Primary Resuscitation Research Articles

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The 2005 Consensus on Science and Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR) serves as the scientific basis for neonatal resuscitation. This consensus reflects the world’s published medical literature and the various perspectives of the representatives to ILCOR from North and South America, Europe, Africa, Australia, and New Zealand. Guidelines reflect not only the science, but also the regional differences in equipment and health priorities. Accordingly, guidelines for the United States may differ in some respects from those of Great Britain or South Africa. The United States guidelines serve as the foundation for the Neonatal Resuscitation Program (NRP) educational program. What are the implications of the new consensus, guidelines, and educational program at the most local level – that of the hospitals and the professionals providing perinatal services? How should the changes be implemented in everyday practice? The 2005 guidelines incorporate several major changes in approach that mean not only behavioral changes, but also new equipment. New educational tools and areas of emphasis in the NRP offer opportunities and challenges to both instructors and providers of neonatal resuscitation. Clearly, the most sweeping change in the 2005 guidelines is the possibility of providing positive-pressure ventilation with oxygen concentrations less than 100% during initial resuscitation. This alters the conduct of resuscitation from the immediate rapid assessment performed in the first several seconds after birth. No longer is the question “Is the baby pink?” asked simultaneously with “Is the amniotic fluid clear?”, “Is the baby breathing or crying?”, “Is there good muscle tone?”, and “Is the baby term?”. Instead, the first 10 to 15 minutes …

Clinical assessment of major injuries

In the UK, trauma is the leading cause of death among individuals aged <50 years; it resulted in 3221 deaths and 281,000 injuries in the UK in 2004. This contribution highlights the management principles of treating multiply-injured patients. These principles are based on guidelines devised by the American College of Surgeons Committee on Trauma i.e. the Advanced Trauma and Life Support™(ATLS™) guidelines. These focus on the ABCDE (airway and C-spine control, breathing, circulation, disability/neurological status, exposure) approach. This management plan was devised to ensure that there is a common structured approach to managing trauma. It also ensures that the life-threatening injuries are identified and treated first before progressing to limb-threatening injuries; the final aim is to identify all injuries. The principles of treating the multiply-injured patient can be divided into four phases: Primary survey (ABCDE) and resuscitation, re-evaluation, secondary survey (full head-to-toe examination) and transfer to definitive care. Problems are identified and addressed in a stepwise manner from a to e, followed by re-evaluation and the secondary survey in a sequence that allows all injuries to be identified. The attending team must restart the primary survey at a once again if the condition deteriorates.

The changing shape of teaching physiology in South Asia: Problems and prospects

It is an established fact that the medical curriculum is not a static document and plays a central role in national health care programmes. Its pertinence to the health care needs is important for medical graduates to tackle the changing needs of the society. It is often a repeated criticism that medical colleges in the South Asian countries are producing graduates who are not well equipped to accept the fresh challenges. From time to time various sections of society emphasize the importance of teaching about primary health care, aging, cardiopulmonary resuscitation, alternative and complementary medicine. The challenging financial, political, consumers and technology trends are regarded as mounting hindrances to scholastic and community-oriented medicine in the south asian countries. A thorough understanding of the basic disciplines of biomedical sciences and provision of state of the art physical facilities are of primary importance.

Trauma and burns in children

In children ages 1–14 years, in the industrialized world, trauma is the second most common cause of death and is a major cause of morbidity. The approach to the seriously injured child involves three phases. The immediate phase includes the primary survey and resuscitation. The focused phase comprises the secondary survey and emergency treatment. The detailed review involves reassessment, continued stabilization and transfer to definitive care. Each of these phases is discussed in detail. Dealing with the burned child is also discussed.

Contribution of perfusion-related, metabolic and respiratory components to gastric mucosal acidosis in acute cardiorespiratory failure

Local mucosal acidosis in acute circulatory and respiratory failure is influenced by three main components: local perfusion and metabolism (mucosal-arterial pCO2 gradient), systemic metabolic acidosis (arterial bicarbonate), and respiration (arterial pCO2). The aim of this study was to determine the effect of primary resuscitation on these components of gastric mucosal pH in surviving and nonsurviving patients admitted to the ICU.

