Death in correctional facilities: opportunities for automated external defibrillation.

BACKGROUND: Death due to cardiovascular disease occurs more frequently in prisons than the national average. Due to close surveillance 24 h/day, the ability to reach the patient within 3 min and time consuming access for the EMS crews, it was hypothesised that the deployment of automated external defibrillators (AEDs) might make improvements regarding Call-to-the-First-AED-Prompt (CTP) interval and formed the aim of this study. METHODS: Our investigation was analysed on an intention to treat basis and conducted in a prospective, open and observational design. As the primary outcome, the CTP-intervals were compared to the arrival intervals of the EMS. As a secondary outcome, an analysis of all deceased inmates was described. RESULTS: The average daily population of inmates in Austrian correctional facilities is 7714. During a period of 13 months, 10 instances in which an AED was activated and electrodes attached to a collapsed inmate, were reported. The CTP-interval (median+/-S.D.) was 2.3+/-1.6 S.D. min. It took the EMS 10.0+/-4.3 S.D. min. to arrive at the patient's side. Four out of 10 cases of cardiac arrest occurred due to myocardial infarction. Of 39 deceased inmates, a post mortem examination was completed in 34 cases. In 13 cases, cardiovascular disease was the cause of death. DISCUSSION: The main finding was a four-fold reduction of the CTP-interval. This fact indicates the potential improvements which could be achieved with the deployment of AEDs. Our secondary objective revealed that death due to cardiovascular disease was found in a high proportion and could be considered to be a strong incentive to initiate programmes to counter cardiovascular death in prison.

Routine fluoroscopic guidance is not required for placement of Hickman catheters via the supraclavicular route.

The purpose of this study was to evaluate the efficacy and safety in placement of Hickman catheters via the supraclavicular route without fluoroscopic guidance. We studied 81 consecutive percutaneous placements of dual lumen Hickman catheters via the supraclavicular route without the use of fluoroscopic guidance. Success rates, technical problems, complications, infections and reasons for explantation were recorded prospectively. Seventy-nine punctures were successful (97.5%). One pneumothorax (1.2%) and three accidental arterial punctures (3.7%) occurred. Difficulties in introducing the catheter through the peel away sheath or misplacement were not observed. The catheters remained in place for a total of 7657 days (mean 94.5, range 3-392 days). Sixteen blood cultures were positive (2.1/1000 catheter days). Five catheters (6.1%) were lost because of mechanical complications. Forty-two lines (52%) were removed electively, 23 (28.4%) because of suspected infection, and two (2.5%) because of tunnel infection. Nine patients died with a functioning catheter. We conclude that the supraclavicular approach to the subclavian vein is safe and efficient for introduction of Hickman catheters. Using this access, routine fluoroscopic or sonographic guidance is not required for proper placement. Implantation of the lines in an intensive care unit did not lead to higher infection rates than those reported in the literature.

Experience with allogeneic and syngeneic blood stem cell transplantation in patients with hematological malignancies.

Between 1995 and 1997 twenty two patients with different hematological diseases ( CML n=10, AML n=6, ALL n=l, NHL n=3, SAA n=1,solid tumor n=1 ) and a median age of 37 (range, 20 to 55) years received unmanipulated peripheral blood stem cell (PBSC) transplants from HLA-identical sibling donors at our institution. Myeloablative chemotherapy consisted of cyclophosphamide (CY) and total body irradiation in 11, and chemotherapy alone in 11 patients. For graft-versus host-disease (GVHD) prophylaxis all patients were given cyclosporine A and methotrexate according to the Seattle protocol. PBSC were mobilized by granulocyte colony-stimulating factor (G-CSF) given at 10 microg/kg body weight (b.w.)/day for four days. Harvest of PBSC was started on day 5 and continued on day 6 if necessary. A median of 1 leukapheresis (range, 1 to 2) was performed and a median of 5.7 x 10(6) CD34+cells/kg b.w. (1.34 to 21.5) were obtained. Ten patients received G-CSF (5 microg/kg b.w.) starting on day one after PBSCT until neutrophil recovery. Absolute neutrophil counts >0.5 x 10(9)/L and ANC >1.0 x 10(9)/L were reached after a median of 13 (range 8 to 18) and 15 (range 9 to 19) days after PBSCT. Unsupported platelet counts >20 x 10(9)/L and 50 x 10(9)/L were reached after 17 (range 8 to 32) and 22 (range 13 to 40) days after PBSCT, respectively. Incidence of acute GVHD grade I to IV was 52%, extensive chronic GVHD occurred in 25% of patients. After a median observation time of 11 (range, 3 to 34) months twelve patients (55%) are alive and well. In summary, infusion of allogeneic PBSC after myeloablative therapy allows rapid and sustained hematologic reconstitution. Incidence of acute GVHD is not increased, for assessment of chronic GVHD longer observation times and larger patient numbers are required.

Suicidal chloroquine poisoning: clinical course, autopsy findings, and chemical analysis.

