reduction was 50% during the same period, while New Jersey dropped 49%, and New York 38%. Overall, in the first three months of this year, the total number of lives lost on our highways dropped almost 25% from what