Treatment Effect or Effective Treatment? Cardiac Compression Fraction and End-tidal Carbon Dioxide Are Higher in Patients Resuscitative Endovascular Balloon Occlusion of the Aorta Compared with Resuscitative Thoracotomy and Open-Chest Cardiac Massage.

The purpose of this study is to compare end-tidal carbon dioxide (EtCO2) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC) versus receiving resuscitative endovascular balloon occlusion of the aorta (REBOA) with closed-chest compressions (CCCs). Patients who received REBOA were compared with patients receiving OCCM for traumatic arrest using continuous vital sign monitoring and videography. Thirty-three patients were enrolled in the REBOA group and 18 patients were enrolled in the OCCM group. Of the total patients, 86.3 per cent were male with a mean age of 36.2 ± 13.9 years. Ninety-four percent of patients suffered penetrating trauma in the OCCM group compared with 30.3 per cent of the REBOA group (P = <0.001). Before aortic occlusion (AO), there was no difference in initial EtCO2 values, but mean, median, peak, and final EtCO2 values were lower in OCCM (P < 0.005). During CPR after AO, the initial, mean, and median values were higher with REBOA (P = 0.015, 0.036, and 0.038). The rate of return of spontaneous circulation was higher in REBOA versus OCCM (20/33 [60.1%] vs 5/18 [33.3%]; P = 0.04), and REBOA patients survived to operative intervention more frequently (P = 0.038). REBOA patients had greater total cardiac compression fraction (CCF) before AO than OCCM (85.3 ± 12.7% vs 35.2 ± 18.6%, P < 0.0001) and after AO (88.3 ± 7.8% vs 71.9 ± 24.4%, P = 0.0052). REBOA patients have higher EtCO2 and cardiac compression fraction before and after AO compared with patients who receive OCCM.

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the "what" in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Dependent Lung Tension Pneumothorax During 1-Lung Ventilation: Treatment by Transmediastinal Thoracentesis.

Contralateral tension pneumothorax during 1-lung ventilation is rare but life threatening. We report the case of a patient who developed tension pneumothorax of the dependent lung during 1-lung ventilation while the surgeon was anastomosing the bronchi after sleeve lobectomy. Ventilation was not possible in either the dependent or nondependent lung, leading to severe desaturation and cardiac arrest. While the surgeons were administering direct cardiac compression, we suspected tension pneumothorax. As soon as the surgeons pierced the mediastinal pleura, adequate circulation was restored. Immediate diagnosis and treatment is important for this complication.

Comparative resuscitation measures for the treatment of desipramine overdose.

A toxic dose of desipramine (tricyclic antidepressant) causes cardiac arrhythmias and ultimately asystole. Resuscitation is difficult and almost always unsuccessful. Anecdotal evidence suggests that an infusion of lipid emulsion may be an effective treatment. The purpose of this study was to determine the optimal combination of lipid rescue and traditional Advanced Cardiac Life Support therapy for the treatment of desipramine overdose. We use a prospective, experimental, between subjects design with a swine model investigating the effectiveness of the drugs and drug combinations administered with cardiopulmonary resuscitation. Subjects were randomly assigned to 1 of 8 cardiopulmonary resuscitation/drug combination interventions, and the results from each group were compared using an analysis of variance and post hoc Tukey where appropriate. The groups that received vasopressin were more likely to survive than those that did not receive vasopressin, and the groups that received lipid emulsion were more likely to survive than those that did not receive lipid emulsion. Vasopressin alone was shown to be the most effective treatment in the management of desipramine overdose. The results of this study may warrant changes in treatment protocols for desipramine overdose.

Hemodynamic rescue and ECG stability during chest compressions using adenosine and lidocaine after 8-minute asphyxial hypoxia in the rat.

