Does Pain Have a Role When It Comes to Tourniquet Training?

BACKGROUND: One of the greatest conundrums with tourniquet (TQ) education is the use of an appropriate surrogate of hemorrhage in the training setting to determine whether a TQ has been successfully used. At our facility, we currently use loss of audible Doppler signal or loss of palpable pulse to represent adequate occlusion of vasculature and thus successful TQ application. We set out to determine whether pain can be used to indicate successful TQ application in the training setting. METHODS: Three tourniquet systems (a pneumatic tourniquet, Combat Application Tourniquet® [C-A-T], and Stretch Wrap and Tuck Tourniquet™ [SWAT-T]) were used to occlude the arterial vasculature of the left upper arm (LUA), right upper arm (RUA), left forearm (LFA), right forearm (RFA), right thigh (RTH), and right calf (RCA) of 41 volunteers. A 4MHz, handheld Doppler ultrasound was used to confirm loss of Doppler signal (LOS) at the radial or posterior tibial artery to denote successful TQ application. Once successful placement of the TQ was noted, subjects rated their pain from 0 to 10 on the visual analog scale. In addition, the circumference of each limb, the pressure with the pneumatic TQ, number of twists with the C-A-T, and length of TQ used for the SWAT-T to obtain LOS was recorded. RESULTS: All 41 subjects had measurements at all anatomic sites with the pneumatic TQ, except one participant who was unable to complete the LUA. In total, pain was rated as 1 or less by 61% of subjects for LUA, 50% for LFA, 57.5% for RUA, 52.5% RFA, 15% for RTH, and 25% for RCA. Pain was rated 3 or 4 by 45% of subjects for RTH. For the C-A-T, data were collected from 40 participants. In total, pain was rated as 1 or less by 57.5% for the LUA, 70% for the LFA, 62.5% for the RUA, 75% for the RFA, 15% for the RTH, and 40% for the RCA. Pain was rated 3 or 4 by 42.5%. The SWAT-T group consisted of 37 participants for all anatomic locations. In total, pain was rated as 1 or less by 27% for LUA, 40.5% for the LFA, 27.0% for the RUA, 43.2 for the RFA, 18.9% for the RTH, and 16.2% for the RCA. Pain was rated 5 by 21.6% for RTH application, and 3 or 4 by 35%. CONCLUSION: The unexpected low pain values recorded when loss of signal was reached make the use of pain too sensitive as an indicator to confirm adequate occlusion of vasculature and, thus, successful TQ application.

Intentional Clinical Process Design to Improve Outcomes for Patients Who Require Emergency Surgery.

Ruptured abdominal aortic aneurysms (AAAs) are associated with a 90% overall mortality and $150 000 cost of care per patient. Despite improvements in intensive care and surgical technology, morbidity and mortality remain unchanged over the past 20 years. The most significant predictor of survival is time from the door of the hospital to the operating room. To streamline operational efficiency, a team utilized Lean Six Sigma methodologies, team training, and intentional clinical process design to institute changes in our clinical processes, enhance care coordination, and improve communication. Changes led to a $1.8 million profit on operations, 10-day reduction in length of stay, and 89% survival rate among patients with ruptured AAA.

The "TRAUMA LIFE" initiative: The impact of a multidisciplinary checklist process on outcomes and communication in a Trauma Intensive Care Unit.

BACKGROUND: Checklists have been advocated to improve quality outcomes/communication in the critical care setting, but results have been mixed. A new checklist process, "TRAUMA LIFE", was implemented in our Trauma Intensive Care Unit (TICU) to replace prior checklists. The purpose of this study was to evaluate the impact of the "TRAUMA LIFE" process implementation on quality metrics and on patient/family communication in the TICU. METHODS: "TRAUMA LIFE" was considered maturely implemented by 2016. Multiple quality metrics, including restraint order compliance, were compared between 2013 and 2016 (pre- and post-implementation). Compliance with the "Family Message" (FM), a part of the "TRAUMA LIFE" communication process, was analyzed in 2016. RESULTS: Improvement was seen in CAUTI, VAE, and IUCU; CLABSI rates increased. Restraint order compliance increased significantly. FM delivery compliance was inconsistent; improvement was noted in concordance between update content and FM documented in Electronic Medical Record. CONCLUSION: Implementation of "TRAUMA LIFE" was well integrated into the rounding process and was associated with some improvement in quality metrics and communication. Additional evaluation is required to assess sustainability.

Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. METHODS: The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. RESULTS: Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. CONCLUSION: Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. LEVEL OF EVIDENCE: Systematic review, level III.