Suicidal overdose of chloroquine is rare. We present a 14-year-old girl who was admitted to our Emergency Department after intentional ingestion of 7.5 g of chloroquine base followed by cardiac and respiratory arrest. Despite early mechanical ventilation, cardiac support, and treatment with high doses of diazepam, the patient died. Laboratory investigation indicated disseminated intravascular coagulation confirmed by petechial hemorrhages in the leptomeninges at autopsy, a finding that has not previously been described. Postmortem tissue analysis demonstrated early drug distribution to the medulla oblongata and cerebellum.

Hemodynamic effects of active compression-decompression after prolonged CPR.

BACKGROUND: This study was designed to test the effects of active compression-decompression (ACD) versus standard (STD) cardiopulmonary resuscitation (CPR) on hemodynamics after prolonged cardiac arrest (CA). METHODS AND RESULTS: After nontraumatic prehospital CA, 21 patients were resuscitated in a prospective nonblinded setting sequentially with STD and ACD CPR at the emergency department, if it had not been possible to achieve restoration of spontaneous circulation (ROSC) before admission. The compression rate was 80/min with a 50% duty cycle, and 1 mg epinephrine was given every 5th min. Invasive arterial, central venous pressure and end tidal CO2 (ETCO2) were monitored. Comparing coronary perfusion pressure (CoPP) and ETCO2, no significant differences between STD and ACD CPR were found. In 3 cases ROSC could be achieved for a short time. CONCLUSIONS: In our study, a comparison of STD and ACD CPR revealed no significant differences in coronary perfusion pressures and ETCO2. We conclude that after prolonged CA, ACD CPR does not provide an apparent hemodynamic advantage over STD CPR.

Possibilities of brain protection with tirilazad after cardiac arrest.

Cardiac arrest and resuscitation often create a cerebral insult caused by the initial cessation of blood flow, followed by the incomplete ischemia of cardiopulmonary resuscitation (low flow), and, following the return of spontaneous circulation, by the post-resuscitation syndrome. A cascade of physiologic, vascular, and biochemical events is set in motion, including changes in neuropeptides, electrolytes such as calcium and magnesium, excitatory neurotransmitters such as glutamate and acetylcholine, lymphokines such as interleukin-1, and arachidonic acid metabolites such as prostaglandins and leukotrienes; and formation of oxygen free radicals and lactic acid. Oxygen free radical-induced lipid peroxidation appears to increase tissue injury during and after brain ischemia. The 21-aminosteroid U74006F (tirilazad mesylate) is a novel inhibitor of lipid membrane peroxidation induced by oxygen free radicals, which has been shown, in animal models of subarachnoid hemorrhage, central nervous system trauma, and cerebral ischemia, to limit the extent of secondary tissue damage, thus improving functional recovery. Since tirilazad appears to have little or no behavioral or physiologic side effects, it appears to be an ideal agent for widespread brain ischemia prophylaxis. Tirilazad mesylate studies in out-of-hospital cardiac arrest are currently being planned.

[Emergency respirator therapy in intermediate altitude with the Ambu Matic]. / Notfallrespiratortherapie in mittlerer Höhenlage mit dem Ambu Matic.

Portable emergency ventilators are commonly used in a pre-hospital setting in the transport of critically ill patients also in hypobaric environments. The aim of our trial was to evaluate the influence of moderate altitude at 2700 m compared to 171 m altitude on minute ventilation and blood gas analysis in healthy volunteers during mechanical ventilation with the Ambu Matic ventilator. At 2700 m altitude, the delivered minute volume increased by 13.8%. paCO2 decreased by 9.2% (p < 0.01 for all reported changes). No statistical change in paO2 at 2700 m altitude was observed. These changes are of sufficient magnitude and importance to require monitoring of minute volume to prevent volutrauma or barotrauma.

Lethal Waterhouse-Friderichsen syndrome in posttraumatic asplenia.

We herein report a case of fulminant lethal Waterhouse-Friderichsen syndrome in an elderly female patient seven years after posttraumatic splenectomy. In contrast to various reports, this patient had not been vaccinated against Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae, respectively, although infections with these microorganisms are known to cause the main lethal diseases in asplenic patients. Again, we recommend obligatory vaccinations against the mentioned bacteria for it is known that this decreases the risk of fatal septic events in these patients. To optimize prevention, it is imperative to vaccinate patients undergoing splenectomy before discharge from hospital.

Patient performance level during inpatient physical rehabilitation: therapist, nurse, and patient perspectives.

A study was undertaken to contrast the perspectives among rehabilitation nurses, physical therapists, and occupational therapists in their ratings of patient mobility and self-care capabilities. Staff members rated every patient (n = 66) whose stay on a physical rehabilitation inpatient unit ended within a specified three-month period. Considerable divergence of views was found in all six areas rated, with nurses rating patients at admission as significantly less independent than did the therapists. This difference remained in the ratings at discharge in four of the six areas. Additionally, those patients able to be interviewed (n = 53) were surveyed as to the degree to which they saw progress (or deterioration) during their stay. Correlations between these patient ratings and change ratings by the staff were not statistically significant. The findings suggest the need for additional communication among the various disciplines, as well as between staff members and patients, to work toward a consensus view of the rehabilitation process.