INTRODUCTION: Sudden cardiac death generally arises from either ventricular fibrillation or asphyxial hypoxia. In an effort to translate the cardioprotective effects of adenosine and lidocaine (AL) from hemorrhagic shock to cardiopulmonary resuscitation, we examined the effect of AL on hemodynamics and electrocardiogram (ECG) stability in the rat model of asphyxial hypoxia. METHODS: Male Sprague-Dawley rats were randomly assigned to 1 of 4 groups (n = 8): saline (SAL), adenosine (ADO), lidocaine (LIDO), and AL. Cardiac arrest (mean arterial pressure <10 mm Hg) was induced by clamping the ventilator line for 8 minutes. A 0.5-mL intravenous drug bolus was injected followed by chest compressions (300 min(-1)), which were repeated every 5 minutes for 1 hour. RESULTS: Return of spontaneous circulation was achieved in 5 SAL (62.6%), 4 ADO (50%), 7 LIDO (87.5%), and 8 AL rats (100%) within 5 minutes but could not be sustained. During chest compressions, mean arterial pressure was consistently higher in the AL-treated rats compared with all groups (P < .05; 35-45 and 55 minutes) followed by the LIDO group and was lowest in the ADO and SAL groups (P < .05). Systolic pressure followed a similar pattern. In addition, diastolic pressure in the AL-treated rats was significantly higher from 25 to 60 minutes than LIDO and ADO alone or SAL, and heart rate was 30% to 40% lower. Improved ECG rhythm and R-R variability were apparent in AL-treated rats during early compressions and hands-off intervals. CONCLUSIONS: We conclude that a small bolus of 0.9% NaCl AL improved hemodynamics with possible diastolic rescue and ECG stabilization during chest compressions compared with ADO, LIDO, or SAL controls.

Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump.

BACKGROUND: Few studies have described the value of the precordial thump (PT) as first-line treatment of monitored out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation and pulseless ventricular tachycardia (VF/VT). METHODS: Patient data was extracted from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for all OHCA witnessed by paramedics between 2003 and 2011. Adult patients who suffered a monitored VF/VT of presumed cardiac aetiology were included. Cases were excluded if the arrest occurred after arrival at hospital, or a 'do not resuscitate' directive was documented. Patients were assigned into two groups according to the use of the PT or defibrillation as first-line treatment. The study outcomes were: impact of first shock/thump on return of spontaneous circulation (ROSC), overall ROSC, and survival to hospital discharge. RESULTS: A total of 434 cases met the eligibility criteria, of which first-line treatment involved a PT in 103 (23.7%) and immediate defibrillation in 325 (74.8%) cases. Patient characteristics did not differ significantly between groups. Seventeen patients (16.5%) observed a PT-induced rhythm change, including five cases of ROSC and 10 rhythm deteriorations. Immediate defibrillation resulted in significantly higher levels of immediate ROSC (57.8% vs. 4.9%, p<0.0001), without excess rhythm deteriorations (12.3% vs. 9.7%, p=0.48). Of the five successful PT attempts, three required defibrillation following re-arrest. Overall ROSC and survival to hospital discharge did not differ significantly between groups. CONCLUSION: The PT used as first-line treatment of monitored VF/VT rarely results in ROSC, and is more often associated with rhythm deterioration.

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device.

BACKGROUND: A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. METHODS: This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3). RESULTS: Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p=0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p=0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. CONCLUSIONS: Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.

Precordial acceleration signals improve the performance of diastolic timed vibrations.

BACKGROUND AND OBJECTIVE: This paper introduces a seismocardiography based methodology of predicting the start and the end of diastole to be used in diastolic timed vibrations (DTV), which provides non-invasive emergency treatment of acute coronary thrombosis by applying direct mechanical vibrations to the patient chest during diastole of heart cycles. It is proposed that seismocardiogram (SCG), in combination with electrocardiogram (ECG), provides a new means of diastole prediction. METHODS: An accelerometer was placed on the sternum of 120 healthy participants and 22 ischemic heart patients to record precordial accelerations created by the heart. The accelerometer signal was used to extract SCG and phonocardiogram (PCG). Two independent trained experts annotated the extracted signals based on the timings of the start and end of diastole. RESULTS: In the ischemic heart disease population by using 15 consecutive SCG cycles, the start and end of diastole was predicted in the upcoming cycles with 95 percentile error margin of 10.7 ms and 5.8 ms, respectively. These error margins were 7.4 ms and 3.5 ms, respectively, for normal participants. CONCLUSION: The results provide that prediction of the aortic valve closure point in the SCG signal helps start the vibrator in time to cover most of the isovolumic relaxation period. Also, through prediction of the mitral valve closure point in the SCG signal, safety of the technique can be assessed through prediction of the amount of unwanted vibrations applied during the isovolumic contraction period.

Extracorporeal cardiac mechanical stimulation: precordial thump and precordial percussion.

