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PubMed2002

Family presence during invasive procedures and resuscitations in the emergency department: a critical review and suggestions for future research.

STUDY OBJECTIVE: We examine the literature relating to family presence in the emergency department, with a specific emphasis on parental experiences and presence during invasive procedures and family presence during cardiopulmonary resuscitation and resuscitation. METHODS: An electronic search and examination of resulting references was conducted using the words, "family centered care," "parent participation," "parent presence," "family presence," and "emergency department," "accident and emergency department," "procedure," "invasive procedure," and "resuscitation." Articles related to out-of-hospital emergency medical services were excluded. Also, articles were included only if the manuscript was based on an empirical study and if the manuscript was published in a peer-reviewed journal. RESULTS: Twenty articles, primarily composed of survey research, were included in this review. Research suggests that families want to be given the option and, when given the option, often choose to remain during invasive procedures and resuscitations. Those who remain generally report favorable experiences and feel it is beneficial to the patient and themselves. Providers, however, have mixed opinions regarding family presence. Nurses may have a more favorable view toward family presence during invasive procedures than physicians. Among physicians, it appears that greater age and experience may be associated with more favorable opinions of family presence. Randomized controlled trials are mixed regarding whether family presence actually helps the patient. CONCLUSION: Despite what appear to be promising data regarding the benefits of family presence, this area of research is in the initial phases of development with many limitations that are discussed. Recommendations for future research are presented.

Attitude of Health Personnel↗
PubMed2002

A selective alpha(2)-adrenergic agonist for cardiac resuscitation.

The effects of selective alpha(2)-adrenergic agonist alpha-methylnorepinephrine on the initial success of resuscitation and postresuscitation myocardial function were compared with nonselective alpha- and beta-adrenergic epinephrine in a swine model of cardiac arrest. Epinephrine, the primary pharmacological intervention in the treatment of cardiac arrest, improves immediate outcome. However, epinephrine increases the severity of myocardial dysfunction after cardiac resuscitation. Both inotropic and chronotropic actions provoke disproportionate increases in myocardial oxygen consumption by the ischemic heart, prompting this study, in which we hypothesized that a selective alpha(2)-adrenergic agonist, alpha-methylnorepinephrine (alpha-MNE), would moderate these adverse effects of epinephrine and minimize postresuscitation myocardial dysfunction. After 7 minutes of untreated ventricular fibrillation (VF) in 14 anesthetized male domestic pigs, precordial compression at a fixed rate of 80 compressions/min was begun, along with mechanical ventilation. Either alpha-MNE (100 microg/kg) or epinephrine (20 microg/kg) was administered as a bolus after 2 minutes of precordial compression. After an additional 4 minutes of precordial compression, defibrillation was attempted. Left ventricular systolic and diastolic function was quantitated with the use of transesophageal echo-Doppler imaging. Comparable increases in coronary perfusion pressure to 15 mm Hg were observed after the administration of both drugs. All animals were successfully resuscitated; epinephrine and alpha-MNE were equally quick in restoring spontaneous circulation after 7 minutes of untreated VF. Ejection fraction was reduced by 35% and 14% by epinephrine and alpha-MNE, respectively, after resuscitation. Epinephrine and alpha-MNE increased postresuscitation heart rate by 38% and 15%, respectively. Accordingly, significantly less postresuscitation impairment followed the administration of alpha-MNE. alpha-MNE, a selective alpha-adrenergic agonist, was as effective as epinephrine in restoring spontaneous circulation after 7 minutes of untreated VF in a porcine model for CPR and demonstrated lesser postresuscitation myocardial injury.

Adrenergic alpha-Agonists↗
PubMed1975

Resuscitation of the newborn.

Resuscitation of the newborn is not different from resuscitation of any other patient, but in newborns, resuscitation requires special skills and considerations because of the size of the patient. If properly done, it can save many lives. If done incorrectly, however, it can save many lives. If done incorrectly, however, it can result in death or permanent neurologic damage to the infant. Because it is difficult to predict the status of the infant before birth, any delivery room must have experienced personnel and adequate equipment necessary for the resuscitation of the newborn.

Acidosis↗
PubMedDate not supplied

Performance of resuscitation skills by paramedic personnel in chemical protective suits.