Critical Care Nurses' Perceived Need for Guidance in Addressing Spirituality in Critically Ill Patients.

BACKGROUND: The term spirituality is highly subjective. No common or universally accepted definition for the term exists. Without a clear definition, each nurse must reconcile his or her own beliefs within a framework mutually suitable for both nurse and patient. OBJECTIVES: To examine individual critical care nurses' definition of spirituality, their comfort in providing spiritual care to patients, and their perceived need for education in providing this care. METHODS: Individual interviews with 30 nurses who worked in a critical care unit at a large Midwestern teaching hospital. RESULTS: Nurses generally feel comfortable providing spiritual care to critically ill patients but need further education about multicultural considerations. Nurses identified opportunities to address spiritual needs throughout a patient's stay but noted that these needs are usually not addressed until the end of life. CONCLUSIONS: A working definition for spirituality in health care was developed: That part of person that gives meaning and purpose to the person's life. Belief in a higher power that may inspire hope, seek resolution, and transcend physical and conscious constraints.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Outcomes in traumatic brain injury for patients presenting on antiplatelet therapy.

An increasing number of patients are presenting to trauma units with head injuries on antiplatelet therapy (APT). The influence of APT on these patients is poorly defined. This study examines the outcomes of patients on APT presenting to the hospital with blunt head trauma (BHT). Registries of two Level I trauma centers were reviewed for patients older than 40 years of age from January 2008 to December 2011 with BHT. Patients on APT were compared with control subjects. Primary outcome measures were in-hospital mortality, intracranial hemorrhage (ICH), and need for neurosurgical intervention (NI). Hospital length of stay (LOS) was a secondary outcome measure. Multivariate analysis was used and adjusted models included antiplatelet status, age, Injury Severity Score (ISS), and Glasgow coma scale (GCS). Patients meeting inclusion criteria and having complete data (n = 1547) were included in the analysis; 422 (27%) patients were taking APT. Rates of ICH, NI, and in-hospital mortality of patients with BHT in our study were 45.4, 3.1, and 5.8 per cent, respectively. Controlling for age, ISS, and GCS, there was no significant difference in ICH (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.61 to 1.16), NI (OR, 1.26; 95% CI, 0.60 to 2.67), or mortality (OR, 1.79; 95% CI, 0.89 to 3.59) associated with APT. Subgroup analysis revealed that patients with ISS 20 or greater on APT had increased in-hospital mortality (OR, 2.34; 95% CI, 1.03 to 5.31). LOS greater than 14 days was more likely in the APT group than those in the non-APT group (OR, 1.85; 95% CI, 1.09 to 3.12). The effects of antiplatelet therapy in patients with BHT aged 40 years and older showed no difference in ICH, NI, and in-hospital mortality.

Trans-abdominal wall traction as a universal solution to the management of giant ventral hernias.

BACKGROUND: Domain loss following damage-control laparotomy is a challenging problem many surgeons face. The authors recently developed trans-abdominal wall traction, which closed 100 percent of domain loss abdomens in the acute setting. They hypothesized that it can be used successfully in patients with chronic giant ventral defects. METHODS: From 2008 to 2013, 44 patients with acute loss of domain and 10 with chronically giant ventral defects were enrolled in the open abdomen protocol with subsequent placement of the trans-abdominal wall traction device. RESULTS: Patients' average age in the acute and chronic groups was 28.2 and 35.3 years and average body mass index was 26.4 and 32.4 kg/m2, respectively. Ventral hernia size was reduced with the first trans-abdominal wall traction insertion from 610.5 cm2 to 274.6 cm2 in the acute setting and from 598 cm2 to 236.9 cm2 in the chronic setting. Average time from damage-control laparotomy to device insertion was 12.9 days in the acute group and more than 3 years in the chronic group. Lost domain was achieved with an average of less than 2.5 trans-abdominal wall traction tightenings, correlating to 9.2 and 8.2 days in the acute and chronic groups, respectively. Enterocutaneous fistula occurrence was 9 percent in the acute group and 0 percent in the chronic group. CONCLUSIONS: All patients were successfully closed after reestablishment of the lost domain. Trans-abdominal wall traction is an effective means of reestablishing abdominal domain and achieving primary abdominal wall closure in all patients with giant ventral defects, both acute and chronic.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Not so fast to skin graft: transabdominal wall traction closes most "domain loss" abdomens in the acute setting.

