http://www.ncbi.nlm.nih.gov/pubmed/18952357?ordinalpos=20&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
A prospective observational study of paediatric patients requiring pre-hospital intubation attended by a helicopter medical team (HMT) included 95 children with a GCS of 3-4. Fifty-four received bag-mask support by EMS paramedics until the HMT arrived and intubated them (survival 63%), and 41 were intubated by EMS paramedics. Of these, ‘correction of tube/ventilation’ was required in 37% and the survival was 5%. The authors conclude that bag-mask support should be the technique of choice by EMS paramedics, as the rate of complications of tracheal intubation in this patient group is unacceptably high. Hard to comment as I only have access to the abstract but one wonders if the EMS-intubation group were sicker patients requiring more aggressive early control of airway and breathing.
http://www.ncbi.nlm.nih.gov/pubmed/18684547?ordinalpos=31&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
A nurse-based pre-hospital care system in Holland describes its experience with pre-hospital CPAP for acute cardiogenic pulmonary oedema. It appears that the simple Boussignac apparatus is straightforward to apply in the ambulance environment. Arguments about lack of outcome studies aside, if it’s necessary to undertake an interhospital transfer of a patient established on CPAP then this might be a relatively straightforward means of doing so.
http://www.ncbi.nlm.nih.gov/pubmed/19164632?dopt=Abstract
http://www.vitaid.com/canada/boussignac/index.html
http://www.ncbi.nlm.nih.gov/pubmed/19164632?dopt=Abstract
http://www.vitaid.com/canada/boussignac/index.html
The introduction of Standard Operating Procedures for trauma management into a German emergency department resulted in quicker resuscitation, shorter time in the ED, and shortened time to definitive diagnosis in polytrauma patients. Nice to see some evidence to support SOP use in critical medical settings, not least because there are still clinicians out there who fail to see their value.
http://www.ncbi.nlm.nih.gov/pubmed/19078832
In septic shock, a central venous oxygen saturation of 70% has been proposed as a target for early (ED-phase) goal-directed haemodynamic resuscitation, indicating adequate oxygen delivery to tissues. However later in the disease course (ICU-phase) disturbances in microcirculation or mitochondrial function may inhibit peripheral oxygen uptake, resulting in a healthy looking ScvO2 value in spite of evidence of inadequate tissue oxygenation (eg. rising lactate). ScvO2 targets are therefore of limited use in the ICU phase. French investigators hypothesised that an increased arterial-central venous CO2 difference [P(cv-a)CO2] may serve as a global index of tissue hypoperfusion when the ScvO2 goal of 70% has been reached in resuscitated septic shock patients. Using a P(cv-a)CO2 cut off of 6 mmHg, there was a significant difference between low and high ‘gap’ patients for cardiac index, lactate clearance, and improvement in SOFA score, but not for ScvO2. The authors conclude that in ICU-resuscitated septic shock patients, ScvO2 may be insufficient to guide therapy, and that when a target of 70% is reached, the presence of P(cv-a)CO2 > 6 mmHg may be a useful tool to identify patients who remain inadequately resuscitated.
http://www.ncbi.nlm.nih.gov/pubmed/18607565
A controlled crossover study cluster randomised among 13 Dutch ICUs examined both selective decontanimation of the digestive tract (SDD) and of the oral cavity (SOD) on 28 day mortality. The mortality rate associated with standard care
was 27.5% at day 28; the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. Concerns over the selection of multi-drug resistant organisms contribute to a lack of uptake of SDD; this study showing similar benefit of SOD which does not require the administration of systemic antibiotics, an so is more likely to be practice-changing.
http://www.ncbi.nlm.nih.gov/pubmed/19118302
A randomised prospective comparison study of 345 adult ED attenders with and without fever showed no difference in the reliability of temperature measurement by tympanic, oral, and axillary readings. Tympanic temperatures were not affected by otitis or by cerumen impaction. Although not statistically significant, tympanic readings were 0.15 degrees higher than oral, which the authors suggest may be advantageous in the elderly, in whom a single temperature reading of 37.8 degrees is a predictor of infection. Axillary temperatures were 0.27 degrees lower than oral.
http://www.ncbi.nlm.nih.gov/pubmed/19078836
The response of pulse-contour derived cardiac index to passive leg raising by 45 degrees predicts fluid responsiveness in patients with circulatory failure. French investigators demonstrated that performing this manoeuvre starting from a semi-recumbent, as opposed to a supine, position detected a greater number of patients with fluid responsiveness, thought to be due to recruitment of the splanchnic venous reservoir. In their study performing the manoeuvre from the supine position missed 15 of 35 fluid responsive patients. The recommend commencing with the patient in the semi-recumbent position, and simultaneous elevating the legs to 45 degrees while transferring the trunk from a semi-recumbent to a horizontal position.