OBJECTIVES: Determine whether wearing a chemical protective suit increases time to successful completion of four resuscitation skills. METHODS: This prospective experimental study examined the ability of civilian paramedic personnel to complete four resuscitative skills (electrical defibrillation, administration of epinephrine subcutaneously, intravenous cannulation, and tracheal intubation) carried out using standard methods on mannequins under two test conditions (wearing the protective suit and not wearing the suit). Primary outcome was time to successful completion of each skill. RESULTS: Sixteen paramedics were enrolled and completed each skill under two test conditions. Paramedics took longer to complete administration of epinephrine (87 vs. 60 seconds; p < 0.01) and intravenous cannulation (220 vs. 158 seconds; p < 0.01) tasks when wearing a protective suit. Wearing the suit did not impair electrical defibrillation (57 vs. 46 seconds) or tracheal intubation (79 vs 69 seconds). CONCLUSIONS: Chemical protective suit use increased time to successful completion of resuscitation skills where fine motor skills are required, namely administration of epinephrine subcutaneously and intravenous cannulation, but did not increase time to successful completion of resuscitation skills requiring gross motor skills, namely electrical defibrillation and tracheal intubation.

Emergency Medical Technicians↗
PubMed2001

Hemorrhagic shock resuscitation with a low molecular weight starch reduces neutrophil-endothelial interactions and vessel leakage in vivo.

BACKGROUND: The polymorphonuclear neutrophil (PMN) has been implicated in the pathogenesis of endothelial cell (EC) damage and organ injury following hemorrhagic shock. Pentastarch (PTS), a low substituted medium molecular weight (MW) colloid, improves hemodynamics in hypovolemic shock and cardiac surgery. No data exist comparing the immunomodulation of PTS and Ringer's lactate (RL) on the activation of PMN in hemorrhagic shock in vivo. METHODS: Using an in vivo murine hemorrhagic shock model (blood withdrawal to maintain 50 mmHg x 45 min), circulating PMN were observed every 15 minutes using intravital microscopy on cremaster muscle. EC-PMN interactions (videorecorded and subsequently analyzed blindly), vessel leakage (live epifluorescence after injection of 50 mg/kg fluorescent albumin) and PMN expression of L-selectin (immunofluorescent monoclonal antibodies and flow cytometry) were evaluated in three resuscitation groups: PTS (7.14 mL/kg 10% pentastarch/0.9% NaCl + shed blood, n = 13), RL (RL [2 x shed blood volume] + shed blood, n = 13) and SHAM (0 hemorrhage, 0 resuscitation, n = 9). Significance was evaluated by ANOVA with Bonferroni correction. RESULTS: PMN rolling was significantly diminished in PTS and SHAM as compared to RL animals at all time points. Similar differences were found in PMN adherence to EC at most time points onwards from 15 minutes following resuscitation. In vivo vessel permeability was lowest in SHAM and PTS animals (mean 0.274 +/- 0.07 and 0.356 +/- 0.15, respectively, p > 0.05) and highest in RL animals (0.667 +/- 0.09, p < 0.001 vs PTS or SHAM). PMN L-selectin expression tended to be higher in the RL group than either SHAM and PTS groups. There were no flow-mechanics differences between groups (vessel diameter, mean red cell velocity, shear stress, shear rate). CONCLUSIONS: 10% pentastarch reduces RL-associated EC-PMN interactions and vessel leakage following hemorrhagic shock. These results support the use of low MW starches to resuscitate hemorrhagic shock, potentially reducing PMN-mediated tissue injury.

Animals↗
PubMed2003

Systemic effects of shock and resuscitation monitored by visible hyperspectral imaging.

Hyperspectral imaging (HSI) has been useful in monitoring several medical conditions, which to date have generally involved local changes in skin oxygenation of isolated regions of interest such as skin flaps or small burns. Here, by contrast, we present a study in which HSI was used to assess the local cutaneous manifestations of significant systemic events. HSI of the ventral surface of the lower jaw was used to monitor changes in skin oxygenation during hypovolemic shock induced by hemorrhage with additional pulmonary contusion injury in a porcine model, and to monitor the subsequent recovery of oxygenation with resuscitation. Quantitative and qualitative changes were observed in the level of skin oxygenation during shock and recovery. Quantitative values were obtained by fitting reference spectra of oxyhemoglobin and deoxyhemoglobin to sample spectra. Qualitative changes included changes in the observed spatial distribution or pattern of skin oxygenation. A mottled pattern of oxygen saturation was observed during hemorrhagic shock, but not observed during hypovolemic shock or following resuscitation. Historically, the assessment of skin color and mottling has been an important, albeit inexact, component of resuscitation algorithms. Now, it is possible to analyze these variables during shock and resuscitation in an objective manner. The clinical utility of these advances needs to be determined.