BACKGROUND: Damage-control laparotomy (DCL) has revolutionized the surgery of injury. However, this has led to the dilemma of the nonclosable abdomen. Subsequently, there exists a subgroup of patients who after resuscitation and diuresis, remain nonclosable. Before the adoption of our open abdomen protocol (OAP) and use of transabdominal wall traction (TAWT), these patients required skin grafting and a planned ventral hernia. We hypothesize that our OAP and TAWT device, which use full abdominal wall thickness sutures to dynamically distribute midline traction, achieve an improved method of fascial reapproximation. METHODS: From 2008 to 2011, all DCL and decompressive laparotomy patients in our urban trauma center were managed by our OAP. Thirty two were noncloseable "domain loss abdomens" after achieving physiologic steady state and near dry weight. All patients received the TAWT device when near dry weight was achieved. Wound size, days to closure, days to TAWT, and TAWT to closure were tracked. RESULTS: During this 36-month period, OAP/TAWT was applied to 32 patients. All patients demonstrated domain loss precluding fascial closure. Average wound size was 18.5-cm width by 30.5-cm length. Mean time DCL surgery to TAWT was 9.5 days. At time of placement, TAWT decreased initial wound width by an average of 9.8 cm (51.4%). Patients returned to the operating room for tightening/washout an average of 2.2 times (excluding TAWT insertion and final closure operations). Mean time TAWT to closure was 8.7 days. Mean time from admission surgery to primary closure was 18.2 days. All patients achieved primary fascial closure using this method without components separation or biologic bridge operations. CONCLUSION: OAP/TAWT has revolutionized the way we manage "domain loss" open abdomen patients and has virtually eliminated the acceptance of planned ventral hernia. TAWT consistently recaptures lost domain, preserves the leading fascial edge, and eliminates the need for biologic bridges, components separation, or skin grafting. LEVEL OF EVIDENCE: Therapeutic study, level III.

Screening for traumatic stress among survivors of urban trauma.

OBJECTIVE: This study piloted the use of the Primary Care PTSD (PC-PTSD) screening tool in an outpatient setting to determine its utility for broader use and to gather data on traumatic stress symptoms among direct (patients) and indirect (families) survivors of traumatic injuries. METHODS: Using the PC-PTSD plus one question exploring openness to seeking help, participants were screened for PTSD in the outpatient clinic of an urban Level 1 trauma center. The survey was distributed during a 23-week period from April to September 2011. The screen was self-administered, a sample of convenience, and participation was voluntary and anonymous. RESULTS: With a response rate of 66%, 307 surveys were completed. Forty-two percent of participants had a positive screen. Patients greater than 30 and 90 days from injury had 1.5 and 1.7 times more positive screens than those less than 30 days. Patients with gunshot wounds were 13 times as likely as those with falls and twice as likely as those in a motor vehicle crash to have a positive screen. Sixty percent of patients with a positive screen noted it would be helpful to talk to someone. CONCLUSION: The PC-PTSD was an easy to administer screening tool. Patients reported PTSD symptoms at higher rates than previous studies. Patients with gunshot wounds and those injured greater than 30 days from the time of the screen were more likely to report PTSD symptoms. Although males represented 82% of positive screens, there was no statistical difference in PTSD symptoms between male and female participants because of the small number of females represented. Families also reported significant levels of PTSD. Both patients and families may benefit from additional screening and intervention in the early posttrauma period.

CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison.

BACKGROUND: An estimated 10,000 Americans suffer cervical spine injuries each year. More than 800,000 cervical spine radiographs (CSR) are ordered annually. The human and healthcare costs associated with these injuries are enormous especially when diagnosis is delayed. Controversy exists in the literature concerning the diagnostic accuracy of CSR, with reported sensitivity ranging from 32% to 89%. We sought to compare prospectively the sensitivity of cervical CT (CCT) to CSR in the initial diagnosis of blunt cervical spine injury for patients meeting one or more of the NEXUS criteria. METHODS: The study prospectively compared the diagnostic accuracy of CSR to CCT in consecutive patients evaluated for blunt trauma during 23 months at an urban, public teaching hospital and Level I Trauma Center. Inclusion criteria were adult patient, evaluated for blunt cervical spine injury, meeting one or more of the NEXUS criteria. All patients received both three-view CSR and CCT as part of a standard diagnostic protocol. Each CSR and CCT study was interpreted independently by a different radiology attending who was blinded to the results of the other study. Clinically significant injuries were defined as those requiring one or more of the following interventions: operative procedure, halo application, and/or rigid cervical collar. RESULTS: Of 1,583 consecutive patients evaluated for blunt cervical spine trauma, 78 (4.9%) patients received only CCT or CSR and were excluded from the study. Of the remaining 1,505 patients, 78 (4.9%) had evidence of a radiographic injury by CSR or CCT. Of these 78 patients with radiographic injury, 50 (3.3%) patients had clinically significant injuries. CCT detected all patients with clinically significant injuries (100% sensitive), whereas CSR detected only 18 (36% sensitive). Of the 50 patients, 15 were at high risk, 19 at moderate risk, and 16 at low risk for cervical spine injury according to previously published risk stratification. CSR detected clinically significant injury in 7 high risk (46% sensitive), 7 moderate risk (37% sensitive), and 4 low risk patients (25% sensitive). CONCLUSION: Our results demonstrate the superiority of CCT compared with CSR for the detection of clinically significant cervical spine injury. The improved ability to exclude injury rapidly provides further evidence that CCT should replace CSR for the initial evaluation of blunt cervical spine injury in patients at any risk for injury.

