Search PubMed⌕ Search

Biomedical subjects

J R Graves

Publications and source records attributed to J R Graves.

At least 19 recordsLinked to original sources
PubMed1995

Out-of-hospital ventricular fibrillation in children and adolescents: causes and outcomes.

STUDY OBJECTIVE: To compare causes and outcomes of patients younger than 20 years with an initial rhythm of ventricular fibrillation versus asystole and pulseless electrical activity. DESIGN: Retrospective cohort study. SETTING: Urban/suburban prehospital system. PARTICIPANTS: Pulseless, nonbreathing patients less than 20 years who underwent out-of-hospital resuscitation. Patients with lividity or rigor mortis or who were less than 6 months old and died of sudden infant death syndrome were excluded. RESULTS: Ventricular fibrillation was the initial rhythm in 19% (29 of 157) of the cardiac arrests. Rhythm assessment was performed by the first responder in only 44% (69 of 157) of patients. All three rhythm groups were similar in age distribution, frequency of intubation (96%), and vascular access (92%); 93% of ventricular fibrillation patients were defibrillated. The causes of ventricular fibrillation were distributed evenly among medical illnesses, overdoses, drownings, and trauma, only two patients had congenital heart defects. Seventeen percent were discharged with no or mild disability, compared with 2% of asystole/pulseless electrical activity patients (P = .003). CONCLUSION: Ventricular fibrillation is not rare in child and adolescent prehospital cardiac arrest, and these patients have a better outcome than those with asystole or pulseless electrical activity. Earlier recognition and treatment of ventricular fibrillation might improve pediatric cardiac arrest survival rates.

Adolescent↗
PubMed1995

CPR and the single rescuer: at what age should you "call first" rather than "call fast"?

STUDY OBJECTIVE: To determine whether the age-related frequency of ventricular fibrillation (VF) in cardiac arrest supports the guideline that single rescuers should "call first" for all victims of sudden collapse older than 8 years. DESIGN: Analysis of data on all nontraumatic cardiac arrests treated by emergency medical service (EMS) personnel in King County, Washington, between 1976 and 1992. MEASUREMENTS: Age, initial cardiac rhythm, witnessed versus unwitnessed status, whether patient was discharged alive. RESULTS: We analyzed 10,992 cardiac arrests. Initial rhythm was VF in 4,252 (40%) and non-VF in 6,740 (60%). VF frequencies were 3% (0 to 8 years old), 17% (8 to 30 years), and 42% (30 years or older). CONCLUSION: Most patients under age 30 were not in VF at the time of EMS evaluation. Our data suggest that a "call fast" strategy may be more effective when a single rescuer is present and the victim is between 8 and 30 years old.

Adolescent↗
PubMed1994

Expected death and unwanted resuscitation in the prehospital setting.

STUDY OBJECTIVE: To determine the outcome, location, preexisting conditions, and resuscitation wishes of prehospital cardiac arrest patients. DESIGN: Retrospective review of paramedic and emergency medical technician run reports. SETTING: Urban area with a two-tiered emergency medical services response system covering an area of 2,128 square miles and serving a population of 1,413,900 (in 1988). PARTICIPANTS: All prehospital cardiac arrest patients to which the King County, Washington, Emergency Medical Services (KCEMS) system responded to during a 12-month period. Unless decapitation, decomposition, or dependent lividity existed, all cardiac arrest patients in the KCEMS system received full resuscitative efforts. MEASUREMENTS: We analyzed run reports from 694 cardiac arrest patients, excluding all cardiac arrests from trauma, overdose, or drowning, or obvious signs of extended downtime such as decomposition or dependent lividity. We defined an unwanted resuscitation as a resuscitation attempt despite written or verbal requests by the patient, family, or private physician. We defined a patient as having severe, chronic disease if the run report listed one or more conditions associated with poor survival rates after inpatient CPR. These included cancer, cerebral vascular accident, dementia, renal failure, dialysis, AIDS, thoracic or abdominal aneurysms, cirrhosis, or if the patient was bedridden or was receiving chronic home nursing care. MAIN RESULTS: Overall 16% (103 of 633) of all cardiac arrest patients survived to hospital discharge. Seven percent (47 of 633) of all cardiac arrest patients fit the unwanted resuscitation definition; 2% (one of 47) survived to hospital discharge. Twenty-five percent (158 of 633) of cardiac arrest patients fit the definition of severe chronic disease; 8% (12 of 158) survived to hospital discharge. CONCLUSION: Severe chronic disease and unwanted resuscitation patients comprised one-third of all resuscitation attempts by KCEMS during a 12-month period. Both groups had lower survival rates compared to cardiac arrest patients who did not have severe chronic disease or indications of unwanted resuscitation.