Animals↗
PubMed1986

Elderly patients' views on cardiopulmonary resuscitation.

A survey was conducted by means of a questionnaire to assess elderly patients' perception of cardiopulmonary resuscitation (CPR) as it might be applied to themselves. Nearly half (47%) of patients were unaware of the existence and practice of this procedure. The majority of patients felt that selective application of CPR in the elderly was appropriate. Factors that may influence selection are discussed. A considerable proportion of patients wished to be resuscitated if the need arose--a fact not in keeping with the scant information available on the subject. Significantly more men than women favoured resuscitation. Some elderly people interviewed, favoured resuscitation of elderly patients other than themselves. Patients welcomed an opportunity to discuss and express their views on their position.

Aged↗
PubMed1980

Minimum artificial lung expansion necessary for resuscitation of the newborn lamb.

In a group of seven lambs, pressure-volume relationships were obtained for the initial artificial expansion of the lungs in the intact chest and subsequent re-expansion afer the lungs had been excised and collapsed. In a second group, of 12 severely asphyxiated lambs, the lungs were expanded in steps and circulatory resuscitation was achieved at pressures ranging from 1.75 to 3.5 kPa, geometric mean 2.3 kPa, with estimated corresponding volumes of 3--24 ml kg-1, geometric mean 5.8 ml kg-1. In a third group, of 24 severely asphyxiated lambs (mean pH 6.84), 22 were successfully resuscitated in the same manner and nine of these survived in apparent good health for more than 6 months. Any resuscitation regime for human neonates should take account of the finding that resuscitation occurred at pressures less than those necessary for full expansion and that, after the first sign of an increase in heart rate, there was a delay of 17--45 s before full circulatory improvement and of 3 min before full improvement in PaO2.

Animals↗
PubMed1986

Rupture of the stomach in a diving accident with attempted resuscitation. A case report.

A compressed air diver suffered pulmonary barotrauma with arterial air embolization; resuscitation was unsuccessful. Attempts at resuscitation included mouth-to-mouth ventilation and cardiac massage. A chest radiograph taken during resuscitation revealed free intraperitoneal air. Postmortem examination showed rupture of the stomach. The two possible aetiological factors--barotrauma of ascent and cardiopulmonary resuscitation--are discussed.

Adult↗
PubMed1991

Calcium for resuscitation?

Calcium ions are essential for myocardial excitation-contraction coupling and for increasing contractility of the heart. Because of these physiological effects, use of calcium has been recommended in the treatment of electromechanical dissociation, asystole and ventricular fibrillation. Recently, however, the use of calcium during cardiac arrest has come into dispute, as there are no controlled clinical trials supporting a favourable haemodynamic effect. It has rather been suggested that, in resuscitation, calcium may have detrimental effects. In order to evaluate the role of calcium in cardiopulmonary resuscitation, it is important to know the serum concentrations of calcium and the haemodynamic effects in this situation. Measurements in some patients with cardiac arrest have demonstrated that severe hypocalcaemia may not be uncommon. In these patients, calcium may augment myocardial contractility, decrease intracardiac filling pressures and increase mean arterial pressure. At present, the more or less established indications for use of calcium during cardiopulmonary resuscitation are in treating patients with proven hypocalcaemia, hyperkalaemia, calcium channel blocker overdose and, possibly, electromechanical dissociation combined with a wide QRS complex. There is no good evidence supporting the routine use of calcium in resuscitation.

Adolescent↗
PubMed1986

Augmentation of cardiac output and carotid blood flow by chest and abdomen phased compression cardiopulmonary resuscitation.

