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Biomedical subjects

P E Pepe

Publications and source records attributed to P E Pepe.

At least 19 recordsLinked to original sources
PubMed2001

Action sequence for layperson cardiopulmonary resuscitation.

Although some minor modifications were forged, the general consensus was to maintain most of the current guidelines for phone first/phone fast, no-assisted-ventilation CPR, the A-B-C (vs C-A-B) sequence of CPR, and the recovery position. The decisions to leave these guidelines as they are were based on a lack of evidence to justify the proposed changes, coupled with a reluctance to make revisions that would require major changes in worldwide educational practices without such evidence.Nonetheless, some major changes were made. The time-honored procedure ol pulse check by lay rescuers was eliminated altogether and replaced with an assessment for other signs of circulation. Likewise, it was recommended that even the professional rescuer now check for these other signs of circulation. Although professional rescuers may simultaneously check for a pulse, they should do so only for a short period of time (within 10 seconds). There was also enthusiasm for deleting the ventilation aspect of EMS dispatcher-assisted CPR instructions that are provided to rescuers at the scene who are inexperienced in CPR. lt was made clear, though, that the data are applicable only to adult patients who are receiving CPR and that the data are appropriate most for EMS systems with rapid response times.

Adult↗
PubMed2000

Attitudes towards CPR training and performance in family members of patients with heart disease.

Considering that heart patients may be at higher risk for cardiac arrest, this study was conducted to evaluate the preparedness and willingness of cardiac patient family members to perform cardiopulmonary resuscitation (CPR). A cross-sectional survey of 100 family members of cardiac patients was conducted at a tertiary care emergency department over a 1.5-month period. Response rate was 95%. While 49% reported prior CPR training, only 7% trained within the past year. The majority received training (59%) because of a school or job requirement with only 8% trained because of 'concern for a family member.' The most frequent reasons for not being trained were 'never thought about it' or 'not interested' (57%). However, 49% of the untrained group did report an interest in future training. While 2% of respondents recalled a healthcare professional suggesting such training, 58% stated they would be influenced positively by such a recommendation. The most frequently reported barriers to performing CPR included fear of harming the patient or a lack of knowledge and skill to help. Despite a presumed higher risk for sudden cardiac death, most family members of cardiac patients do not maintain skills in basic CPR. Healthcare professionals may have the ability to significantly alter this concerning statistic through education and routine recommendations to patients' families.

Adult↗
PubMed2000

Traumatic brain injuries evaluated in U.S. emergency departments, 1992-1994.

OBJECTIVE: To describe the incidence and patient characteristics of traumatic brain injuries (TBIs) treated in U.S. emergency departments (EDs). METHODS: A secondary analysis was performed on data from the National Hospital Ambulatory Medical Care Survey administered from 1992 to 1994. An ED visit was determined to represent a case of TBI if the case record contained ICD-9-CM codes of 800.0-801.9, 803.0-804.9, or 850.0-854.1. RESULTS: The average annual estimate of new TBI treated in U.S. EDs was 1,144,807, equaling 444 per 100,000 persons (95% CI = 390 to 498), which represents approximately 3,136 new cases of TBI per day and accounts for 1.3% of all ED visits. Males were 1.6 times as likely as females to suffer TBI until the age of 65 years, when the female rate exceeded the male. The rate for blacks was 35% higher than that for whites. The highest overall incidence rate of TBI occurred in the less-than-5-year age group (1,091 per 100,000), closely followed by the more-than-85-year age group (1,026 per 100,000). Falls represented the most common mechanism of TBI injury, followed by motor vehicle-related trauma. CONCLUSIONS: This study underscores the ongoing need for effective surveillance of all types of TBI and evaluation of prevention strategies targeting high-risk individuals. It serves as a clinically grounded and ED-based corroboration of prior survey research, providing a basis for comparison of incidence rates over time and a tool with which to measure the efficacy of future interventions.

Accidental Falls↗
PubMed1999

A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest.

STUDY OBJECTIVES: To perform a population-based study addressing the demography, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest (PCPA). METHODS: Prospective, population-based study of all children (17 years of age or younger) in a large urban municipality who were treated by EMS personnel for apneic, pulseless conditions. Data were collected prospectively for 3(1/2) years using a comprehensive data collection tool and on-line computerized database. Each child received standard pediatric advanced cardiac life support. RESULTS: During the 3(1/2)-year period, 300 children presented with PCPA (annual incidence of 19. 7/100,000 at risk). Of these, 60% (n=181) were male (P =.0003), and 54% (n=161) were patients 12 months of age or younger (152,500 at risk). Compared with the population at risk (32% black patients, 36% Hispanic patients, 26% white patients), a disproportionate number of arrests occurred in black children (51.6% versus 26.6% in Hispanics, and 17% in white children; P <.0001). Over 60% of all cases (n=181) occurred in the home with family members present, and yet those family members initiated basic CPR in only 31 (17%) of such cases. Only 33 (11%) of the total 300 PCPA cases had a return of spontaneous circulation, and 5 of the 6 discharged survivors had significant neurologic sequelae. Only 1 factor, endotracheal intubation, was correlated positively with return of spontaneous circulation (P =.032). CONCLUSION: This population-based study underscores the need to investigate new therapeutic interventions for PCPA, as well as innovative strategies for improving the frequency of basic CPR for children.