Advance Directives↗
PubMed1994

Translating traditional principles of system development into a process for designing clinical information systems.

Traditional software development methodologies enhanced by a clinical component result in information systems that support the practice of nursing. This paper describes the clinical informatics model used to develop and evaluate a mobile computer assessment tool. Data entry of atomic-level elements, with storage in a relational database, allows the synthesis and analysis by multiple disciplines to aid in real-time decision making. The system is designed to improve the recording and accessibility of patient data and nursing observations on a geriatric unit at the Salt Lake VA Medical Center.

Clinical Medicine↗
PubMed1993

Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest.

BACKGROUND: Transcutaneous cardiac pacemakers generate electrical stimuli that pace the heart through external electrodes that adhere to the chest wall. Transcutaneous pacing has been useful in some patients with bradycardia, but its efficacy in patients with asystole and full cardiac arrest has been limited, possibly because of delays in the initiation of pacing. We studied the efficacy of early transcutaneous pacing in patients with out-of-hospital asystolic cardiac arrest. METHODS: For three years we provided transcutaneous pacemakers to about half the fire districts in a large emergency-medical-services system (the intervention group). In these districts, we authorized emergency medical technicians (EMTs) to begin transcutaneous pacing in patients with cardiac arrest and primary asystole or post-defibrillation asystole. Pacing was done as early as possible, before endotracheal intubation or intravenous medication. EMTs in the other fire districts (the control group) treated similar patients with basic cardiopulmonary resuscitation but without transcutaneous pacing. RESULTS: The EMTs in the intervention group initiated transcutaneous pacing in 112 of the 278 patients with primary asystole. Of these patients, 22 (8 percent) were admitted to the hospital, and 11 (4 percent) were discharged. Among the 259 patients treated by the EMTs in the control group, 21 (8 percent) were admitted to the hospital, and 5 (2 percent) were discharged. The two groups did not differ significantly with respect to the rate of hospital admission or survival. Survival after early pacing for post-defibrillation asystole was no better than survival after pacing for primary asystole. CONCLUSIONS: Transcutaneous pacing appears to offer no benefit in patients with asystolic cardiac arrest, even when it is performed as early as possible by EMTs in the field. Our data suggest that the widespread implementation of early transcutaneous pacing for out-of-hospital asystolic cardiac arrest would be ineffective.

Cardiac Pacing, Artificial↗
PubMed1993

Clinical nursing informatics. Developing tools for knowledge workers.

Current research in clinical nursing informatics is proceeding along three important dimensions: (1) identifying and defining nursing's language and structuring its data; (2) understanding clinical judgment and how computer-based systems can facilitate and not replace it; and (3) discovering how well-designed systems can transform nursing practice. A number of efforts are underway to find and use language that accurately represents nursing and that can be incorporated into computer-based information systems. These efforts add to understanding nursing problems, interventions, and outcomes, and provide the elements for databases from which nursing's costs and effectiveness can be studied. Research on clinical judgment focuses on how nurses (perhaps with different levels of expertise) assess patient needs, set goals, and plan and deliver care, as well as how computer-based systems can be developed to aid these cognitive processes. Finally, investigators are studying not only how computers can help nurses with the mechanics and logistics of processing information but also and more importantly how access to informatics tools changes nursing care.

Clinical Competence↗
PubMed1992

Incidence of agonal respirations in sudden cardiac arrest.

STUDY OBJECTIVE: To discover the frequency of agonal respirations in cardiac arrest calls, the ways callers describe them, and discharge rates associated with agonal respirations. DESIGN: We reviewed taped recordings of calls reporting cardiac arrests and emergency medical technician and paramedic incident reports for 1991. Arrests after arrival of emergency medical services were excluded. SETTING: King County, Washington, excluding the city of Seattle. PARTICIPANTS: Four hundred forty-five persons with out-of-hospital cardiac arrests receiving emergency medical services. INTERVENTIONS: Telephone CPR, emergency medical technicians-defibrillation, and advanced life support by paramedics. MEASUREMENTS AND MAIN RESULTS: Any attempts at breathing described by callers were identified, as well as whether agonal respirations could be heard by dispatcher, emergency medical technicians, or paramedics. Agonal respirations occurred in 40% of 445 out-of-hospital cardiac arrests. Callers described agonal breathing in a variety of ways. Agonal respirations were present in 46% of arrests caused by cardiac etiology compared with 32% in other etiologies (P < .01). Fifty-five percent of witnessed arrests had agonal activity compared with 16% of unwitnessed arrests (P < .001). Agonal respirations occurred in 56% of arrests with a rhythm of ventricular fibrillation compared with 34% of cases with a nonventricular fibrillation rhythm (P < .001). Twenty-seven percent of patients with agonal respirations were discharged alive compared with 9% without them (P < .001). CONCLUSION: There is a high incidence of agonal activity associated with out-of-hospital cardiac arrest. Presence of agonal respirations is associated with increased survival. These findings have implications for public CPR training programs and emergency dispatcher telephone CPR programs.

