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1.
N Engl J Med ; 385(21): 1951-1960, 2021 11 18.
Artigo em Inglês | MEDLINE | ID: mdl-34407339

RESUMO

BACKGROUND: Early administration of convalescent plasma obtained from blood donors who have recovered from coronavirus disease 2019 (Covid-19) may prevent disease progression in acutely ill, high-risk patients with Covid-19. METHODS: In this randomized, multicenter, single-blind trial, we assigned patients who were being treated in an emergency department for Covid-19 symptoms to receive either one unit of convalescent plasma with a high titer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or placebo. All the patients were either 50 years of age or older or had one or more risk factors for disease progression. In addition, all the patients presented to the emergency department within 7 days after symptom onset and were in stable condition for outpatient management. The primary outcome was disease progression within 15 days after randomization, which was a composite of hospital admission for any reason, seeking emergency or urgent care, or death without hospitalization. Secondary outcomes included the worst severity of illness on an 8-category ordinal scale, hospital-free days within 30 days after randomization, and death from any cause. RESULTS: A total of 511 patients were enrolled in the trial (257 in the convalescent-plasma group and 254 in the placebo group). The median age of the patients was 54 years; the median symptom duration was 4 days. In the donor plasma samples, the median titer of SARS-CoV-2 neutralizing antibodies was 1:641. Disease progression occurred in 77 patients (30.0%) in the convalescent-plasma group and in 81 patients (31.9%) in the placebo group (risk difference, 1.9 percentage points; 95% credible interval, -6.0 to 9.8; posterior probability of superiority of convalescent plasma, 0.68). Five patients in the plasma group and 1 patient in the placebo group died. Outcomes regarding worst illness severity and hospital-free days were similar in the two groups. CONCLUSIONS: The administration of Covid-19 convalescent plasma to high-risk outpatients within 1 week after the onset of symptoms of Covid-19 did not prevent disease progression. (SIREN-C3PO ClinicalTrials.gov number, NCT04355767.).

2.
Prehosp Emerg Care ; 25(4): 588-592, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32776812

RESUMO

The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the National Association of EMTs (NAEMT) have previously offered varied guidance on the use of ketamine in trauma patients. The following consensus statement represents the collective positions of the ACS-COT, ACEP, NASEMSO, NAEMSP and NAEMT. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, nurses and pharmacists in their treatment of the trauma patient in both the prehospital and hospital setting.


Assuntos
Serviços Médicos de Emergência , Ketamina , Consenso , Serviço Hospitalar de Emergência , Hospitais , Humanos
3.
BMJ Glob Health ; 5(6)2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32503887

RESUMO

INTRODUCTION: As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation. METHODS: The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time. RESULTS: Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges. CONCLUSIONS: Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.


Assuntos
Diabetes Mellitus , Hipertensão , Brasil/epidemiologia , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/terapia , Índia/epidemiologia , África do Sul/epidemiologia
4.
EClinicalMedicine ; 29-30: 100632, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33437949

RESUMO

Background: We describe implementation, evaluate performance, and report outcomes from the first program serving an entire metropolitan area designed to rapidly deliver extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation to patients with refractory ventricular fibrillation/ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA). Methods: This observational cohort study analyzed consecutive patients prospectively enrolled in the Minnesota Mobile Resuscitation Consortium's ECMO-facilitated resuscitation program. Entry criteria included: 1) adults (aged 18-75), 2) VF/VT OHCA, 3) no return of spontaneous circulation following 3 shocks, 4) automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System (LUCAS™), and 5) estimated transfer time of < 30 min. The primary endpoint was functionally favorable survival to hospital discharge with Cerebral Performance Category (CPC) 1 or 2. Secondary endpoints included 3-month functionally favorable survival, program benchmarks, ECMO cannulation rate, and safety. Essential program components included emergency medical services, 3 community ECMO Initiation Hospitals with emergency department ECMO cannulation sites and 24/7 cardiac catheterization laboratories, a 24/7 mobile ECMO cannulation team, and a single, centralized ECMO intensive care unit. Findings: From December 1, 2019 to April 1, 2020, 63 consecutive patients were transported and 58 (97%) met criteria and were treated by the mobile ECMO service. Mean age was 57 ± 1.8 years; 46/58 (79%) were male. Program benchmarks were variably met, 100% of patients were successfully cannulated, and no safety issues were identified. Of the 58 patients, 25/58 (43% [CI:31-56%]) were both discharged from the hospital and alive at 3 months with CPC 1 or 2. Interpretation: This first, community-wide ECMO-facilitated resuscitation program in the US demonstrated 100% successful cannulation, 43% functionally favorable survival rates at hospital discharge and 3 months, as well as safety. The program provides a potential model of this approach for other communities. Funding: The Helmsley Charitable Trust.

5.
Prehosp Emerg Care ; 23(3): 430-433, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30110189

RESUMO

We report a case of a 56 year old male in ventricular fibrillation (VF) cardiac arrest for a total of 2 hours and 50 minutes who was diagnosed with ST elevation myocardial infarction (STEMI) during a brief 10 min period of return of spontaneous circulation (ROSC). The patient underwent successful percutaneous coronary intervention (PCI) while receiving mechanical chest compressions for ongoing VF. Our case demonstrates the potential for neurologically intact survival in VF cardiac arrest patients despite prolonged periods of VF who are treated with mechanical CPR and intra-arrest PCI.


