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Daniel P Davis

Publications and source records attributed to Daniel P Davis.

At least 37 records · Page 2Linked to original sources
PubMed2004

Prospective randomized study of viscous lidocaine versus benzocaine in a GI cocktail for dyspepsia.

We hypothesized that Benzocaine (Hurricaine) would work as quickly and effectively as viscous Lidocaine in this preparation. This was a prospective randomized, single-blinded comparison between Benzocaine and Lidocaine as the topical anesthetic in a gastrointestinal (GI) cocktail. Patients 18 years or older were approached for participation when a GI cocktail was ordered by the Emergency Physician. Patients were randomized to equivalent doses of either Benzocaine or viscous Lidocaine in addition to 30 cc of Maalox and 10 cc of Donnatal. Assessment using a visual analog pain scale occurred at time intervals of 0, 5, 15, and 30 min. Eighty-two patients were enrolled (44 to Benzocaine, 38 to viscous Lidocaine), with each group having a statistically significant improvement in pain (p < 0.001). There were no statistical differences between the Benzocaine and viscous Lidocaine groups in terms of the relief of symptoms at each of the assessment times. There were no adverse outcomes in either group.

Adult↗
PubMed2004

Combination of isoflurane and caspase inhibition reduces cerebral injury in rats subjected to focal cerebral ischemia.

BACKGROUND: Recent data indicate that the neuroprotective efficacy of isoflurane is not sustained. Delayed neuronal death, mediated in part by apoptosis, contributes to the gradual increase in the size of the infarction. These data suggest that isoflurane may not be able to inhibit delayed neuronal death. The prevention of apoptosis by a caspase inhibitor might provide neuroprotection in addition to that provided by isoflurane. The current study was conducted to determine whether isoflurane-mediated neuroprotection can be made more durable with the administration of z-VAD-fmk, a nonspecific caspase inhibitor. METHODS: Fasted Wister rats were allocated to awake-zVAD, awake-vehicle, isoflurane-zVAD, or isoflurane-vehicle groups (n = 16/group). Animals were subjected to focal ischemia for 60 min by filament occlusion of the middle cerebral artery. In the awake groups, isoflurane was discontinued after occlusion of the middle cerebral artery. In the isoflurane groups, isoflurane anesthesia was maintained at 1.5 minimum alveolar concentration during occlusion of the middle cerebral artery. Before and after ischemia, daily injections of z-VAD-fmk or vehicle were administered into the lateral cerebral ventricle for 14 days. Neurologic assessment was performed 14 days after ischemia. The volume of cerebral infarction and the number of intact neurons in the periinfarct cortex were determined by image analysis of hematoxylin and eosin-stained coronal brain sections. RESULTS: Infarction volume was less in the isoflurane-zVAD group (23 +/- 11 mm, mean +/- SD) than in isoflurane-vehicle, awake-vehicle, and awake-zVAD groups (82 +/- 31, 86 +/- 31, and 59 +/- 25 mm, respectively; P < 0.05). In comparison with the awake-vehicle and isoflurane-vehicle groups, the administration of z-VAD-fmk significantly decreased infarction volume (P < 0.05). The infarction volume between the awake-vehicle and isoflurane-vehicle groups was not different. The number of intact neurons within the periinfarct cortex was significantly less in the awake-vehicle group than in the other three groups (P < 0.05). The isoflurane-zVAD group demonstrated better neurologic function than the awake-vehicle group (P < 0.05). CONCLUSION: These findings are consistent with the premise that ongoing delayed neuronal death, in part mediated by apoptosis, contributes to the progression of cerebral infarction during the recovery period, and its inhibition can provide sustained neuroprotection.

Amino Acid Chloromethyl Ketones↗
PubMed2004

The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation.

BACKGROUND: This study aimed to determine whether field end-tidal carbon dioxide CO2 (ETCO2) monitoring decreases inadvertent severe hyperventilation after paramedic rapid sequence intubation. METHODS: Data were collected prospectively as part of the San Diego Paramedic Rapid Sequence Intubation Trial, which enrolled adults with severe head injuries (Glasgow Coma Score, 3-8) that could not be intubated without neuromuscular blockade. After preoxygenation, the patients underwent rapid sequence intubation using midazolam and succinylcholine. A maximum of three intubation attempts were allowed before Combitube insertion was mandated. Tube confirmation was accomplished by physical examination, qualitative capnometry, pulse oximetry, and syringe aspiration. Standard ventilation parameters (tidal volume, 800 mL; 12 breaths/minute) were taught. One agency used portable ETCO2 monitors, with ventilation modified to target ETCO2 values of 30 to 35 mm Hg. Trial patients transported by aeromedical crews also underwent ETCO2 monitoring. The primary outcome measure was the incidence of inadvertent severe hyperventilation, defined as arterial blood gas partial pressure of CO2 (pCO2) of less than 25 mm Hg at arrival, for patients with and those without ETCO2 monitoring. These groups also were compared in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival arterial blood gas data, and survival. RESULTS: The study enrolled 426 patients and administered neuromuscular blocking agents to 418 patients. Endotracheal intubation was successful for 355 of these patients (85.2%). Another 58 patients (13.6%) underwent Combitube insertion. For 291 successfully intubated patients, arrival pCO2 values were documented, with continuous ETCO2 monitoring performed for 144 of these patients (49.4%). Patients with ETCO2 monitoring had a lower incidence of inadvertent severe hyperventilation than those without ETCO2 monitoring (5.6% vs. 13.4%; odds ratio, 2.64; 95% confidence interval, 1.12-6.20; p = 0.035). There were no significant differences in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival partial pressure of oxygen (PO2) and pH, or survival. The patients in both groups with severe hyperventilation had a significantly higher mortality rate than the patients without hyperventilation (56 vs. 30%; odds ratio, 2.9; 95% confidence interval, 1.3-6.6; p = 0.016), which could not be explained solely on the basis of their injuries. CONCLUSIONS: The use of ETCO2 monitoring is associated with a decrease in inadvertent severe hyperventilation.

Abbreviated Injury Scale↗
PubMed2004

The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients.

BACKGROUND: An increase in mortality has been documented in association with paramedic rapid sequence intubation (RSI) of severely head-injured patients. This analysis explores the impact of hypoxia and hyperventilation on outcome. METHODS: Adult severely head-injured patients (Glasgow Coma Scale score of 3-8) unable to be intubated without neuromuscular blockade underwent paramedic RSI using midazolam and succinylcholine; rocuronium was administered after confirmation of tube position. Standard ventilation parameters were used for most patients; however, one agency instituted use of digital end-tidal carbon dioxide (ETCO2) and oxygen saturation (Spo2) monitoring during the trial. Each patient undergoing digital ETCO2/Spo2 monitoring was matched to three historical nonintubated controls on the basis of age, gender, mechanism, and Abbreviated Injury Scale scores for each of six body regions. Logistic regression was used to explore the impact of oxygen desaturation during laryngoscopy and postintubation hypocapnia and hypoxia on outcome. The relationship between hypocapnia and ventilatory rate was explored using linear regression and univariate analysis. In addition, trial patients and controls were compared with regard to mortality and the incidence of "good outcomes" using an odds ratio analysis. RESULTS: Of the 426 trial patients, a total of 59 had complete ETCO2/Spo2 monitoring data; these were matched to 177 controls. Logistic regression revealed an association between the lowest ETCO2 value and final ETCO2 value and mortality. Matched-controls analysis confirmed an association between hypocapnia and mortality. A statistically significant association between ventilatory rate and ETCO2 value was observed (r = -0.13, p < 0.0001); the median ventilatory rate associated with the lowest recorded ETCO2 value was significantly higher than for all other ETCO2 values (27 mm Hg vs. 19 mm Hg, p < 0.0001). In addition, profound desaturations during RSI and hypoxia after intubation were associated with higher mortality than matched controls. Overall mortality was 41% for trial patients versus 22% for matched controls (odds ratio, 2.51; 95% confidence interval, 1.33-4.72; p = 0.004). CONCLUSIONS: Hyperventilation and severe hypoxia during paramedic RSI are associated with an increase in mortality.

Adult↗
PubMed2003

The Combitube as a salvage airway device for paramedic rapid sequence intubation.

STUDY OBJECTIVE: The safety of out-of-hospital rapid sequence intubation depends on a reliable strategy when orotracheal intubation is unsuccessful. Here we describe our experience with the Combitube (esophageal-tracheal twin-lumen airway device) as a salvage airway device for paramedic rapid sequence intubation. METHODS: The San Diego Paramedic Rapid Sequence Intubation Trial was performed to assess the effect of paramedic rapid sequence intubation on outcome in severely head-injured patients. Adults with severe head trauma (Glasgow Coma Scale score 3 to 8) who were unable to be intubated without medications were enrolled. Midazolam and succinylcholine were administered, and paramedics were allowed a maximum of 3 attempts at orotracheal intubation. If the attempts were unsuccessful, Combitube insertion was mandated. After confirmation of tube position, rocuronium was given and standard ventilation protocols were used. The primary outcome measure for this analysis was the success rate for Combitube insertion after unsuccessful orotracheal intubation. In addition, Combitube insertion and orotracheal intubation patients were compared with regard to demographic, clinical, and outcome data. RESULTS: A total of 426 patients were enrolled in the trial, with 420 meeting inclusion criteria for this analysis. Orotracheal intubation was successful in 355 (84.5%) of 420; Combitube insertion was successful in 58 (95.1%) of 61 attempts, with no reported complications. Patients undergoing Combitube insertion had higher Face Abbreviated Injury Scale scores and were more likely to have oropharyngeal blood or vomitus. Arrival Pco(2) values were higher, and arrival Po(2) values were lower but still supranormal in patients undergoing Combitube insertion. There were no mortality differences between patients undergoing Combitube insertion and those undergoing orotracheal intubation. CONCLUSION: The Combitube can be an effective salvage airway device for paramedic rapid sequence intubation in an urban/suburban, high-volume emergency medical services system with paramedics who are experienced in Combitube placement and with stringent protocols for its use. The device should be tested in other sizes and types of systems and under less medical scrutiny than was used in this study.

Abbreviated Injury Scale↗
PubMed2003

Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation.

STUDY OBJECTIVE: We determine the incidence of desaturation and pulse rate reactivity during paramedic rapid sequence intubation of patients with severe head injuries (Glasgow Coma Scale score <or=8). METHODS: Adult patients with severe head injuries had recording oximeter-capnometers applied before rapid sequence intubation. Desaturation was defined as a reduction in oxygen saturation (Spo(2)) to less than 90% from an initial Spo(2) of greater than or equal to 90% or a decrease from a baseline of less than 90%. Event records were analyzed with emergency medical services (EMS) run sheets and debriefing reports. RESULTS: Thirty-one (57%) of 54 patients demonstrated desaturation during rapid sequence intubation. Twenty-six (84%) of these 31 events occurred in patients whose initial Spo(2) value with basic airway skills was greater than or equal to 90%. The median duration of desaturation was 160 seconds (interquartile range 48 to 272 seconds), and the median decrease in Spo(2) was 22%. Six (19%) patients experienced marked bradycardia (pulse rate <50 beats/min) during desaturation events. Paramedics described rapid sequence intubation as "easy" in 26 (84%) of 31 patients with desaturation. CONCLUSION: Out-of-hospital rapid sequence intubation by paramedics was complicated by a concerning incidence of desaturation and bradycardia. Paramedic reports did not reflect the presence of these concerning derangements. Most patients had acceptable Spo(2) values before rapid sequence intubation. An effective strategy for preoxygenation is needed before it can be concluded that rapid sequence intubation is of value in the out-of-hospital care of patients with serious closed head injury.