INTRODUCTION: External cardiac mechanical stimulation is one of the fastest resuscitative manoeuvres possible in the emergency setting. Precordial thump (PT), initially reported for treatment of atrio-ventricular block, has been subsequently described to cardiovert also ventricular tachycardia (VT) and fibrillation (VF). PT efficacy, mechanics and mechanisms remain poorly characterized. SOURCES OF DATA: Appropriate MESH and free terms were searched on PubMed, Embase and the Cochrane Library. Cross-referencing from articles and reviews, and forward search using SCOPUS and Google scholar have also been performed. Pre-set inclusion and exclusion criteria were applied to retrieved references on PT, which were then reviewed, summarized and interpreted. AREAS OF AGREEMENT: PT is not effective in treating VF, and of limited use for VT, although it has a very good safety profile (97% no changed/improved rhythm). If delivered, PT should be applied as early as possible after cardiac arrest, and cardio-pulmonary resuscitation (CPR) should begin with no delay if not effective. AREAS OF CONTROVERSY: A relatively large fraction of reported positive outcomes (both for PT and the less forceful but serially applied precordial percussion) in witnessed asystole should be considered when critically reviewing present CPR recommendations. In addition, mechanisms, energy requirements and timing are analysed and discussed. GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH: The 2005 ALS guidelines recommend PT delivery only by healthcare professionals trained in the technique. The use of training aids should therefore be explored, regardless of whether they are based on stand-alone devices or integrated within resuscitation mannequins.

Disminución de la presión arterial en pacientes con arteriopatía periférica mediante el masaje reflejo del tejido conjuntivo / Decrease in blood pressure in patients with peripheral arterial disease by connective tissue reflex massage

Objetivos: Evaluar la eficacia del masaje reflejo del tejido conjuntivo en la presión arterial sistólica y diastólica en pacientes con enfermedad arterial periférica. Metodología: Participaron en el estudio 26 pacientes con enfermedad arterial periférica del Distrito Sanitario de Granada durante un período de intervención de 15 semanas. La muestra de estudio se dividió de forma aleatoria en grupo experimental y grupo control. Los criterios de exclusión fueron los siguientes: insuficiencia arterial periférica en estadios más avanzados, insuficiencia venosa periférica, insuficiencia cardíaca, renal o hepática. La variable independiente considerada ha sido la aplicación del masaje reflejo del tejido conjuntivo según el método de Elizabeth Dicke. Asimismo, la variable dependiente estudiada ha sido la evaluación de la presión arterial sistólica y diastólica en ambas extremidades superiores. Resultados: Se observan diferencias significativas entre la valoración basal y las valoraciones posbasales, entre los dos grupos de estudio, en la presión arterial diastólica derecha (basal, p<0,043; primera valoración, p<0,041; segunda valoración, p<0,047) y la presión arterial sistólica izquierda (basal, p<0,042; primera valoración, p<0,04; segunda valoración, p<0,049). Conclusiones: El masaje reflejo del tejido conjuntivo genera un descenso de la presión arterial en pacientes con enfermedad arterial periférica en estadio I(AU)

Aims: Evaluate the effectiveness of connective tissue reflex massage on systolic and diastolic blood pressure in patients with peripheral arterial disease. Methodology: Twenty-six patients with peripheral arterial disease from the Health District of Granada participated in the study during a 15-week intervention period. The study sample was randomly divided into an experimental group and a control group. Exclusion criteria were peripheral arterial insufficiency at more advanced stages, peripheral venous insufficiency, cardiac, renal or hepatic insufficiency. Application of the connective tissue reflex massage according to the method of Elizabeth Dicke was regarded as the independent variable. The dependent variable was evaluation of systolic and diastolic blood pressure in both upper limbs. Outcomes: Significant differences could be observed between the baseline and post-baseline evaluations between the two study groups in the right diastolic blood pressure (baseline, p<0.043; 1st evaluation, p<0.041; 2nd evaluation, p<0.047), and left systolic blood pressure (basal, p<0.042; 1st evaluation, p<0.04; 2nd evaluation, p<0.049). Conclusions: Connective tissue reflex massage causes a blood pressure decrease in patients with stage I peripheral arterial disease(AU)

Limits of conventional therapies after prolonged normovolemic cardiac arrest in swine.