http://www.ncbi.nlm.nih.gov/pubmed/18795254
A retrospective analysis of 16 365 patients from a Level I trauma center registry examined patient outcomes for several levels of pre-hospital systolic blood pressure. PSBP strongly correlated with systolic blood pressure obtained in the emergency department. The risk of death increased sharply when PSBP dropped less than 110 mmHg, which the authors suggest should become the cut-off for triage to a trauma centre.
http://www.ncbi.nlm.nih.gov/pubmed/19078832
In septic shock, a central venous oxygen saturation of 70% has been proposed as a target for early (ED-phase) goal-directed haemodynamic resuscitation, indicating adequate oxygen delivery to tissues. However later in the disease course (ICU-phase) disturbances in microcirculation or mitochondrial function may inhibit peripheral oxygen uptake, resulting in a healthy looking ScvO2 value in spite of evidence of inadequate tissue oxygenation (eg. rising lactate). ScvO2 targets are therefore of limited use in the ICU phase. French investigators hypothesised that an increased arterial-central venous CO2 difference [P(cv-a)CO2] may serve as a global index of tissue hypoperfusion when the ScvO2 goal of 70% has been reached in resuscitated septic shock patients. Using a P(cv-a)CO2 cut off of 6 mmHg, there was a significant difference between low and high ‘gap’ patients for cardiac index, lactate clearance, and improvement in SOFA score, but not for ScvO2. The authors conclude that in ICU-resuscitated septic shock patients, ScvO2 may be insufficient to guide therapy, and that when a target of 70% is reached, the presence of P(cv-a)CO2 > 6 mmHg may be a useful tool to identify patients who remain inadequately resuscitated.
http://www.ncbi.nlm.nih.gov/pubmed/18607565
A controlled crossover study cluster randomised among 13 Dutch ICUs examined both selective decontanimation of the digestive tract (SDD) and of the oral cavity (SOD) on 28 day mortality. The mortality rate associated with standard care
was 27.5% at day 28; the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. Concerns over the selection of multi-drug resistant organisms contribute to a lack of uptake of SDD; this study showing similar benefit of SOD which does not require the administration of systemic antibiotics, an so is more likely to be practice-changing.
http://www.ncbi.nlm.nih.gov/pubmed/19118302
A randomised prospective comparison study of 345 adult ED attenders with and without fever showed no difference in the reliability of temperature measurement by tympanic, oral, and axillary readings. Tympanic temperatures were not affected by otitis or by cerumen impaction. Although not statistically significant, tympanic readings were 0.15 degrees higher than oral, which the authors suggest may be advantageous in the elderly, in whom a single temperature reading of 37.8 degrees is a predictor of infection. Axillary temperatures were 0.27 degrees lower than oral.
http://www.ncbi.nlm.nih.gov/pubmed/19078836
The response of pulse-contour derived cardiac index to passive leg raising by 45 degrees predicts fluid responsiveness in patients with circulatory failure. French investigators demonstrated that performing this manoeuvre starting from a semi-recumbent, as opposed to a supine, position detected a greater number of patients with fluid responsiveness, thought to be due to recruitment of the splanchnic venous reservoir. In their study performing the manoeuvre from the supine position missed 15 of 35 fluid responsive patients. The recommend commencing with the patient in the semi-recumbent position, and simultaneous elevating the legs to 45 degrees while transferring the trunk from a semi-recumbent to a horizontal position.
http://www.ncbi.nlm.nih.gov/pubmed/18795254
A retrospective analysis of 16 365 patients from a Level I trauma center registry examined patient outcomes for several levels of pre-hospital systolic blood pressure. PSBP strongly correlated with systolic blood pressure obtained in the emergency department. The risk of death increased sharply when PSBP dropped less than 110 mmHg, which the authors suggest should become the cut-off for triage to a trauma centre.
Further evidence that the APLS formula (2 x (age +4)) underestimates a child’s weight is provided by a prospective study of 544 kids in Britain, in which the formula was compared with length-based and age-based estimates from growth chart reference data. While length-based estimates of weight were the most accurate, the authors concede that the practical difficulties of measuring a child during a resuscitation mean that the ready availability of age-based reference tables or charts in critical care areas is the best option, and more accurate than the APLS formula.
http://www.ncbi.nlm.nih.gov/pubmed/19104098?dopt=Abstract
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