Phased compression cardiopulmonary resuscitation, whereby the chest and abdomen are compressed sequentially, is a new approach to the classical cardiopulmonary resuscitation technique, which is based on the compression of the chest alone. Six dogs with cardiac arrest were treated by external chest and abdominal compression using a rigid plexiglas suit lined with flexible perithoracic and periabdominal bladders. Fast inflation and deflation of the two independent bladders, together with forced ventilation of the lung, generated phased pressure pulses. The physiological variables monitored throughout the experiment included central venous, left ventricular, and central arterial pressures, carotid blood flow, cardiac output, and acid base balance. The phased compression technique was performed with phased time lags of 0, 150, 300, 400, 600, 700, and 850 ms between the abdominal and thoracic pressure pulses. A random sequence of the different phased compression modes, each lasting for 3-10 minutes, was applied during the prolonged resuscitation procedure that lasted for up to 70 minutes. By starting the abdominal compression 300-400 ms before the thoracic compression the carotid flow index improved by 77% (from 13% with simultaneous compression to 23% with phased compression) and the cardiac output index increased by 65% (from 7.8% with simultaneous compression to 12.5%). The results provide insight into the chest pump concept and the role of intrathoracic and intra-abdominal pressures in generating improved blood circulation during cardiopulmonary resuscitation, and show the advantages of phased compression over chest compression alone and simultaneous chest and abdominal compression.

Animals↗
PubMed1989

End tidal carbon dioxide as an haemodynamic determinant of cardiopulmonary resuscitation in the rat.

End tidal PCO2 (PETCO2) has been found to be a good prognostic indicator of successful resuscitation from cardiac arrest. To explore the value of this measurement further, we carried out a series of experiments during cardiac arrest and closed chest resuscitation in 14 mechanically ventilated Sprague-Dawley rats. Ventricular fibrillation (VF) was induced by a 10 mA current delivered to the right ventricular endocardium. After 4 min of VF, precordial compression was begun with a mechanical thumper and defibrillation was attempted 2 min later. PETCO2 decreased abruptly during cardiac arrest to 0.3 mm Hg (0.04 kPa). With precordial compression, it increased to 11 mm Hg (1.5 kPa). Within 3 min of successful defibrillation, there was an overshoot in the PETCO2 to 44 mm Hg (5.8 kPa) with return to baseline levels approximating those of the pre-arrest control measurements over the 60 min that followed restoration of spontaneous circulation. The PETCO2 measurement during precordial compression predicted the success of defibrillation with return of spontaneous circulation. When PETCO2 exceeded 9 mm Hg (1.2 kpA), 7 of 8 animals were successfully resuscitated. When PETCO2 was less than 9 mm Hg during precordial compression, none of six animals were successfully resuscitated. The PETCO2 correlated with the mean aortic (r = 0.71) and coronary perfusion pressure (r = 0.80) generated during precordial compression. In corroboration of previously reported observations on pigs, dogs, and human patients, PETCO2 served as a non-invasive monitor of the effectiveness of precordial compression for maintaining coronary perfusion and therefore cardiac viability during CPR. The PETCO2 was also useful in that it promptly signalled restoration of spontaneous circulation.

Animals↗
PubMed1988

Physicians' and spouses' predictions of elderly patients' resuscitation preferences.

"Substituted judgment," in which surrogate decisionmakers approximate patients' wishes, has been recommended for decision making for mentally incapacitated patients. To test understanding of patients' preferences by potential surrogate decisionmakers, we studied primary care physicians' (n = 105) and spouses' (n = 90) predictions of elderly outpatients' (n = 258) preferences for cardiopulmonary resuscitation (CPR) and CPR plus ventilator (CPR + V), assuming three baseline health states: current health, stroke, and chronic lung disease. Although more than three-quarters of physicians and spouses surveyed believed their predictions of patients' preferences were accurate, the accuracy of physicians' and spouses' predictions did not exceed that expected due to chance alone in 5 of 6, and 3 of 6 decisions, respectively. Physicians significantly underestimated patients' preferences for resuscitation in the stroke and chronic lung disease scenarios (p less than .01), and significantly overestimated them in the current health/CPR decision (p less than .05). Spouses overestimated patients' preferences for resuscitation in all decisions, significantly so in the three CPR + V decisions (p less than .05). These results suggest physicians and spouses often do not understand elderly outpatients' resuscitation preferences. Under these circumstances they are unlikely to provide accurate substituted judgments.