Adolescent↗
PubMed1998

Reappraising the prehospital care of the patient with major trauma.

Recent research efforts have demonstrated that many long-standing practices for the prehospital resuscitation of trauma patients may be inappropriate, particularly in certain circumstances. Traditional practices, such as application of antishock garments and IV fluid administration, may even be detrimental in certain patients with uncontrolled bleeding. Endotracheal intubation, although potentially capable of prolonging a patient's ability to tolerate circulatory arrest, may be harmful if overzealous ventilation further compromises cardiac output in such severe hemodynamic instability. If these procedures delay patient transport, any benefit they may offer could be outweighed by delaying definitive care. To improve current systems of trauma care, future trauma research must address the different mechanisms of injury, the anatomic areas involved, and the physiologic staging in a given patient.

Emergency Treatment↗
PubMed1998

Ensuring the chain of recovery for stroke in your community.

Until recently, the prehospital and ED management of nonhemorrhagic stroke was largely supportive care. Studies have now demonstrated the potential of certain therapeutic interventions to reverse the debilitating consequences of such strokes. The clinical benefit for such interventions and the risk of significant therapeutic complications are highly time-dependent. To optimize the chances of a better outcome for the patient with stroke, each community must establish and continue to refine a chain of recovery for stroke patients. The chain of recovery is a metaphor that describes a series of sequential actions that must take place in a timely fashion to optimize the chances of recovery from stroke. Each of these sequential actions forms an individual link in the chain, and each link must be intact. The links include: identification of the onset of stroke symptoms by the patient or bystanders; dispatch life support services, which preferably include enhanced 9-1-1 and medically supervised and trained dispatchers who can rapidly deploy the closest responders and transport units; emergency medical services (EMS) personnel who can rapidly assess and transport the stroke patient to the closest appropriate center capable of providing advanced stroke diagnostics and interventions; en route notification of the receiving facility so that appropriate personnel can be readied for rapid diagnosis and intervention; and receiving facilities capable of providing rapid diagnosis and advanced treatment of stroke, including the availability of specialists who can evaluate underlying etiologies as well as plan future therapies and rehabilitation. To ensure that the chain of recovery is in place, aggressive public education campaigns should be implemented to increase the probability that stroke symptoms and signs will be recognized as soon as possible by patients and bystanders. In addition, because most of the current training programs for EMS dispatchers and EMS personnel are lacking with regard to stroke, it is recommended that such personnel and their EMS system managers be updated on current management and treatment strategies for stroke.

Cerebrovascular Disorders↗
PubMed1996

Resuscitation from severe hemorrhage.

The potential to be successfully resuscitation from severe traumatic hemorrhagic shock is not only limited by the "golden 1 hr", but also by the "brass (or platinum) 10 mins" for combat casualties and civilian trauma victims with traumatic exsanguination. One research challenge is to determine how best to prevent cardiac arrest during severe hemorrhage, before control of bleeding is possible. Another research challenge is to determine the critical limits of, and optimal treatments for, protracted hemorrhagic hypotension, in order to prevent "delayed" multiple organ failure after hemostasis and all-out resuscitation. Animal research is shifting from the use of unrealistic, pressure-controlled, hemorrhagic shock models and partially realistic, volume-controlled hemorrhagic shock models to more realistic, uncontrolled hemorrhagic shock outcome models. Animal outcome models of combined trauma and shock are needed; a challenge is to find a humane and clinically realistic long-term method for analgesia that does not interfere with cardiovascular responses. Clinical potentials in need of research are shifting from normotensive to hypotensive (limited) fluid resuscitation with plasma substitutes. Topics include optimal temperature, fluid composition, analgesia, and pharmacotherapy. Hypotensive fluid resuscitation in uncontrolled hemorrhagic shock with the addition of moderate resuscitative (28 degrees to 32 degrees C) hypothermia looks promising in the laboratory. Regarding the composition of the resuscitation fluid, despite encouraging results with new preparations of stroma-free hemoglobin and hypertonic salt solutions with colloid, searches for the optimal combination of oxygen-carrying blood substitute, colloid, and electrolyte solution for limited fluid resuscitation with the smallest volume should continue. For titrating treatment of shock, blood lactate concentrations are of questionable value although metabolic acidemia seems helpful for prognostication. Development of devices for early noninvasive monitoring of multiple parameters in the field is indicated. Molecular research applies more to protracted hypovolemic shock followed by the systemic inflammatory response syndrome or septic shock, which were not the major topics of this discussion.