Adult↗
PubMed2003

Acute cerebellar ataxia in a toddler: case report and literature review.

Acute cerebellar ataxia (ACA) is an inflammatory CNS disease that is characterized by rapid onset of ataxia in a child under 6 years of age. Symptoms typically occur in association with a relatively benign viral illness and have been reported after vaccination as well. Immunological studies suggest that both involve autoimmune destruction of axon tracts, with pathological and radiographic evidence of a link with multiple sclerosis. The emergency approach should be focused on excluding more significant illnesses, such as meningitis or an intracranial mass lesion. Here we present a case of a young girl with ACA and review the relevant literature.

Acute Disease↗
PubMed2003

Diagnosis and monitoring of hemorrhagic shock during the initial resuscitation of multiple trauma patients: a review.

The initial management of the multiple trauma victim requires evaluation for potential hemorrhage and ongoing monitoring to assess the efficacy of resuscitation and avoid complications related to hemorrhagic shock. A variety of strategies exist to assess circulatory status, including hemodynamic monitoring, tissue perfusion measurement, and use of serum markers of metabolism. We review available technologies used to assess fluid status and tissue perfusion in patients with blood loss or hemorrhagic shock, discuss how these methods can be used effectively and efficiently during initial trauma resuscitation to guide therapy and disposition, and suggest directions for future research to improve outcomes by providing more appropriate and timely care and avoiding unnecessary complications.

Biomarkers↗
PubMed2003

Ischemic preconditioning in the brain.

PURPOSE OF REVIEW: Brain ischemia is responsible for significant morbidity and mortality associated with cardiovascular surgery, and is the end result of multiple disease states, including cardiac arrest, stroke, and traumatic brain injury. Despite significant resources dedicated to developing neuroprotective strategies, little progress has been made in this regard. Neuronal ischemic preconditioning is an endogenous neuroprotective strategy that provides sustained and robust ischemic tolerance. Identification of the mechanisms responsible for mediating the preconditioning response may offer novel therapeutic targets and further our understanding of the natural adaptations to brain injury. RECENT FINDINGS: Recent research efforts have elucidated many intracellular signaling pathways that ultimately lead to ischemic tolerance after a preconditioning stimulus. Most of these are associated with glutamate receptor signal transduction, the intracellular kinases, and several transcription regulators. Microarray analysis has identified several gene families that warrant further investigation to identify novel candidates for neuroprotective therapies. These include genes involved in synaptic architecture and signal propagation, cell cycle and transcription regulators, and mediators of apoptosis such as the heat shock proteins and anti-apoptotic mitochondrial proteins. SUMMARY: Neuronal ischemic preconditioning is an endogenous mechanism that leads to robust neuroprotection from ischemia. Identification of the upstream pathways that initiate preconditioning and candidate genes that mediate this phenomenon may offer novel therapeutic targets, with applicability to a variety of disease states and perioperative complications.

Journal Article↗
PubMed2003

Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients.