A Randomized Trial Comparing Oxygen Delivery on Intermittent Positive Pressure With Nasal Cannulae Versus Facial Mask in Neonatal Primary Resuscitation

A Randomized Trial Comparing Oxygen Delivery on Intermittent Positive Pressure With Nasal Cannulae Versus Facial Mask in Neonatal Primary Resuscitation

A randomized trial comparing oxygen delivery on intermittent positive pressure with nasal cannulae versus facial mask in neonatal primary resuscitation

To compare, in a prospective clinical trial, oxygen delivery on intermittent positive pressure with nasal cannulae versus facial mask in primary resuscitation of the newborn with moderate asphyxia. 617 neonates with moderate asphyxia at birth were randomized: 303 were resuscitated by oxygen on intermittent positive pressure with nasal cannuale and 314 neonates by mask. Resuscitation followed the Neonatal Resuscitation Program guidelines of the American Academy of Pediatrics, 3rd edition. Resuscitation through the nasal route less frequently requires chest compressions and intubations (26 neonates needed chest compression and 20 needed intubation out of 314 resuscitated by mask; five neonates needed chest compression and two needed intubation out of 303 resuscitated by nasal cannulae). Apgar scores, admission rates to neonatal intensive care units, air-leak syndromes, birthweight, gestational age, use of prenatal steroids and deaths did not differ between groups. Oxygen delivery on intermittent positive pressure with nasal cannulae in primary resuscitation of the newborn with moderate asphyxia is a less aggressive and potentially advantageous alternative to the traditional oral route.

A randomized trial comparing oxygen delivery on intermittent positive pressure with nasal cannulae versus facial mask in neonatal primary resuscitation

A randomized trial comparing oxygen delivery on intermittent positive pressure with nasal cannulae versus facial mask in neonatal primary resuscitation

Primary esophageal repair for Boerhaave's syndrome whatever the free interval between perforation and treatment.

Boerhaave's syndrome is the most sinister cause of esophageal perforation responsible with mortality rate ranging from 20 to 30%. Combination of mediastinal contamination with microorganisms, gastric acid and digestives enzymes, long free interval between injury and initiation of treatment causes severe mediastinitis which is fatal in most untreated cases. The aim of this paper is to emphasize primary esophageal repair and resuscitation whatever the free interval from rupture and repair. A retrospective review of patients treated for Boerhaave's syndrome in our department from January 1980 to February 2003 was performed. The principle of treatment was surgical treatment and avoidance of esophageal exclusion or esophagectomy whichever was possible. There were 25 patients (17 males and 8 females). All patients were operated on by primary esophageal repair, except for three who underwent immediate exclusion of the esophagus and one patient who deceased on arrival before being operated. Patients were classified according to free interval between perforation and treatment: group 1 (n=9; 36%) within the 24 h (range from 12 to 24 h) and group 2 (n=16; 64%) more than 24 h (range from 2 to 17 days). Altogether 6 patients deceased (24%). In hospital mortality rate for groups 1 and 2 was, respectively, 44% (four patients) and 13% (two patients), not significantly different. Mean hospital stay was 63 days. Two patients developed anastomotic leakage needing esophagectomy and retrosternal coloplasty in one or more steps. One patient developed pleural abscess treated by percutaneous drainage. Three patients presented temporary symptomatic esophageal stenosis, of whom one underwent dilation. Long free interval before treatment does not preclude primary esophageal repair in Boerhaave's syndrome. Esophageal exclusion may be more often than not avoided in most cases.

