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PubMed1997

Acute thyroid hormone administration increases systemic oxygen delivery and consumption immediately following resuscitation from cardiac arrest without changes in thyroid-stimulating hormone.

This study determined the acute effects of intravenous levothyroxine sodium (LT4) on systemic oxygen delivery and consumption for 6 h following resuscitation from 9 min of normothermic cardiac arrest in dogs. Male mongrel dogs (15-25 kg) were randomly assigned to two groups of seven. The treated group received a pre-cardiac arrest infusion of 15 micrograms/kg per h of LT4 for 1.5 h prior to arrest and for 6 h after, while controls received a comparable volume of 0.9 N saline infusion. Neurologic outcome was recorded at 1, 2 and 6 h following resuscitation. Systemic oxygen consumption (VO2), carbon dioxide production (VCO2) and respiratory quotient (RQ) were calculated from directly measured cardiac output, arterial and mixed venous blood gases and contents. Serum levels of circulating canine thyroid-stimulating hormone (cTSH), total thyroxine (T4), free thyroxine (FT4), total 3,5,3'-triiodothyronine (T3), free 3,5,3'-triiodothyronine (FT3), reverse 3,3',5'-triiodothyronine (rT3), and plasma markers of oxidant injury (malonaldehyde (MDA), 4-hydroxynonenal (4-OH) and erythrocyte GSH) were measured before administration and after resuscitation. Following resuscitation, treated dogs maintained significantly higher cardiac output when compared with their control counterparts at 4 h (5.5 ml/g per h vs. 2.9 ml/g per h, respectively, P < 0.05) and at 6 h (5.5 ml/g per h vs. 3.0 mg/g per h, respectively, P < 0.05). The level of VO2 was significantly higher in treated dogs than control dogs at 1, 4 and 6 h (P < 0.05). Treated dogs had significantly elevated levels of T4, FT4, T3, FT3 and rT3 (P < 0.01), compared with control dogs. No changes in cTSH were detected between groups or over time. Acute administration of LT4 enhances systemic oxygen delivery and apparently, therefore, oxygen consumption following resuscitation.

Animals↗
PubMed1997

The decision to terminate resuscitative efforts: results of a questionnaire.

Despite all the progress made in emergency medicine, out-of-hospital resuscitative efforts still remain unsuccessful in the majority of cases and a decision concerning termination of cardiopulmonary resuscitation (CPR) has to be made. We used a multi-question survey to assess the attitude of emergency physicians towards the duration of an unsuccessful resuscitation attempt in non-traumatic cardiac arrest, and to identify the criteria affecting the decision to terminate CPR in the prehospital setting. More than 400 physicians participated in the inquiry on CPR in adults. If spontaneous circulation cannot be restored, the majority (65%) abandon the resuscitation attempt at the latest after performing advanced cardiac life support for 45 min. The participants indicated the following factors as criteria for the termination of unsuccessful CPR: pre-existing diseases (92%), presumed interval between onset of arrest and application of CPR (92%), duration of the resuscitation attempt (90%), age of the patient (89%), electrocardiographic (ECG) alterations such as persistent asystole/ventricular fibrillation or electromechanical dissociation (83%), persistent fixed and dilated pupils (78%), lack of brain stem reflexes (31%), body temperature (12%) and suspected drug intoxication (8%). The answers reflect the physicians opinions on termination of CPR even if they do not present real decisions under emergency conditions. The results indicate that in addition to the failure to restore spontaneous circulation, other factors are involved in decision making at the scene. A high rate of respondents include criteria of weak diagnostic value such as the pupillary status, or factors of doubtful prognostic significance such as the patient's age. Concerning the patient's history and underlying diseases, the emergency physician often has to resort to presumptions. We conclude that the decision to terminate CPR is made by most physicians considering the specific circumstances of the cardiac arrest.

Adult↗
PubMed1997

Gastric rupture--an uncommon complication after successful cardiopulmonary resuscitation: report of two cases.

Gastric rupture is a poorly described complication following cardiopulmonary resuscitation. An incidence of 0.1% has been reported in the literature. Published reports describe traumatic gastric rupture after use of the CardioPump, after mouth-to-mouth ventilation, and in children after resuscitation performed by paramedics. We report on two patients who developed gastric rupture after successful standard cardiopulmonary resuscitation. Preexisting gastric ulcerations or osseous trauma during resuscitation had been excluded. Neither patient developed abdominal symptoms; in both cases the gastric rupture was diagnosed by routine chest X-ray and both patients underwent-after stabilization-surgical treatment. One patient recovered well, but the other developed cardiogenic shock due to malignant arrhythmias and severely impaired left ventricular function. This patient died on the 6th postinterventional day. Gastric rupture rarely occurs after cardiopulmonary resuscitation. The causes of gastric rupture and the means to avoid this complication will be discussed.

Aged↗
PubMed1998

Selective neurological recovery or dissociated cardiac death--to be or not to be--during cardiopulmonary resuscitation.

Of 111 victims of circulatory arrest, 93 (84%) retained or regained some brain function during the resuscitation process. Twenty-six of these (24%) did not have spontaneous circulation restored, and a further 18 (16%) were left in cardiogenic shock and died within 24 h. Bradyarrhythmia or asystole during the resuscitation efforts or prolonged resuscitative attempts beyond 20 min were related to the irreversible failure of heart pump function. Individuals developing either this type of 'dissociated cardiac death' or cardiogenic shock could not be identified prior to resuscitation by the cause of the arrest nor by the initial cardiac arrhythmia. 'Dissociated cardiac death' and cardiogenic shock are major problems in cardiopulmonary resuscitation. A code of practice is urgently needed.

Arrhythmias, Cardiac↗
PubMedDate not supplied

Identification of rib cage's lower margin in cardiopulmonary resuscitation.

The Guidelines of the American Heart Association (J Am Med Assoc 1992;268(16):2184-2198) and the European Resuscitation Council (Resuscitation 1992;24:103-110; Resuscitation 1998;37:67-80) for adult basic cardiopulmonary resuscitation (CPR), suggest that the hands of the rescuer should be positioned on the sternum of the victim after identification of the lower margin of the rib cage, but how this identification is made is not described. Lay persons have problems with the identification of anatomical structures that they cannot actually see (Bahr et al., Resuscitation 1997;35:23-6). Although this does not present a problem for those familiar with human anatomy, we have noticed that lay persons have problems with the identification of the lower margin of the rib cage. In this report, we suggest a method for correct and rapid recognition of the costal margin.

Cardiopulmonary Resuscitation↗
PubMedDate not supplied

Measurement of myocardial contractility following successful resuscitation: quantitated left ventricular systolic function utilising non-invasive wall stress analysis.

After successful resuscitation from cardiac arrest, prolonged contractile failure has been demonstrated in animal experiments. No systematic evaluation of myocardial contractility following successful resuscitation after human cardiac arrest exists. The aim of this study was to assess left ventricular contractility following human cardiac arrest with successful resuscitation. In 20 adult patients after cardiac arrest and in four control patients, the relation between meridional wall stress (MWS) and rate-corrected mean velocity of circumferential fibre shortening (Vcf(c)), a load independent and rate corrected index of left ventricular contractility was measured within 4 h after return of spontaneous circulation and after 24 h by means of transoesophageal echocardiography. As the normal values of Vcf(c) depend on MWS, a normal deviate (z) was calculated. A normal z-score is defined as 0+/-2, < -2 indicates reduced contractility, > + 2 increased contractility. Data are presented as median and the interquartile range (IQR). For the comparison of related samples the Wilcoxon sign test was used. In most patients after cardiac arrest contractility was severely impaired within 4 h after successful resuscitation [z - 7.0 (IQR - 8.9 - (-2.5))]. Contractility did not significantly improve within the observational period [z after 24 h - 3.7 (IQR - 7.9 - (-1.8))] (P = 0.3). The four control patients had normal left ventricular contractility on arrival (z 0.0, range - 0.9-0.8) and after 24 h (z 0.7, range - 1.5-2.7). In conclusion non-invasive wall stress analysis can be applied to quantitate systolic left ventricular function, which was severely compromised in most patients within the first 24 h after successful resuscitation. Whether depression of left ventricular function is caused by cardiac arrest itself or by the underlying disease remains speculative.

Adult↗
PubMedDate not supplied

Experimental model of cardiovascular post-resuscitation syndrome--no effect of platelet activating factor antagonism.

The cardiovascular instability seen in the reperfusion phase after resuscitation from cardiac arrest may contribute to secondary brain injury. The aim of the present study was to characterise post-resuscitation cardiovascular instability in an experimental model of cardiac arrest and to test if cardiovascular stability could be improved by pre-treatment with the platelet activating factor (PAF) antagonist BN52021. Ten anaesthetised pigs received pre-treatment with BN52021 before induction of ventricular fibrillation (arrest/BN52021 group), while ten animals received only the vehicle (arrest/vehicle group). After a non-intervention interval of 9 min, resuscitation was attempted. Resuscitated animals were observed for 5 h and compared to a sham arrest group of seven animals. The haemodynamic situation after resuscitation was characterised by a low cardiac output that was inadequate in relation to the oxygen demand, as reflected by a low mixed venous oxygen saturation. The arterial blood pressure was to some extent reduced and the filling pressures in both the right and left heart were increased, but urinary output was not reduced. The severe haemodynamic compromise was not adequately reflected by standard monitoring variables such as arterial blood pressure and urinary output. Pre-treatment with BN52021 was unable to improve any aspect of short-term survival or haemodynamic stability.

Acid-Base Equilibrium↗
PubMedDate not supplied

Lack of a neuroprotective effect from N-acetylcysteine after cardiac arrest and resuscitation in a canine model.

OBJECTIVE: Oxygen free radicals cause brain injury following resuscitation from cardiac arrest. In preclinical trials, some free radical scavenging drugs reduce oxidative neuronal damage after ischemia and reperfusion, but these drugs are generally not yet available for clinical testing or use. N-Acetylcysteine (NAC), a commonly used antidote in acetaminophen poisoning, is also a potent free radical scavenger that can ameliorate oxidative injury following ischemia and reperfusion in neuronal cell culture. We hypothesized that treatment with NAC would improve neurological outcome after cardiac arrest and resuscitation. METHODS: In 16 adult female beagles, 10 min of ventricular fibrillation was followed by 3 min of open-chest CPR, and defibrillation. Immediately following return of spontaneous circulation, animals randomly received either 150 mg/kg NAC (3% solution) (n = 8) or an equivalent volume of normal saline (n = 8). Twenty-three hours later, neurological deficit was scored (0 = normal, 100 = brain death). RESULTS: All animals were successfully resuscitated, and there were no apparent adverse effects to the administration of NAC in post resuscitative animals. There was, however, no significant difference in neurological deficit in the animals receiving NAC (40 +/- 12.9, mean +/- SD) compared to control animals (44 +/- 6.5, P = 0.73). CONCLUSION: No neuroprotective effect was found from the administration of NAC at currently used clinical dosages, to dogs subjected to 10 min of global cerebral ischemia from cardiac arrest and resuscitation.

Acetylcysteine↗
PubMed1999

Time accuracy of a barcode system for recording resuscitation events: laboratory trials.

UNLABELLED: Barcode systems for recording clinical data from resuscitation attempts offer the prospect of more complete and time-accurate data collection; in addition, collection of data in digital form and the resulting ease of computer processing promises to facilitate data analysis for quality improvement and research. We conducted trials of such a barcode system, recording events during a videotaped, simulated in-hospital resuscitation, with particular attention to time accuracy. METHODS: Nine subjects watched a videotape of a simulated cardiac resuscitation, recording events first with the barcode system and then with a conventional handwritten form. Recorded times were compared to an accurate record of events (gold standard) from the videotape. RESULTS: Mean absolute errors and standard deviations of errors from the gold standard were significantly smaller with the barcode system (P < 0.01 for both). Numbers of event omissions did not differ significantly. CONCLUSION: The barcode system is more accurate than conventional handwritten recording in capturing event times from a simulated resuscitation. The system shows promise as a means to improve time accuracy of resuscitation records.

Cardiopulmonary Resuscitation↗
PubMed2001

Current attitudes to burns resuscitation in the UK.

In recent years, much discussion has occurred regarding the efficacy and safety of using albumin as part of burns resuscitation regimes. The discussion was fuelled in 1998 by the publication of the findings of the Cochrane Injuries Group Albumin Reviewers, Br Med J 1998; 317: 235-240. The current usage of human albumin solutions as part of the burn resuscitation regimes of burns units in the UK was assessed by telephone questionnaire by contacting medical staff from all the burns units in the UK that admit burn patients for resuscitation. Knowledge of the albumin controversy, details of their current resuscitation regimes and recent or planned changes were included in the questionnaire, Most individuals were aware of the albumin controversy. A total of eight units had made changes to their resuscitation regimes since July 1998, although five were still using albumin. Four more were considering making changes, while 13 units that had been using albumin prior to the controversy had made no changes at all. Only three units had stopped using albumin-based colloid altogether. Only one unit was not using albumin prior to the controversy. The implications of these results and possible ways forward are discussed.

Albumins↗
PubMed2001

Cardiac apoptosis in burned rats with delayed fluid resuscitation.

Clinical and experimental studies have shown that delayed fluid resuscitation postburn decreases heart function. We hypothesized that apoptosis occurs in the cardiomyocyte in this condition. To investigate this hypothesis, rats were burned, fluid resuscitation was delayed, and the integrity of cardiac genomic DNA in the burned rats was determined with an LM-PCR Ladder Assay kit. DNA fragmentation shown as DNA ladders on gels, the hallmark of apoptosis, was found in the heart tissue of these rats. In the early phase of delayed fluid resuscitation, the nuclear factor kappa B (NF-kappa B) was examined using an electrophoretic mobility shift assay and was found to be activated. In comparison with burned rats with immediate fluid resuscitation, nitric oxide levels in hearts from burned rats with delayed fluid resuscitation were significantly lower (P<0.01). These results suggest that apoptosis may be an important pathway for cardiac injury, which may result from the activation of NF-kappa B and decreased nitric oxide levels.

Animals↗
PubMed1997

Fluid resuscitation following a burn injury: implications of a mathematical model of microvascular exchange.

A validated mathematical model of microvascular exchange in thermally injured humans has been used to predict the consequences of different forms of resuscitation and potential modes of action of pharmaceuticals on the distribution and transport of fluid and macromolecules in the body. Specially, for 10 and/or 50 per cent burn surface area injuries, predictions are presented for no resuscitation, resuscitation with the Parkland formula (a high fluid and low protein formulation) and resuscitation with the Evans formula (a low fluid and high protein formulation). As expected, Parkland formula resuscitation leads to interstitial accumulation of excess fluid, while use of the Evans formula leads to interstitial accumulation of excessive amounts of proteins. The hypothetical effects of pharmaceuticals on the transport barrier properties of the microvascular barrier and on the highly negative tissue pressure generated postburn in the injured tissue were also investigated. Simulations predict a relatively greater amelioration of the acute postburn edema through modulation of the postburn tissue pressure effects.

Burns↗
PubMed2004

[Extremely preterm infants: resuscitation criteria in the delivery room and dialogue with parents before birth].