BACKGROUND: The purpose of this study was to evaluate the effect of paramedic-administered neuromuscular blocking agents as part of a rapid-sequence intubation (RSI) protocol on successful intubation of severely head-injured patients in a large, urban prehospital system. METHODS: Adult head-injured patients were prospectively enrolled over 1 year using these inclusion criteria: Glasgow Coma Scale (GCS) score of 3 to 8, transport time > 10 minutes, and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. All adult trauma victims with a GCS score of 3 to 8 were identified during the first 12 months of the study as the trial cohort and from the preceding 12 months as the control cohort. The trial and control cohorts were compared with regard to demographic data, mechanism of injury, initial vital signs, and GCS scores. The primary outcome measure was intubation success, defined as insertion of either an endotracheal tube or a Combitube, with patients stratified by GCS score. RESULTS: The trial cohort (n = 249) and control cohort (n = 189) were similar with regard to demographic data, mechanism of injury, and initial vital signs and GCS scores. Intubation success rates increased significantly during the trial period for all patients and when stratified into GCS score of 3 and GCS score of 4 to 8. The percentage of patients intubated without neuromuscular blocking agents actually increased during the trial period. Although the number of intubations by helicopter flight crews decreased during the trial, the overall use of aeromedical resources did not change. CONCLUSION: Paramedic-administered neuromuscular blockade as part of an RSI protocol improves intubation success in a large, urban prehospital system.

Adolescent↗
PubMed2003

The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury.

OBJECTIVE: To evaluate the effect of paramedic rapid sequence intubation (RSI) on outcome in patients with severe traumatic brain injury. METHODS: Adult major trauma victims were prospectively enrolled over two years using the following inclusion criteria: Glasgow Coma Scale (GCS) 3-8, suspected head injury by mechanism or physical examination, transport time > 10," and inability to intubate without RSI. Midazolam and succinylcholine were administered before laryngoscopy; rocuronium was given after tube placement was confirmed using physical examination, capnometry, syringe aspiration, and pulse oximetry. The Combitube was used as a salvage airway device. For this analysis, trial patients were excluded for absence of a head injury (Head/Neck AIS score < 2), failure to fulfill major trauma outcome study criteria, unsuccessful intubation or Combitube insertion, or death in the field or in the resuscitation suite within 30" of arrival. Each study patient was hand matched to three nonintubated historical controls from our trauma registry using the following parameters: age, sex, mechanism of injury, trauma center, and AIS score for each body system. Controls were excluded for Head/Neck AIS defined by a c-spine injury or death in the field or in the resuscitation suite within 30" of arrival. chi 2, odds ratios, and logistic regression were used to investigate the impact of RSI on the primary outcome measures of mortality and incidence of a "good outcome," defined as discharge to home, rehabilitation, psychiatric facility, jail, or signing out against medical advice. RESULTS: A total of 209 trial patients were hand matched to 627 controls. The groups were similar with regard to all matching parameters, admission vital signs, frequency of specific head injury diagnoses, and incidence of invasive procedures. Mortality was significantly increased in the trial cohort versus controls for all patients (33.0% versus 24.2%, p < 0.05) and in those with Head/Neck AIS scores of 3 or greater (41.1% versus 30.3%, p < 0.05). The incidence of a "good outcome" was lower in the trial cohort versus controls (45.5% versus 57.9%, p < 0.01). Factors that may have contributed to the increase in mortality include transient hypoxia, inadvertent hyperventilation, and longer scene times associated with the RSI procedure. CONCLUSION: Paramedic RSI protocols to facilitate intubation of head-injured patients were associated with an increase in mortality and decrease in good outcomes versus matched historical controls.

Abbreviated Injury Scale↗
PubMed2002

Toomey syringe aspiration may be inaccurate in detecting esophageal intubation after gastric insufflation.

We sought to determine whether gastric distention from air insufflation affects the accuracy of the Toomey syringe in detecting esophageal intubation. We conducted a randomized, single-blinded, crossover trial using human cadavers in which cuffed endotracheal (ET) tubes were placed into the esophagus and trachea. Operators used the Toomey syringe to determine the location of the ET tube before and after gastric insufflation via Ambu-bag ventilation. Greater amounts of air were aspirated (35.4 cc vs. 13.7 cc, respectively, p < 0.001) and less resistance was noted on a five-point scale (3.2 vs. 4.8, respectively, p < 0.001) from esophageally placed ET tubes after gastric insufflation. Sensitivity in detecting esophageally placed ET tubes decreased from 100% in noninsufflated cadavers to only 58% after gastric insufflation (p < 0.001). In the thawed fresh frozen cadaveric model, the Toomey syringe was unreliable in detecting an esophageal intubation after gastric distention insufflation.