Hypertonic solutions for pediatric patients

To describe the current knowledge and indications for use of hypertonic saline solutions in pediatrics patients. Medline recent review articles and personal files. Basic physiologic principles were reviewed concerning the distribution of fluid inside the intravascular, interstitial and intracellular compartments. We also reviewed the findings concerning the mechanisms responsible for the rapid onset of cardiocirculatory effects and the additional effect of the colloid component. Finally, we present the medical terms used in the context of small-volume resuscitation, the indications for clinical use, the evidence from clinical research (hemorrhagic shock, preclinical trauma care, septic shock, and head trauma), and the disadvantages and potential adverse effects of small-volume resuscitation. Resuscitation by means of hypertonic saline solutions associated or not with colloid solutions is one of the most innovative concepts for primary resuscitation from trauma and shock established in the past decade. Currently, the spectrum of potential indications involves not only prehospital trauma care, but also perioperative and intensive care therapy. However, additional randomized double-blind studies are required with both children and adult patients to confirm the advantages of the method in terms of survival.

Fluid resuscitation in the Canadian Forces.

In general, the Canadian Forces follow widely accepted principles of fluid resuscitation. These are simply guidelines for fluid resuscitation, and the Canadian Forces currently do not have an absolute doctrine that the clinician in the field must follow. In addition, these principles are adapted to our field environment and the tactical situation that may present itself. In general, Advanced Trauma Life Support guidelines are followed not only for fluid resuscitation but also for the overall resuscitation of the patient. Ringer's lactate is the primary resuscitation fluid that is used. Emphasis is placed on attempting to control ongoing hemorrhage specifically either with direct pressure, surgical control, or splinting of long bone or pelvic fractures at the earliest possible stage.

Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions.

The concept of small-volume resuscitation (SVR) using hypertonic solutions encompasses the rapid infusion of a small dose (4 ml per kg body weight, i.e. approximately 250 ml in an adult patient) of 7.2-7.5% NaCl/colloid solution. Originally, SVR was aimed for initial therapy of severe hypovolemia and shock associated with trauma. The present review focuses on the findings concerning the working mechanisms responsible for the rapid onset of the circulatory effect, the impact of the colloid component on microcirculatory resuscitation, and describes the indications for its application in the preclinical scenario as well as perioperatively and in intensive care medicine. With respect to the actual data base of clinical trials SVR seems to be superior to conventional volume therapy with regard to faster normalization of microvascular perfusion during shock phases and early resumption of organ function. Particularly patients with head trauma in association with systemic hypotension appear to benefit. Besides, potential indications for this concept include cardiac and cardiovascular surgery (attenuation of reperfusion injury during declamping phase) and burn injury. The review also describes disadvantages and potential adverse effects of SVR: Small-volume resuscitation by means of hypertonic NaCl/colloid solutions stands for one of the most innovative concepts for primary resuscitation from trauma and shock established in the past decade. Today the spectrum of potential indications involves not only prehospital trauma care, but also perioperative and intensive care therapy.

Anesthesia for Pediatric Chest Trauma

Thoracic trauma in children is the second most frequent cause of death in the pediatric population. The majority of these children will have multisystem injuries. Management of these patients starts with the primary survey, resuscitation, and secondary survey as described in Advanced Trauma Life Support training. Most children with thoracic injuries can be observed or treated nonoperatively. The majority of children who do need surgery will need exploratory laparotomy and may have significant blood loss. The anesthesiologist needs to be prepared to manage a patient with severe underlying respiratory derangements, ongoing blood loss, and /or cardiac dysfunction. Moreover, one-lung ventilation may be necessary for optimal surgical exposure, which will present considerable challenges.

Comparison of lactate or BE during out-of-hospital cardiac arrest to determine metabolic acidosis

During cardiopulmonary resuscitation, pH and base excess (BE) decrease to a variable degree due to metabolic acidosis. The main cause has been shown to be lactate, which cannot be eliminated sufficiently because of low perfusion during cardiac massage. Both BE and lactate can be measured in the prehospital phase. The aim of the study was to determine if BE and lactate are comparable variables during cardiopulmonary resuscitation (CPR) and if the measurement of lactate level alone would be sufficient to determine the patient's metabolic status and sufficiently reliable to determine the administration of buffer solutions. During the observation period, we registered 31 patients (21 males, ten females) who were resuscitated according to European Resuscitation Council recommendations, who had blood gas analysis and lactate levels measured in blood taken by arterial puncture or arterial line. The first measurement from each patient was taken after primary resuscitation (within 5–20 min). The mean lactate level was 9.85±2.98 (range, 4.1–18.7) mmol/l, and the mean BE was –15.0±5.98 (range, 5.5 to –24.3). There were statistically significant correlations between the lactate level and BE and pH (linear correlation, r=−0.673, P<0,001 and r=−0,683, P<0,001, respectively), but not with pO 2 and pCO 2. The receiver-operated curve analysis showed that a cut-off point of 7.0 mmol/l lactate indicates a BE below −10 with a sensitivity of 96% and a specificity of 67%. Lactate measurement is a valuable tool to determine metabolic acidosis during CPR and may be able to replace blood gas analysis in this situation.