Aged↗
PubMed2005

Benchmarking iron dextran sensitivity: reactions requiring resuscitative medication in incident and prevalent patients.

BACKGROUND: Reliable information on the incidence of severe reactions to iron dextran is limited. Administration of agents of resuscitation in acute anaphylaxis may serve as a marker to quantify life-threatening adverse drug reactions. METHODS: To determine the incidence of the most serious reactions to intravenous (i.v.) iron dextran, we searched the Gambro Healthcare US medical database for evidence of same-day administration of both i.v. iron dextran and parenteral adrenaline, corticosteroids or antihistamines. We confirmed each case as an iron dextran sensitivity reaction by direct inquiry. We also determined the total reported number of suspected adverse iron dextran reactions. RESULTS: During the 16 month study period, we determined that 1,066,099 doses of i.v. iron dextran were given to 48,509 patients, including 20,213 patients who had not previously received iron dextran (iron dextran naïve). We identified seven patients who experienced reactions requiring resuscitative agents, all in response to a test dose (five patients) or first therapeutic dose (two patients), and therefore all in the iron-naïve (incident) group. Thus, we found the incidence of iron dextran reactions requiring resuscitative agents to be 0.035% (7 out of 20,213). No reaction was fatal. In a combined group of incident and prevalent patients, we found 337 total reports of suspected adverse reactions to iron dextran, without regard to severity of reaction, yielding an overall per patient adverse drug event (ADE) rate of 0.69% (337 out of 48,509) and per exposure rate of 0.03% (337 out of 1,066,099). CONCLUSIONS: The incidence of reactions to iron dextran requiring resuscitative medications, per exposure or per patient, is approximately 0.035%. Reactions of this severity occur after either the test dose or first dose of iron dextran.

Adrenal Cortex Hormones↗
PubMed2000

Successful resuscitation from recurrent ventricular fibrillation secondary to butane inhalation.

Resuscitation from cardiac arrest caused by volatile substance abuse is rarely successful. Large doses of catecholamines given during resuscitation, in the presence of butane, may cause recurrent ventricular fibrillation. We report a case of prolonged resuscitation in a young man who had inhaled butane. Cardiac output was restored 10 min after the administration of intravenous amiodarone. We suggest that antiarrhythmic agents should be used early during resuscitation to prevent recurrent arrhythmias.

Adolescent↗
PubMed1995

Resuscitation from bupivacaine-induced asystole in rats: comparison of different cardioactive drugs.

The objective of this study was to compare the success of resuscitation attempts with different cardioactive drugs after bupivacaine-induced asystole. Saline, amrinone (1 mg/kg), dopamine (5 micrograms/kg), norepinephrine (2 micrograms/kg), epinephrine (10 micrograms/kg), or isoproterenol (1 microgram/kg) were tested. Sixty rats assigned to six treatment groups (n = 10/group) were lightly anesthetized (0.5% halothane, 70% N2O), paralyzed (doxacurium), and given bupivacaine intravenously at 4 mg.kg-1.min-1 until asystole. Five seconds later up to three treatment drug doses were given at 30-s intervals. Then external cardiac massage was instituted as needed. Spontaneous heartbeat was restored in all animals given norepinephrine or epinephrine. It was not restored in one saline-treated, one dopamine-treated, one isoproterenol-treated, and three amrinone-treated animals. The highest (best) arbitrary scores for overall resuscitation success were achieved with norepinephrine and the lowest with amrinone (P < 0.05). The incidence of ventricular arrhythmias after resuscitation was significantly higher (P < 0.05) in epinephrine- and isoproterenol-treated animals versus other animals. Cardiac rhythm disturbance disappeared within 20 min after successful resuscitation with norepinephrine. Amrinone was no more effective than saline in treating bupivacaine-induced asystole. A drug such as norepinephrine, which has both cardiostimulator (beta 1-receptor agonist) and peripheral vasoconstrictor (alpha 1-receptor agonist) activity, may be the drug of choice for treating asystole induced by bupivacaine.

Amrinone↗
PubMed1999

Effect of small-dose dopamine on mesenteric blood flow and renal function in a pig model of cardiopulmonary resuscitation with vasopressin.