Adult↗
PubMedDate not supplied

Air medical transport of severely head-injured patients undergoing paramedic rapid sequence intubation.

INTRODUCTION: The San Diego Paramedic Rapid Sequence Intubation (RSI) Trial documented an increase in mortality with paramedic RSI of patients with severe traumatic brain injury. This analysis explores the impact of air medical transport of trial patients on outcome. METHODS: Adult trauma victims with severe traumatic brain injury (Glasgow Coma Scale score of 3 to 8) were prospectively enrolled. Paramedics performed RSI using midazolam and succinylcholine; air medical crews could be called at the discretion of ground paramedics, generally for anticipated prolonged transports. Patients were matched to historical controls using the following parameters: age, gender, mechanism, injury of severity score, and abbreviated injury scale scores for each body system. Patients transported by air and ground were compared with regard to demographics, clinical parameters, vital signs, arterial blood gas data, and outcome. RESULTS: A total of 336 patients were included (79 air medical and 257 ground transports). No significant differences arose between the groups with regard to demographic, clinical, vital sign, and arterial blood gas data. Air medical patients had decreased mortality (28% vs 31%, OR 0.9), and ground patients had increased mortality versus matched controls (33% vs 22%, OR 1.8). Discordant groups analysis revealed a statistically significant effect of transport personnel on outcome (P=.009). Neither advanced procedures nor the use of mannitol accounted for the improved outcomes; air medical crews used capnometry to guide ventilation on all study patients. CONCLUSION: Air medical transport of severely head-injured patients undergoing paramedic RSI was associated with improved outcomes. Improved ventilation by capnometry may account for part of these improvements.

Adult↗
PubMedDate not supplied

Auto launch/early activation: a survey of AAMS members and literature review.

BACKGROUND: Rapid access to definitive care is a fundamental tenet of trauma care and forms the basis for current emergency medical and trauma systems. Helicopters offer expedited transport to trauma centers and can deliver advanced practice personnel to the scene of injury, but many systems do not dispatch air medical crews until after assessment by ground providers. OBJECTIVES: Here we report data from the AAMS Auto Launch Survey and perform a literature review. METHODS: A 7-question survey was developed by the AAMS Research Committee and approved by the board. An invitation to participate in the survey was sent by electronic mail to all current members. A link to an online survey was included. Results were presented descriptively. Some respondents were willing to share auto launch protocols, which were categorized into patient-related factors, event-related factors, and geographic considerations. RESULTS: A total of 86 usable responses were recorded, which represented about a third of the 240 total AAMS members. Of these, 38 respondents (44.2%) routinely use auto launch. Just over half of those using early activation reported using a combination of event- and patient-related considerations; most also incorporating geographic criteria. About one-third of respondents auto launch only at the request of ground personnel, and about one-quarter use geographic criteria alone. Threshold distances ranged from 20 to 25 miles or 20 to 30 minutes by ground. CONCLUSIONS: About half of respondents routinely use auto launch, although protocols are not consistent. Auto launch appears to offer a mechanism for decreasing EMS response times, but additional research is needed to help define optimal dispatch criteria.

Air Ambulances↗
PubMedDate not supplied

Hospital bed surge capacity in the event of a mass-casualty incident.