Assuntos
Reanimação Cardiopulmonar/instrumentação , Desfibriladores , Parada Cardíaca/terapia , Intervenção Coronária Percutânea , Sobrevida , Serviços Médicos de Emergência , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST , Fatores de Tempo , Resultado do Tratamento , Fibrilação Ventricular/terapia
6.
Prehosp Emerg Care ; 21(5): 567-574, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28418753

RESUMO

STUDY OBJECTIVE: Invasively monitoring blood pressure through the IO device has not been thoroughly demonstrated. This study attempted to establish baseline values of IO pressure in a healthy human population. METHODS: This was a prospective, healthy volunteer, observational study. Participants had two IO devices placed (humerus and tibia), and participant IO pressures, vital signs, and pain scores were monitored for up to 60 minutes. Participants were contacted at 24-hours and 7 days post-testing to assess for adverse events. Summary statistics were calculated for systolic, diastolic, and mean humeral and tibial IO pressure. The ratio of IO to non-invasive blood pressure was calculated, and Bland Altman plots were created. The slope (linear) of the mean humeral and the tibial IO pressures were also calculated. RESULTS: Fifteen subjects were enrolled between April and July 2015. Fourteen of 15 humeral IOs were placed successfully (93.3%) and all 15 of the tibial IOs were placed successfully. Mean tibial systolic, diastolic, and mean IO pressure were 55.8 ± 27.9, 49.3 ± 27.1, and 48.4 ± 29.4 mm Hg, respectively. Humeral systolic, diastolic, and mean IO pressure were 32.9 ± 16.0, 27.4 ± 15.2, and 24.5 ± 14.3 mm Hg. The mean tibial IO pressure was 52.5% ± 32.0% of external cuff pressure ratio. The mean humeral IO pressure was 26.5% ± 15.2% of the external mean blood pressure. The Bland Altman plots showed an inconsistent relationship between the systolic and diastolic cuff pressure and the IO pressures. We observed a 1% per minute decrease in IO pressure from the initial placement until the final reading. CONCLUSIONS: Intraosseous pressure readings can be obtained in healthy human volunteers. However, absolute IOP values were not consistent between subjects. Future research may determine how IO pressure can be used to guide therapy in ill and injured patients.


Assuntos
Determinação da Pressão Arterial/métodos , Infusões Intraósseas/métodos , Adulto , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial/efeitos adversos , Serviços Médicos de Emergência/métodos , Feminino , Voluntários Saudáveis , Humanos , Úmero , Infusões Intraósseas/efeitos adversos , Infusões Intraósseas/instrumentação , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Medição da Dor , Estudos Prospectivos , Tíbia , Adulto Jovem
7.
Prehosp Disaster Med ; 31(4): 386-91, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27217077

RESUMO

UNLABELLED: Introduction Traditionally, Emergency Medical Services (EMS) educators have divided the pediatric population into age groups to assist in targeting their clinical and didactic curriculum. Currently, the accrediting body for paramedic training programs requires student exposure to pediatric patients based entirely on age without specifying exposure to specific pathologies within each age stratification. Identifying which pathologies are most common within the different pediatric age groups would allow educators to design curriculum targeting the most prevalent pathologies in each age group and incorporating the physiologic and psychological developmental milestones commonly seen at that age. Hypothesis It was hypothesized that there are unique clusterings of pathologies, represented by paramedic student primary impressions, that are found in different age groups which can be used to target provider education. METHODS: This is a retrospective review of prospectively collected data documented by paramedic students in the Fisdap (Field Internship Student Data Acquisition Project; Saint Paul, Minnesota USA) database over a one-year period. For the purposes of this study, pediatric patients were defined arbitrarily as those between the ages of 0-16 years. All paramedic student primary impressions recorded in Fisdap for patients aged 0-16 years were abstracted. Primary impression by age was calculated and graphed. The frequency of primary impression was then assessed for significance of trend by age with an alpha ≤.05 considered significant. RESULTS: The following primary impressions showed clinically and statistically significant variability in prevalence among different pediatric age groups: respiratory distress, medical-other, abdominal pain, seizure, overdose/poisoning, behavioral, and cardiac. In patients less than 13 years old, respiratory and other-medical were the most common two primary impressions and both decreased with age. In patients 5-16 years old, the prevalence of abdominal pain and behavioral/psych increased. Bimodal distributions for overdose were seen with one spike in the toddler and another in the adolescent population. Seizures were most common in the age group associated with febrile seizure. Sepsis was seen most often in the youngest patients and its prevalence decreased with age. CONCLUSION: There are statistically significant variations in the frequency of paramedic student primary impressions as a function of age in the pediatric population. Emphasizing paramedic student exposure to the most common pathologies encountered in each age group, in the context of the psychological and physiological milestones of each age, may improve paramedic student pediatric practice. Ernest EV , Brazelton TB , Carhart ED , Studnek JR , Tritt PL , Philip GA , Burnett AM . Prevalence of unique pediatric pathologies encountered by paramedic students across age groups. Prehosp Disaster Med. 2016; 31(4):386-391.


Assuntos
Serviços Médicos de Emergência/normas , Auxiliares de Emergência/educação , Medicina de Emergência Pediátrica/normas , Adolescente , Distribuição por Idade , Criança , Pré-Escolar , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Minnesota/epidemiologia , Medicina de Emergência Pediátrica/métodos , Medicina de Emergência Pediátrica/estatística & dados numéricos , Prevalência , Estudos Retrospectivos
8.
Adv Emerg Nurs J ; 38(1): 56-68, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26817431

RESUMO

High influxes of patients during disasters have led to increased incidence of medical errors in emergency departments (EDs), ultimately leading to poor patient outcomes. