Early Magnesium Treatment After Aneurysmal Subarachnoid Hemorrhage: Individual Patient Data Meta-Analysis.

BACKGROUND AND PURPOSE: Delayed cerebral ischemia (DCI) is an important cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Trials of magnesium treatment starting <4 days after symptom onset found no effect on poor outcome or DCI in SAH. Earlier installment of treatment might be more effective, but individual trials had not enough power for such a subanalysis. We performed an individual patient data meta-analysis to study whether magnesium is effective when given within different time frames within 24 hours after the SAH. METHODS: Patients were divided into categories according to the delay between symptom onset and start of the study medication: <6, 6 to 12, 12 to 24, and >24 hours. We calculated adjusted risk ratios with corresponding 95% confidence intervals for magnesium versus placebo treatment for poor outcome and DCI. RESULTS: We included 5 trials totaling 1981 patients; 83 patients started treatment<6 hours. For poor outcome, the adjusted risk ratios of magnesium treatment for start <6 hours were 1.44 (95% confidence interval, 0.83-2.51); for 6 to 12 hours 1.03 (0.65-1.63), for 12 to 24 hours 0.84 (0.65-1.09), and for >24 hours 1.06 (0.87-1.31), and for DCI, <6 hours 1.76 (0.68-4.58), for 6 to 12 hours 2.09 (0.99-4.39), for 12 to 24 hours 0.80 (0.56-1.16), and for >24 hours 1.08 (0.88-1.32). CONCLUSIONS: This meta-analysis suggests no beneficial effect of magnesium treatment on poor outcome or DCI when started early after SAH onset. Although the number of patients was small and a beneficial effect cannot be definitively excluded, we found no justification for a new trial with early magnesium treatment after SAH.

Incidence of "secondary drowning" after saltwater submersion.

Most authorities recommend admission of all near-drowning victims out of fear of "secondary drowning." Identifying victims at risk could promote vigorous evaluation and reduce unnecessary hospitalization. We prospectively studied 52 swimmers with symptoms of respiratory distress after submersion. Thirty-one (60%) were released on the beach, and none of 26 followed up by telephone sought medical care or exhibited symptoms of respiratory distress as many as five days later. Twenty-one patients (40%) were transported to a hospital for further evaluation. All who required admission displayed signs of respiratory distress within four hours. No patient developed "secondary drowning" after an asymptomatic interval, indicating that emergency department observation for four to six hours could effectively screen for those patients requiring inpatient therapy. We question the existence of "secondary drowning" as anything other than established, detectable respiratory insufficiency.

A prehospital approach to multiple-victim incidents.

Although most prehospital systems have well-developed protocols for single-victim rescues and mass casualties, multiple-victim incidents falling between the two in scope have not been analyzed in detail. Forty-one audio tapes of incidents with four or more victims were evaluated for techniques and decisions that affected the runs' speed and efficiency. Common problems both in the field and at the base hospital were identified. Recommendations for management in the field and for paramedic and base station transmissions are given.

Prospective study of manikin-only versus manikin and human subject endotracheal intubation training of paramedics.

STUDY OBJECTIVES: To determine the effect of manikin-only training on field success of endotracheal intubation by paramedics. DESIGN: Prospective evaluation of individual field endotracheal intubation success rates for paramedics after they participated in a manikin-only or a manikin-plus-cadaver training program. TYPES OF PARTICIPANTS: Paramedics responding to emergency calls involving adult medical or trauma victims. INTERVENTIONS: All participants were trained using a controlled manikin training program; then, half were randomly selected for additional instruction using fresh human cadavers. MEASUREMENTS AND MAIN RESULTS: Individuals trained using only the manikin program had mean +/- SD individual success rates of 82 +/- 32%, and individuals who received additional cadaver training had mean individual success rates of 83 +/- 31%. Overall success rates for the two groups were 86% for the manikin-only group and 85% for the manikin-plus-cadaver-trained group. The sample size was not adequate to allow rejection of the null hypothesis. CONCLUSION: Paramedics trained in endotracheal intubation using a systematic manikin-only teaching program can attain acceptable individual success rates in the actual field setting.

Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.

CONTEXT: Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome. OBJECTIVE: To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI. DESIGN: Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997. SETTING: Two large, urban, rapid-transport emergency medical services (EMS) systems. PARTICIPANTS: A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up. INTERVENTIONS: Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420). MAIN OUTCOME MEASURES: Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group. RESULTS: There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22). CONCLUSION: These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.