Animals↗
PubMed1995

Ventricular fibrillation, automatic external defibrillators, and the United States Food and Drug Administration: confrontation without comprehension.

More people die in the United States each day of potentially reversible VF than of any other cause of death, reversible or not. Early defibrillation is the definitive treatment. Automated external defibrillation is a proven technology now confirmed to have saved thousands of lives. As with all medical devices and technology, perfection is not possible. Some problems, such as those represented by the two cases discussed in this article, are inevitable and acceptable and give little cause for alarm. One would not stop penicillin from being manufactured and distributed because of a sudden, unexpected allergic reaction in one patient (error of commission) or an unexpected resistant organism in another (error of omission). The FDA must understand that AEDs, even if they are imperfect, are not anywhere near as dangerous as no defibrillator at all. AEDs have finally allowed many EMS systems to achieve early defibrillation. Discontinuing use of AEDs or closing AED manufacturers could mean a significant number of lives lost unnecessarily. Therefore EMS agencies planning to implement early-defibrillation programs should continue with such plans. Why the agents of an important federal regulatory agency have singled out this technology for an intense review puzzles many observers in the medical-device field. Two meetings have been hosted by officials of the FDA to discuss the continuing concern the FDA officials have expressed over automated defibrillation technology. These meetings included representatives from the AHA, the American College of Cardiology, ACEP, defibrillator manufacturers, and other interested organizations. The FDA leadership has repeatedly focused on data acquired through the FDA Medical Device Reporting systems. Congress requires the FDA to investigate reports of problems with "critical medical devices." Because the indication for the use of a defibrillator is cardiac arrest, there will inevitably be a high association between defibrillator use and patient deaths. FDA personnel may view such reports of device problems in association with patient deaths as evidence that an intrinsically flawed technology has reached the marketplace without rigorous testing and evaluation. From the clinician's perspective, however, these reports represent a small numerator over a huge denominator of daily, lifesaving clinical use. The non-FDA participants at the two meetings have stated that the FDA complaints appear to be random and reveal a lack of understanding of AED technology.(ABSTRACT TRUNCATED AT 400 WORDS)

Algorithms↗
PubMed1995

Older nursing home residents have a cardiac arrest survival rate similar to that of older persons living in the community.

OBJECTIVE: To determine the survival rates of older nursing home residents after cardiopulmonary resuscitation (CPR) and to compare it with that of older persons who experienced cardiac arrest in an outpatient setting. To identify patient characteristics, arrest characteristics, and effort characteristics that are associated with higher survival rates. DESIGN: Retrospective review of emergency medical service charts and hospital medical records of a cohort of older nursing home residents (n = 114) after cardiopulmonary resuscitation and a matched cohort of community-residing older persons (n = 228) matched on age, gender, and year of cardiac arrest. SETTING: A large metropolitan city served by a tiered emergency medical service. MEASUREMENTS: Independent variables related to patient, cardiac arrest, and resuscitation effort characteristics. Dependent variables were defined as immediate survival after cardiopulmonary resuscitation and survival status at discharge. RESULTS: The mean age of nursing home residents was 80.3 years; 62.3% were females. The majority of cardiac arrests for both groups were unwitnessed (67%) and had agonal rhythms (asystole and electromechanical dissociation). Emergency medical service efforts were similar for the two cohorts. Among nursing home residents, 26.3% had a return of blood pressure for more than 5 minutes, 70.2% were pronounced dead in the emergency room, and 10.5% were discharged from hospitals alive. In the matched community-residing subjects, 22.7% had a return of blood pressure, 78.1% were pronounced dead in the emergency room, and 9.2% were discharged alive. Between-group comparisons of these variables revealed no significant differences even though our sample size was adequate. CONCLUSIONS: We conclude that survival after cardiac arrest of older persons residing in nursing homes is low; however, with an appropriate CPR/DNR selection process and an effective emergency medical system, survival of certain groups of nursing home residents following cardiac arrest could be comparable to that of community residing older persons. Despite the reasonably good survival rates for older persons seen above, our analyses indicated that patients who have unwitnessed arrests are not likely to survive to discharge and that patients with initial rhythms such as asystole or electromechanical dissociation rarely survive. These data suggest that patients who have an unwitnessed arrest in the nursing home should not receive resuscitation attempts, and in those patients for whom paramedics are called, resuscitation efforts should not proceed any further if their original rhythm is asystole or electromechanical dissociation. Thus, modification in nursing home policies regarding CPR efforts is needed.

Aged↗