INTRODUCTION: Traditional strategies to determine hospital bed surge capacity have relied on cross-sectional hospital census data, which underestimate the true surge capacity in the event of a mass-casualty incident. OBJECTIVE: To determine hospital bed surge capacity for the County more accurately using physician and nurse manager assessments for the disposition of all in-patients at multiple facilities. METHODS: Overnight- and day-shift nurse managers from each in-patient unit at four different hospitals were approached to make assessments for each patient as to their predicted disposition at 2, 24, and 72 hours post-event in the case of a mass-casualty incident, including transfer to a hypothetical, onsite nursing facility. Physicians at the two academic institutions also were approached for comparison. Age, gender, and admission diagnosis also were recorded for each patient. RESULTS: A total of 1,741 assessments of 788 patients by 82 nurse managers and 25 physicians from the four institutions were included. Nurse managers assessed approximately one-third of all patients as dischargeable at 24 hours and approximately one-half at 72 hours; one-quarter of the patients were assessed as being transferable to a hypothetical, on-site nursing facility at both time points. Physicians were more likely than were nurse managers to send patients to such a facility or discharge them, but less likely to transfer patients out of the intensive care unit (ICU). Inter-facility variability was explained by differences in the distribution of patient diagnoses. CONCLUSIONS: A large proportion of in-patients can be discharged within 24 and 72 hours in the event of a mass-casualty incident (MCI). Additional beds can be made available if an on-site nursing facility is made available. Both physicians and nurse managers should be included on the team that makes patient dispositions in the event of a MCI.

Bed Occupancy↗
PubMedDate not supplied

The use of etomidate for prehospital rapid-sequence intubation.

Prehospital hypoxia and hypotension increase morbidity and mortality in head-injured patients. Etomidate is a sedative agent with increasing use for emergent rapid-sequence intubation (RSI) because of its favorable hemodynamic profile. This prospective, observational study documents the authors' preliminary experience with etomidate as part of an aeromedical RSI protocol. Major trauma victims received etomidate 0.1 to 0.3 mg/kg intravenously (IV) before administration of a neuromuscular-blocking agent. After confirmation of endotracheal tube position, 1 to 2 mg midazolam IV was administered. The main outcome measure was systolic blood pressure (SBP) before and after the RSI procedure and the incidence of hypotension after RSI; individual patient plots of SBP versus time were also included for graphic analysis. An improvement in SBP after RSI with etomidate was observed (123 mm Hg to 136 mm Hg, p = 0.011) with a 9% incidence of hypotension, defined as a decrease in SBP to 90 mm Hg or less. Graphic analysis of individual SBP-time plots reveals hemodynamic stability, especially in patients with lower initial SBP values. These data suggest that the use of etomidate as part of a prehospital RSI protocol is associated with hemodynamic stability and a low incidence of hypotension.

Adolescent↗
PubMedDate not supplied

The efficacy of nebulized albuterol/ipratropium bromide versus albuterol alone in the prehospital treatment of suspected reactive airways disease.

OBJECTIVE: Ipratropium bromide has demonstrated efficacy when added to albuterol for the treatment of reactive airways disease (RAD). Its prehospital use has not been explored. METHODS: A before-and-after design was used. Prehospital and emergency department (ED) medical records were examined retrospectively six months before and six months after institution of a new protocol, which allowed the addition of ipratropium bromide to all nebulized treatments with albuterol. Primary outcome measures included: changes in vital signs (heart rate, respiratory rate, oxygen saturation), clinical improvement as assessed by paramedics, and admission rates. RESULTS: A total of 371 patients were included (n = 192 albuterol alone, n = 179 ipratropium/albuterol). There was no statistically significant difference between groups with regard to the change in heart rate, respiratory rate, or oxygen saturation. In addition, there was no difference in the proportion of patients with clinical improvement or deterioration as assessed by paramedics. There was no statistically significant difference in the admission rate from the ED except in the subgroup of patients using a metered-dose inhaler at the time of illness. Of note, more than one-third (133/371) of the patients were ultimately determined to have a diagnosis other than RAD, the majority of whom were diagnosed as having cardiac disease. CONCLUSIONS: The addition of ipratropium bromide to albuterol for the prehospital treatment of RAD does not appear to result in clinical outcome improvements. A substantial number of patients enrolled in the study were diagnosed as having cardiac disease.

Administration, Inhalation↗