UNLABELLED: Vasopressin (antidiuretic hormone) seems a promising alternative to epinephrine for cardiopulmonary resuscitation (CPR) in cardiac arrest victims, mediating a pronounced blood flow shift toward vital organs. We evaluated the effects of small-dose dopamine on splanchnic blood flow and renal function after successful resuscitation with this potent vasoconstrictor in an established porcine CPR model. After 4 min of cardiac arrest and 3 min of CPR, animals received 0.4 U/kg vasopressin and were continuously infused with either dopamine 4 microg x kg(-1) x min(-1) (n = 6), or saline placebo (n = 6). Defibrillation was performed 5 min after drug administration; all animals were observed for 6 h after return of spontaneous circulation. During the postresuscitation phase, average mean +/- SD superior mesenteric artery blood flow was significantly (P = 0.002) higher in the dopamine group compared with the placebo group (1185+/-130 vs 740+/-235 mL/min), whereas renal blood flow was comparable between groups (255+/-40 vs 250+/-85 mL/min). The median calculated glomerular filtration rate had higher values in the dopamine group (70-120 mL/min) than in the placebo group (40-70 mL/min; P = 0.1 at 0 min and P = 0.08 at 360 min). We conclude that small-dose dopamine administration may be useful in improving superior mesenteric artery blood flow and renal function after successful resuscitation with vasopressin. IMPLICATIONS: Long-term survival after cardiac arrest may be determined by the ability to ensure adequate organ perfusion during cardiopulmonary resuscitation and in the postresuscitation phase. In this regard, small-dose dopamine improved postresuscitation blood flow to the mesenteric bed when vasopressin was used as an alternative vasopressor in an animal model of cardiac arrest.

Animals↗
PubMed2001

Cardiac resuscitation after incremental overdosage with lidocaine, bupivacaine, levobupivacaine, and ropivacaine in anesthetized dogs.

UNLABELLED: There is no information comparing the ability to reverse the cardiotoxic effects associated with incremental overdosage of bupivacaine (BUP) to levobupivacaine (LBUP), ropivacaine (ROP), or lidocaine (LIDO). Open-chest dogs were randomized to receive incremental escalating infusions of BUP, LBUP, ROP, and LIDO to the point of cardiovascular collapse (mean arterial pressure [MAP] < or = 45 mm Hg). Hypotension and arrhythmias were treated with epinephrine, open-chest massage, and advanced cardiac life support protocols, respectively. Outcomes were defined as the following: successful (stable rhythm and MAP > or = 55 mm Hg for 20 min), successful with continued therapy (stable rhythm and MAP <55 mm Hg after 20 min), or death. Continued therapy was required in 86% of LIDO dogs compared with only 10%-30% of the other dogs (P < 0.002). Mortality from BUP, LBUP, ROP, and LIDO was 50%, 30%, 10%, and 0%, respectively. Myocardial depression was primarily responsible for the profound hypotension, as the occurrence of lethal arrhythmias preceding resuscitation was not different among local anesthetics. Epinephrine-induced ventricular fibrillation occurred more frequently in BUP-intoxicated dogs than in dogs given LIDO or ROP (P < 0.05). The unbound plasma concentrations at collapse were larger for ROP, 19.8 microg/mL (10-39 microg/mL), compared with BUP, 5.7 microg/mL (3-11 microg/mL); whereas the concentrations of LBUP, 9.4 microg/mL (5-18 microg/mL) and BUP were not significantly different from each other. IMPLICATIONS: There were consistent differences among the local anesthetics, the sum of which suggests that larger doses and blood concentrations of ropivacaine (ROP) and lidocaine will be tolerated as compared with bupivacaine (BUP) and levobupivacaine (LBUP). Lidocaine intoxication results in myocardial depression from which resuscitation is consistently successful but will require continuing drug support. After BUP, LBUP, or ROP, resuscitation is not always successful, and the administration of epinephrine may lead to severe arrhythmias. The unbound plasma concentrations at collapse were larger for ROP compared with BUP, whereas the concentrations of LBUP and BUP were not significantly different from each other. Furthermore, larger plasma concentrations of ROP than BUP are present after resuscitation, suggesting a wider margin of safety when large volumes and large concentrations are used to establish upper or lower extremity nerve blocks for surgical anesthesia and during long-term infusions for pain management.

Amides↗