AIM: Patients' outcomes after prolonged cardiac arrest are often grim. The aim of this study was to find the longest period of normovolemic, normothermic, cardiac arrest no-flow after which good neurologic outcome can be achieved with conventional therapies. METHODS: Swine (28-37 kg) were subjected to ventricular fibrillation cardiac arrest, after which they were randomized into groups with 13 min (n=6), 15 min (n=6), or 17 min (n=6) of untreated cardiac arrest followed by advanced life support (ALS) for 20 min (epinephrine 0.04 mg/kg every 3 min and vasopressin 0.4 IE/kg every 6 min, no defibrillation attempts), followed by cardiopulmonary bypass (CPB). To mimic an unresuscitable situation after prolonged cardiac arrest, CPB was initiated 20 min after the start of resuscitation, followed by defibrillation attempts. Therapeutic mild hypothermia was applied for 20 h and a final neurologic evaluation (neurologic deficit score, NDS; overall performance category, OPC) was done after 9 days. RESULTS: In the 13-min group, restoration of spontaneous circulation (ROSC) was achieved in five of six swine, four of which survived to day 9, and all had favorable neurologic outcomes [one swine OPC 1, three swine OPC 2, NDS 15% (IQR 6-21)]. In the 15- and 17-min groups, ROSC was achieved in three of six and two of six swine, respectively, one survived to day 9 with OPC 3 in each group, and NDS values were 45 and 58%, respectively (Kruskal-Wallis test for OPC, p=0.048). CONCLUSIONS: In our model, the limit of normovolemic, normothermic, cardiac arrest no-flow time, followed by ACLS, CPB, and prolonged mild hypothermia, seems to be 13 min.

Improved hemodynamic performance with a novel chest compression device during treatment of in-hospital cardiac arrest.

INTRODUCTION: The purpose of this pilot clinical study was to determine if a novel chest compression device would improve hemodynamics when compared to manual chest compression during cardiopulmonary resuscitation (CPR) in humans. The device is an automated self-adjusting electromechanical chest compressor based on AutoPulse technology (Revivant Corporation) that uses a load distributing compression band (A-CPR) to compress the anterior chest. METHODS: A total of 31 sequential subjects with in-hospital sudden cardiac arrest were screened with institutional review board approval. All subjects had received prior treatment for cardiac disease and most had co-morbidities. Subjects were included following 10 min of failed standard advanced life support (ALS) protocol. Fluid-filled catheters were advanced into the thoracic aorta and the right atrium and placement was confirmed by pressure waveforms and chest radiograph. The coronary perfusion pressure (CPP) was measured as the difference between the aortic and right atrial pressure during the chest compression's decompressed state. Following 10 min of failed ALS and catheter placement, subjects received alternating manual and A-CPR chest compressions for 90 s each. Chest compressions were administered without ventilation pauses at 100 compressions/min for manual CPR and 60 compressions/min for A-CPR. All subjects were intubated and ventilated by bag-valve at 12 breaths/min between compressions. Epinephrine (adrenaline) (1mg i.v. bolus) was given at the request of the attending physician at 3-5 min intervals. Usable pressure signals were present in 16 patients (68 +/- 6 years, 5 female), and data are reported from those patients only. A-CPR chest compressions increased peak aortic pressure when compared to manual chest compression (153 +/- 28 mmHg versus 115 +/- 42 mmHg, P < 0.0001, mean +/- S.D.). Similarly, A-CPR increased peak right atrial pressure when compared to manual chest compression (129 +/- 32 mmHg versus 83 +/- 40 mmHg, P < 0.0001). Furthermore, A-CPR increased CPP over manual chest compression (20 +/- 12 mmHg versus 15 +/- 11 mmHg, P < 0.015). Manual chest compressions were of consistent high quality (51 +/- 20 kg) and in all cases met or exceeded American Heart Association guidelines for depth of compression. CONCLUSION: Previous research has shown that increased CPP is correlated to increased coronary blood flow and increased rates of restored native circulation from sudden cardiac arrest. The A-CPR system using AutoPulse technology demonstrated increased coronary perfusion pressure over manual chest compression during CPR in this terminally ill patient population.

Prevención y tratamiento de las emergencias en odontología: 1ra parte / Prevention and treatment of emergencies in dentistry: 1st part

Es sumamente importante reconocer las urgencias en nuestra profesión y poder resolverlas eficientemente, pero más aún lo es poseer la capacidad, conocimiento y manejo adecuado de las emergencias que pueden presentarse en nuestra vida profesional, sea o no en nuestro ámbito laboral. Si es seguro que con un manejo adecuado de la mayoría de las emergencias el resultado será exitoso (AU)

Prevención y tratamiento de las emergencias en odontología: 1ra parte / Prevention and treatment of emergencies in dentistry: 1st part

Es sumamente importante reconocer las urgencias en nuestra profesión y poder resolverlas eficientemente, pero más aún lo es poseer la capacidad, conocimiento y manejo adecuado de las emergencias que pueden presentarse en nuestra vida profesional, sea o no en nuestro ámbito laboral. Si es seguro que con un manejo adecuado de la mayoría de las emergencias el resultado será exitoso