The use of the spinal board after the pre-hospital phase of trauma management

Objectives—For pre-hospital spinal immobilisation the spinal board is the established gold standard. There are concerns that its subsequent use in hospital may adversely affect patient outcome. This review examines the...

Effects of primary resuscitation from shock on distribution of myocardial blood flow.

Hemorrhagic shock alters heterogeneity of regional myocardial perfusion (RMP) in the presence of critical coronary stenosis in pigs. Conventional resuscitation has failed to reverse these effects. We hypothesized that improvement of the resuscitation regime would lead to restoration of RMP heterogeneity. Diaspirin-cross-linked hemoglobin (10 g/dl; DCLHb) and human serum albumin (8.0 g/dl; HSA) were used. After baseline, a branch of the left coronary artery was stenosed; thereafter, hemorrhagic shock was induced. Resuscitation was performed with either DCLHb or HSA. At baseline, the fractcal dimension (D) of subendocardial myocardium was 1.31 +/- 0.083 (HSA) and 1.35 +/- 0.106 (DCLHb) (mean +/- SD). Coronary stenosis increased subendocardial D slightly but consistently only in the DCLHb group (1.39 +/- 0.104; P < 0.05). Shock reduced subendocardial D: 1.21 +/- 0.093 (HSA; P = 0.10), 1.25 +/- 0.092 (DCLHb; P < 0.05). Administration of DCLHb increased subendocardial D in 7 of 10 animals (1.31 +/- 0.097; P = 0.066). HSA was ineffective in this respect. DCLHb infusion restored arterial pressure and increased cardiac index (CI) to 80% of baseline values. Administration of HSA left animals hypotensive (69 mmHg) and increased CI to 122% of the average baseline value. Shock-induced disturbances of the distribution of RMP were improved by administration of DCLHb but not by HSA.

Intraosseous lines in preterm and full term neonates

AIMTo evaluate the use of intraosseous lines for rapid vascular access in primary resuscitation of preterm and full term neonates.METHODSThirty intraosseous lines were placed in 27 newborns, in whom conventional...

The Influence of Chronic Prearrest Health Conditions on Mortality and Functional Neurological Recovery in Cardiac Arrest Survivors

Purpose: To study the impact of chronic prearrest health conditions on mortality and neurological recovery in patients after witnessed cardiac arrest and primary successful resuscitation. Patients and Methods: The study was set in the community of Vienna, Austria. Data concerning cardiopulmonary resuscitation of adult patients who survived a witnessed cardiac arrest were collected according to an internationally recommended protocol (Utstein-Style). Chronic prearrest health conditions and New York Heart Association (NYHA) functional classes were evaluated. All patients were followed up for 6 months after the event or death. Adverse outcome was defined as death or severe neurological impairment. A forward stepwise logistic regression model was applied to assess the impact of pre-arrest morbidity on unfavorable outcome, expressed as odds ratio (OR) with 95% confidence intervals (CI). Results: Of 411 patients, 269 (66%) had one or more of the following pre-arrest diseases: coronary heart disease (45%), hypertension (26%), congestive heart failure (20%), diabetes mellitus (14%), chronic pulmonary disease (6%), and cerebrovascular disease (5%). In 22% a NYHA class of III or IV was present before cardiac arrest. At 6-month follow-up, 161 (40%) of the patients were alive with favorable neurological recovery; overall mortality was 57% (n = 233). Increasing NYHA classes (OR 1.4 per NYHA class increase; CI 1.1 to 1.7) and increasing age were independent predictors of adverse outcome (OR 1.03 per 10-year increase; CI 1.01 to 1.05), as were durations of cardiac arrest (OR 1.10 per 5-minute increase; CI 1.07 to 1.12) and the presence of ventricular fibrillation or tachycardia (OR 0.3; CI 0.2 to 0.5). The remaining health conditions, as listed above, were not independently associated with outcome. Conclusions: A large proportion of patients with cardiac arrest had chronic diseases before the event. The presence of impaired functional performance in patients with structural heart disease increased unfavorable outcome within 6 months in primary cardiac arrest survivors. However, the impact of chronic prearrest conditions on outcome seems to be very small, and should not influence decisions whether to withhold or withdraw therapy.