Taser X26 discharges in swine: ventricular rhythm capture is dependent on discharge vector.

BACKGROUND: Data from our previous studies indicate that Taser X26 stun devices can acutely alter cardiac function in swine. We hypothesized that most transcardiac discharge vectors would capture ventricular rhythm, but that other vectors, not traversing the heart, would fail to capture the ventricular rhythm. METHODS: Using an Institutional Animal Care and Use Committee (IACUC) approved protocol, four Yorkshire pigs (25-36 kg) were anesthetized, paralyzed with succinylcholine (2 mg/kg), and then exposed to 10 second discharges from a police-issue Taser X26. For most discharges, the barbed darts were pushed manually into the skin to their full depth (12 mm) and were arranged in either transcardiac (such that a straight line connecting the darts would cross the region of the heart) or non-transcardiac vectors. A total of 11 different vectors and 22 discharge conditions were studied. For each vector, by simply rotating the cartridge 180-degrees in the gun, the primary current-emitting dart was changed and the direction of current flow during the discharge was reversed without physically moving the darts. Echocardiography and electrocardiograms (ECGs) were performed before, during, and after all discharges. p values < 0.05 were considered significant. RESULTS: ECGs were unreadable during the discharges because of electrical interference, but echocardiography images clearly demonstrated that ventricular rhythm was captured immediately in 52.5% (31 of 59) of the discharges on the ventral surface of the animal. In each of these cases, capture of the ventricular rhythm with rapid ventricular contractions consistent with ventricular tachycardia (VT) or flutter was seen throughout the discharge. A total of 27 discharges were administered with transcardiac vectors and ventricular capture occurred in 23 of these discharges (85.2% capture rate). A total of 32 non-transcardiac discharges were administered ventrally and capture was seen in only eight of these (25% capture rate). Ventricular fibrillation (VF) was seen with two vectors, both of which were transcardiac. In the remaining animals, VT occurred postdischarge until sinus rhythm was regained spontaneously. CONCLUSIONS: For most transcardiac vectors, Taser X26 caused immediate ventricular rhythm capture. This usually reverted spontaneously to sinus rhythm but potentially fatal VF was seen with two vectors. For some non-transcardiac vectors, capture was also seen but with a significantly (p < 0.0001) decreased incidence.

Acute effects of MK63 stun device discharges in miniature swine.

OBJECTIVE: Electromuscular incapacitation (EMI) devices are being used and evaluated by both military and law enforcement agencies. Although the gross muscular response is obvious, physiological responses to these devices are poorly understood. We hypothesized that the intense, repetitive, muscle contractions evoked by EMI devices would cause dose-dependent metabolic acidosis, accompanied by neuromuscular or cardiac injury. METHODS: Using an approved protocol, 26 Yucatan mini-pigs (22 experimental animals and 4 control animals) were anesthetized with ketamine and xylazine. Experimental animals were exposed to MK63 (Aegis Industries, Bellevue, Idaho) discharges over the left anterior hind limb for 10, 20, 40, or 80 seconds. Electrocardiograms, electromyograms, troponin I levels, blood gas values, and electrolyte levels were recorded before and 5, 15, 30, and 60 minutes and 24, 48, and 72 hours after discharge. Skin, muscle, and nerve biopsies were taken from the shocked and contralateral sides. RESULTS: Core body temperature significantly decreased (1.0-1.5 degrees C) in all shocked animals but not in sham-treated control animals. No cardiac dysrhythmias or deaths were seen, and heart rate was unaffected. No clinically significant changes were seen in troponin I, myoglobin, or creatine kinase-MB levels. Central venous blood pH decreased, whereas carbon dioxide pressure and lactate levels increased for 60 minutes after discharge. All values returned to normal by 24 hours after discharge, and no significant histological or electromyographic changes were found. CONCLUSIONS: Changes in blood chemistry were observed but were of little clinical significance, and no neuromuscular damage was detected. Therefore, within the limitations of this model, it appears that EMI can safely be achieved by using this device, even for lengthy periods, without causing significant injury.