Emergency Medical Services↗
PubMed1992

Transcutaneous cardiac pacing in the treatment of out-of-hospital pediatric cardiac arrests.

STUDY OBJECTIVE: To evaluate the effectiveness of transcutaneous cardiac pacing in out-of-hospital treatment of cardiac arrests in pediatric patients. DESIGN: We describe the outcome of patients treated during a prospective trial of transcutaneous cardiac pacing in the field. We compare their outcome with that of out-of-hospital arrests in submersion patients who were not paced. We identified patients from Seattle and King County Emergency Medical Services reports, hospitals, and medical examiner's registries. MEASUREMENTS AND MAIN RESULTS: Nine patients in cardiac arrest caused by drowning (six) and sudden infant death syndrome (three) were paced in the field. All were less than 6 years old. The one survivor was severely neurologically impaired and died six months later. Transcutaneous cardiac pacing produced electrical capture in two patients but no detectable pulse or blood pressure. Ten submersion patients less than 6 years old in cardiac arrest were not paced. One survived, with mild neurologic impairment at hospital discharge. CONCLUSION: Transcutaneous cardiac pacing was not effective and was not associated with improved survival.

Cardiac Pacing, Artificial↗
PubMed1990

Near-fatal yew berry intoxication treated with external cardiac pacing and digoxin-specific FAB antibody fragments.

The case of a 5-year-old girl who survived a near-fatal ingestion of yew plant leaves after treatment with CPR, transcutaneous pacing, and digoxin-specific FAB antibody fragments is presented. Multiple rhythm disturbances, including profound bradycardia, occurred. She required endotracheal intubation, external chest compressions, and application of a transcutaneous pacemaker. Paced cardiac contractions produced a dramatic improvement in her blood pressure and clinical condition. Two empiric injections of digoxin-specific FAB antibody fragments were administered, after which cardiac function and rhythm gradually improved. She was discharged in her normal state of health three days later. Yew leaves and berries contain several alkaloids that can produce fatal conduction disturbances. Transcutaneous cardiac pacemakers may be lifesaving for patients with transient cardiac toxicity from drug or toxin ingestions. In addition, cross-reactivity between digoxin-specific FAB antibodies and the alkaloids in the yew plant may exist and may have therapeutic importance, although this mechanism was unlikely to have helped our patient.

Bradycardia↗
PubMed1990

A research-knowledge system (ARKS) for storing, managing, and modeling knowledge from the scientific literature.

Nursing knowledge and nursing data are the foundation for nursing practice. Domain knowledge that is stored in the literature of nursing and related disciplines, if not in memory, needs to be available to nurses during the process of clinical decision making. Although the electromechanical technology for delivering knowledge is available, conceptual technology lags far behind. An informatics solution to the conceptual problem is provided by knowledge engineering, the branch of informatics that addresses such problems by developing methods for restructuring knowledge from one form into a form that is more useful. The purpose of this article is to describe a research program for engineering nursing knowledge that has resulted in the development of such a tool, a prototype computer system for storing, managing, and modeling research-knowledge. The system is called ARKS, acronym for A Research-Knowledge System.

Computer Simulation↗
PubMed1989

The study of nursing informatics.

A framework for organizing the study of nursing informatics is presented. The management and processing of nursing data, information science and nursing science is proposed as an area for study. The premises for such study and the key concepts and relationships are discussed. Nursing informatics would support the practice of nursing and delivery of nursing care.

Education, Nursing↗
PubMed1988

An innovative approach to medical control: semiautomatic defibrillators with solid-state memory modules for recording cardiac arrest events.

We evaluated the use of microprocessor-based memory modules incorporated into automatic external defibrillators. These solid-state modules store information about each clinical use, including selected segments of the ECG rhythm and notations on defibrillator operation. A playback unit provides annotated printouts of the recorded information. The purpose of our evaluation was to determine whether this memory module could adequately support medical control "run-reviews" when compared with dualfunction (voice and ECG) tape recordings. A total of 41 resuscitation attempts by emergency medical technicians trained to defibrillate (EMT-Ds) were evaluated in five preselected performance areas: defibrillation skills, command and communication at the scene, patient assessment and support, safety, and speed. When performance was reviewed using the tape recordings, the average EMT-D performance score was 16.2 (maximum, 20); when reviewed using the printouts from the medical control modules, the average score, 7.2, was significantly lower (P less than .01). The lower scores with the medical control module occurred because not all five areas of skill could be evaluated adequately by the memory module approach. Assessment of the areas of communication/command at the scene, patient assessment/support, and safety required verbal tape recordings. The medical control module appeared superior to the tape recordings at providing a quick, convenient, and accurate evaluation of rhythm assessment, shock decisions, time intervals, and defibrillator performance. They make several features of medical control review easier and more convenient, and may encourage implementation of early defibrillation programs. We conclude, however, that medical control modules cannot replace on-scene tape recordings for adequate medical control of EMT-D programs.