The resuscitation of extremely preterm infants presents complex medical, social and ethical issues for the families and the health professionals. The principle of a systematic resuscitation "temporary intensive care" does not prohibit the question of a limit in terms of gestational age and birth weight. In France, a do not resuscitate order (comfort care alone) is appropriate for newborns weighing less than 500g and/or with a gestational age of less than 24 weeks' since the mortality is nearly 100%. The survival of infants born at 24 weeks' gestational age remains low with significant risks of chronic medical problems and neurodevelopmental disabilities. The decisions regarding the extent of resuscitative efforts depend on antenatal factors, condition of the neonate at birth and the parental opinion. Before the delivery, parents should receive appropriate information about survival and risks of adverse long-term outcome. The physician should follow the parents' desires whenever the parents' decision would not obviously violate the infants' best interests. However, they must be informed that decisions about neonatal management made before the delivery can have to be changed in the delivery room, depending on the condition of the neonate at birth. At 25 weeks of gestational age, the prognosis is better and the resuscitation should be more intensive.

Gestational Age↗
PubMed1990

Cardiac effects of carbon dioxide-consuming and carbon dioxide-generating buffers during cardiopulmonary resuscitation.

Recent studies have demonstrated an increase in carbon dioxide (CO2) tension (PCO2) in both mixed venous and coronary vein blood early in the course of cardiac arrest and cardiopulmonary resuscitation. Because increased PCO2 in the myocardium correlates with both ischemic injury and depression of contractile function, the effects of hypertonic solutions of either the CO2-"generating" sodium bicarbonate (NaHCO3) buffer, a mixture of sodium carbonate (Na2CO3) and sodium bicarbonate (carbicarb) acting as a CO2-"consuming" buffer, or saline placebo (NaCl) were compared during cardiopulmonary resuscitation in 25 healthy minipigs. Both buffer agents significantly increased the pH and HCO3- of arterial, mixed venous and coronary vein blood. Bicarbonate increased whereas carbicarb reduced blood PCO2 in the systemic circuit as anticipated. However, neither the PCO2 nor the lactate content of coronary vein blood was favorably altered by buffer therapy. Four of eight animals treated with bicarbonate, five of eight treated with carbicarb and six of nine placebo-treated animals were successfully resuscitated and had a comparable 24 h survival rate. Coronary perfusion pressure during precordial compression, a critical determinant of resuscitability, was transiently decreased by each of the hypertonic solutions. Accordingly, neither CO2-generating nor CO2-consuming buffers mitigated increases in coronary vein PCO2 or improved the outcome of cardiopulmonary resuscitation under these experimental conditions.

Acid-Base Equilibrium↗
PubMedDate not supplied

The facilitated pediatric resuscitation room.

Pediatric resuscitation is challenging for the emergency physician because the diverse range in the age and size of the patients encountered complicates the appropriate selection of medications, equipment, and supplies. The following enhancements in the pediatric resuscitation room were made to facilitate effective management of critically ill neonates and children: 1) expanding the concept of the Broselow tape as the central color theme of organization of all medication doses and equipment; 2) use of a large, simplified, color-coded wall chart to define patient parameters; 3) color-coded equipment; 4) adjustable "break-away" resuscitation stretcher; and 5) equipment suspended from the ceiling: a) radiant warmer; b) suction, oxygen, and electricity; c) cardiac monitor and fluid controller; d) X-ray unit. These changes give the resuscitation team greater accessibility to both the patient and the needed resuscitation supplies.

Beds↗
PubMed2003

Should relatives be denied access to the resuscitation room?

Within a health care system that promotes choice and autonomy, it no longer seems appropriate to exclude relatives from the resuscitation room. There is a growing body of research that suggests there are indeed many long-term benefits to be gained from witnessing the resuscitation of a loved one. There seems no doubt that relatives would like the opportunity to spend the last few valuable minutes with their loved one to say goodbye. However, it is the views of many staff working in the critical care setting that appear to be preventing witnessed resuscitation from becoming normal practice. This paper considers the staffs', the relatives' and the patients' perspectives on witnessed resuscitation and concludes that the majority of relatives should not be denied access to the resuscitation room.

Attitude of Health Personnel↗
PubMed2003

Regionally differentiated fibrinolytic responses during volume-resuscitated acute endotoxemia in pigs.