Role of Transesophageal Echocardiography in Differential Diagnosis of The Cause of Cardiac Arrest During The Secondary Survey of Advanced Cardiac Life Support

원주의과대학 응급의학교실 내과학교실 ** 황성오·김 현·이강현·임종천·오범진·조준 휘 강구현·김성환·이승환 ** ·윤정한 ** ·최경훈 ** Background:During the secondary survey of advanced cardiac life support(ACLS, differential diagnosis to seek the cause of cardiac arrest is an important step in patients who failed to restore spontaneous circulation after the primary survey and resuscitation. This study was to evaluate the role of transesophageal echocardiography(TEE for assessing the cause of cardiac arrest during the secondary survey of ACLS. Methods:We performed biplane TEE during cardiopulmonary resuscitation(CPR in 52 consecutive patients(31 male, 21 female, mean age:58 years old with cardiac arrest who failed to restore spontaneous circulation after the primary survey and resuscitation attempt. Initial presenting ECG rhythm was ventricular fibrillation in 7, asystole in 25, and pulseless electrical activity in 20 patients. TEE was performed immediately if spontaneous circulation was not restored after the primary survey and resuscitation. Possible causes of cardiac arrest were detected in 23 patients(44% by TEE. Positive findings were observed in 3(43% of 7 patients with ventricular fibrillation, 12 (48% of 25 patients with asystole, and 8(40% of 20 patients with pulseless electrical activity. TEE findings were as follows:pericardial effusion in 10, aortic dissection in 5, occlusion of mitral orifice

Creatine kinase-MB fraction and cardiac troponin T to diagnose acute myocardial infarction after cardiopulmonary resuscitation

This study sought to evaluate the diagnostic value of the biochemical markers creatine kinase (CK), creatine kinase-MB fraction (CK-MB) and cardiac troponin T (cTNT) to diagnose acute myocardial infarction (AMI) after cardiopulmonary resuscitation (CPR). Elevations of CK and CK-MB after CPR are a frequent finding and might be associated with ischemic myocardial injury, as well as physical trauma to the chest. Patients who had cardiac arrest and primary successful resuscitation were included in the study. The diagnosis of AMI was confirmed or ruled out by means of typical electrocardiographic findings, thallium-201 myocardial scintigraphy or autopsy, if death occurred during the hospital period, in 39 primary survivors of sudden cardiac death. In 24 patients (62%) the diagnosis of AMI was established. Serum cTNT, CK and CK-MB were measured, and the CK-MB/CK ratio was calculated on admission and after 12 h. On admission all markers of myocardial injury proved to be weak methods for the diagnosis of AMI. After 12 h cTNT as well as CK-MB exhibited a similar diagnostic performance; CK and the CK-MB/CK ratio proved to be worthless. Sensitivity and specificity for a cTNT cutoff value of 0.6 ng/ml, 12 h after cardiac arrest, were 96% and 80%, respectively. For a CK-MB cutoff value of 26 U/liter, sensitivity was 96% and specificity was 73%. Cardiac TNT and CK-MB are valuable tools in detecting AMI as the cause of sudden cardiac death. However, there is a considerable lack of sensitivity and specificity. Cardiac injury is probably caused not only by AMI, but also by myocardial damage related to CPR efforts.