TASER X26 discharges in swine produce potentially fatal ventricular arrhythmias.

OBJECTIVES: Data from the authors and others suggest that TASER X26 stun devices can acutely alter cardiac function in swine. The authors hypothesized that TASER discharges degrade cardiac performance through a mechanism not involving concurrent acidosis. METHODS: Using an Institutional Animal Care and Use Committee (IACUC)-approved protocol, Yorkshire pigs (25-71 kg) were anesthetized, paralyzed with succinylcholine (SCh; 2 mg/kg), and then exposed to two 40-second discharges from a TASER X26 with a transcardiac vector. Vital signs, blood chemistry, and electrolyte levels were obtained before exposure and periodically for 48 hours postdischarge. Electrocardiograms and echocardiography (echo) were performed before, during, and after the discharges. p-Values < 0.05 were considered significant. RESULTS: Electrocardiograms were unreadable during the discharges due to electrical interference, but echo images showed unmistakably that cardiac rhythm was captured immediately at a rate of 301 +/- 18 beats/min (n = 8) in all animals tested. Capture continued for the duration of the discharge and in one animal degenerated into fatal ventricular fibrillation (VF). In the remaining animals, ventricular tachycardia (VT) occurred postdischarge for 1-17 seconds, whereupon sinus rhythm was regained spontaneously. Blood chemistry values and vital signs were minimally altered postdischarge and no significant acidosis was seen. CONCLUSIONS: Extreme acid-base disturbances usually seen after lengthy TASER discharges were absent with SCh, but TASER X26 discharges immediately and invariably produced myocardial capture. This usually reverted spontaneously to sinus rhythm postdischarge, but fatal VF was seen in one animal. Thus, in the absence of systemic acidosis, lengthy transcardiac TASER X26 discharges (2 x 40 seconds) captured myocardial rhythm, potentially resulting in VT or VF in swine.

Acute effects of TASER X26 discharges in a swine model.

BACKGROUND: Very little objective laboratory data are available describing the physiologic effects of stun guns or electromuscular incapacitation devices (EIDs). Unfortunately, there have been several hundred in-custody deaths, which have been temporally associated with the deployment of these devices. Most of the deaths have been attributed to specific cardiac and metabolic effects. We hypothesized that prolonged EID exposure in a model animal system would induce clinically significant metabolic acidosis and cardiovascular disturbances. METHODS: Using an Institutional Animal Care and Use Committee-approved protocol, 11 standard pigs (6 experimentals and 5 sham controls) were anesthetized with ketamine and xylazine. The experimentals were exposed to two 40-second discharges from an EID (TASER X26, TASER Intl., Scottsdale, AZ) across the torso. Electrocardiograms, blood pressure, troponin I, blood gases, and electrolyte levels were obtained pre-exposure and at 5, 15, 30, and 60 minutes and 24, 48, and 72 hours postdischarge. p values <0.05 were considered significant. RESULTS: Two deaths were observed immediately after TASER exposure from acute onset ventricular fibrillation (VF). In surviving animals, heart rate was significantly increased and significant hypotension was noted. Acid-base status was dramatically affected by the TASER discharge at the 5-minute time point and throughout the 60-minute monitoring period. Five minutes postdischarge, central venous blood pH (6.86 +/- 0.07) decreased from baseline (7.45 +/- 0.02; p = 0.0004). Pco2 (94.5 mm Hg +/- 14.8 mm Hg) was significantly increased from baseline (45.3 mm Hg +/- 2.6 mm Hg) and bicarbonate levels significantly decreased (15.7 mmol/L +/- 1.04 mmol/L) from baseline (30.4 mmol/L +/- 0.7 mmol/L). A large, significant increase in lactate occurred postdischarge (22.1 mmol/L +/- 1.5 mmol/L) from baseline (1.5 mmol/L +/- 0.3 mmol/L). All values returned to normal by 24 hours postdischarge in surviving animals. A minor, nonsignificant increase in troponin I was seen at 24 hours postdischarge (0.052 ng/mL +/- 0.030 ng/mL, mean +/- SEM). CONCLUSIONS: Immediately after the discharge, two deaths occurred because of ventricular fibrillation. In this model of prolonged EID exposure, clinically significant acid-base and cardiovascular disturbances were clearly seen. The severe metabolic and respiratory acidosis seen here suggests the involvement of a primary cardiovascular mechanism.