BACKGROUND: Microcirculatory dysfunction and formation of microthrombi are common in sepsis as a result of a procoagulant state. A profibrinolytic change has however, been reported in early sepsis. This study investigates systemic and regional (pulmonary, preportal, hepatic, renal) fibrinolytic capacity as mirrored by fluxes of tissue-type plasminogen activator (t-PA) in response to acute endotoxemia and volume resuscitation. METHODS: Eight anaesthetized, ventilated pigs (24-29 kg) were instrumented for systemic and regional haemodynamic monitoring. Aortic, pulmonary arterial, portal, hepatic and renal venous blood samples were collected. Following baseline stabilisation, Escherichia coli endotoxin was infused for 120 min. During the last 30 min of infusion, volume resuscitation was initiated targeting baseline cardiac output, and animals were observed for 3 h. Total tPA was analyzed by ELISA calibrated for porcine tPA. Net organ tPA fluxes were calculated based on in/outflowing plasma concentrations and regional blood flows. RESULTS: Preportal release and hepatic extraction of tPA was observed at baseline. Pulmonary and renal net fluxes of tPA were not significantly different from zero. Endotoxemia increased plasma tPA levels in all investigated vascular beds. Preportal tPA release increased approximately 10-fold and hepatic extraction increased approximately 12-fold in non-resuscitated acute endotoxemia. No significant changes in pulmonary or renal tPA fluxes were observed. Volume resuscitation restored net fluxes to baseline values while plasma levels remained elevated approximately twofold compared with baseline. CONCLUSION: Acute endotoxemia induces a prompt, marked and regionally differentiated pro-fibrinolytic response that cannot be discerned based on systemic levels of circulating tPA and that was normalized during volume resuscitation.

Acute Disease↗
PubMed1997

Resuscitating effect of melanocortin peptides after prolonged respiratory arrest.

1. The resuscitating activity of melanocortin peptides (MSH-ACTH peptides) was tested in an experimental model of prolonged respiratory arrest. 2. Anaesthetized, endotracheally intubated rats subjected to a 5 min period of ventilation interruption, invariably died from cardiac arrest within 6-9 min of resumption of ventilation. 3. When resumption of ventilation was associated with the simultaneous intravenous (i.v.) injection of a melanocortin peptide (alpha-MSH or ACTH-(1-24)) (160 microg kg(-1) there was an almost immediate (within 1 min), impressive increase in cardiac output, heart rate, mean arterial pressure (+ 560% of the before-treatment value) and pulse pressure (+356% of the before-treatment value), with full recovery of electroencephalogram after 30-45 min. Blood gases and pH were normalized within 15-60 min after treatment, and all treated animals eventually recovered completely and survived indefinitely (= more than 15 days). 4. The same response was observed in adrenalectomized animals, as well as in animals pretreated with a beta1-adrenoceptor blocking agent (atenolol, 3 mg kg(-1), i.v.), or with an alpha1-adrenoceptor blocking agent (prazosin, 0.1 mg kg(-1), i.v.), or with an adrenergic neurone blocking agent (guanethidine, 10 mg kg(-1), intraperitoneally). 5. An effect quite similar to that produced by melanocortins was obtained with ouabain (0.1 mg kg(-1), i.v.); the antioxidant drug, glutathione (75 mg kg(-1), i.v.) also produced 100% resuscitation, but the effect was slower in onset. On the other hand, adrenaline (0.005 mg kg(-1), i.v.) was able to resuscitate only 1 out of 8 rats and dobutamine (0.02 mg kg(-1), i.v.) resuscitated 4 out of 8 rats; moreover, the effect of both catecholamines was much slower in onset than that of melanocortins and the initial, impressive stimulation of cardiovascular function was absent. 6. These results show that melanocortin peptides have a resuscitating effect in a pre-terminal condition produced in rats by prolonged asphyxia. This effect seems primarily due to the restoration of cardiac function, not mediated by catecholamines. These data also suggest that these peptides may have potential therapeutic value in conditions of transient cardiac hypoxia and re-oxygenation such as occur in coronary artery disease.

Adrenocorticotropic Hormone↗