Automation↗
PubMed1987

Automatic external defibrillators used by emergency medical technicians. A controlled clinical trial.

In a randomized controlled clinical trial, the effectiveness of emergency medical technician (EMT) use of automatic external defibrillators (AEDs) was compared with EMT use of standard defibrillators for patients in cardiac arrest. A total of 321 cardiac arrest patients were treated during the study: 116 were treated by EMTs using the AED (AUTO group), 158 were treated by EMTs using the standard defibrillators (standard group), and 47 were treated by EMTs using the standard defibrillator when they were assigned to use the AED. There was no significant differences in hospital admission or discharge rates between the AUTO group (54% admitted, 28% discharged) and the standard group (52% admitted, 23% discharged) for patients in ventricular fibrillation (VF), for patients in non-VF rhythms, or for all patients combined. The only significant difference observed was in the time from power ON to first shock: 1.1 minutes average AUTO group and 2.0 minutes average standard group. The treatment groups did not differ significantly in sensitivity for VF (78% AED, 76% standard), specificity for non-VF rhythms (100% AED, 95% standard), or rates of defibrillation to a non-VF rhythm (62% AED, 57% standard). We conclude that in clinical outcomes and device performance, AEDs are comparable with standard defibrillators and should be considered an acceptable alternative. Automatic external defibrillators appear to have advantages over standard defibrillators in training, skill retention, and faster operation. Such devices can make early defibrillation available for a much larger portion of the population. They are a major innovation for the prehospital care of cardiac arrest patients.

Analysis of Variance↗
PubMed1986

Ventilation skills of emergency medical technicians: A teaching challenge for emergency medicine.

We assessed the ability of 64 emergency medical technicians (EMTs) to ventilate a resuscitation manikin with a bag valve mask and with a pocket face mask to determine if their skill levels met the American Heart Association standard of 12 ventilations per minute, each with a tidal volume of 800 mL or more. All ventilation attempts were made during ongoing chest compressions (60 per minute). A successful ventilation was defined as a tidal volume of 800 mL +/- 40 mL. In a preliminary skills assessment, EMTs averaged 4.8 attempts with the bag valve mask and 2.9 attempts with the pocket face mask before a successful ventilation (P less than .01). In a formal skills assessment that lasted two minutes, successful ventilations per minute averaged 8.3 with the bag value mask and 9.9 with the pocket face mask (P less than 0.1). EMTs passed if they averaged ten or more successful ventilations per minute; 67% passed with the bag valve mask and 77% with the pocket face mask (NS). During a ten-minute extended skill assessment the EMTs averaged 9.6 ventilations per minute with the bag valve mask and 9.5 with the pocket face mask (NS). EMTs achieved initial success and maintained continued success better with the pocket face mask, but a reasonably high percentage (67%) met an objective standard when using the bag valve mask. We propose that objective standards be used to test the skills of EMTs for any ventilatory adjunct that they are permitted to use.

Allied Health Personnel↗
PubMed1985

What is a "save"?: Outcome measures in clinical evaluations of automatic external defibrillators.

Automatic external defibrillators (AEDs) represent an important technologic innovation in the management of out-of-hospital cardiac arrest. We propose the following concept: AEDs are machines with the limited task of ventricular fibrillation (VF) identification, countershock delivery, and defibrillation. They cannot be expected to produce "saves" independently. This study tested this concept by using the same AED in two different emergency medical systems: outcomes dependent upon the device should be the same in both groups, whereas outcomes dependent upon patient and system factors should be different. Paramedics, with the AED as their initial monitor/defibrillator, treated 16 cardiac arrest patients in VF; EMTs (emergency medical technicians), with the same AED, treated 17 patients in VF. There were no significant differences in the outcomes proposed to be machine-dependent: sensitivity, defined as the percentage of VF rhythm segments shocked; specificity, defined as the percentage of non-VF rhythms not shocked; and defibrillation of segments of VF to non-VF rhythms. There were, however, differences in the outcomes dependent on patient and system factors (paramedic group presented first): percent converted to a perfusing rhythm (23% vs 69%; p less than 0.05); percent admitted to the hospital (19% vs 65%; p less than 0.025); and percent discharged from the hospital (6% vs 29%; p = N.S.). We conclude that AEDs should be compared and evaluated on device-dependent outcomes and not on the basis of producing "saves".

Aged↗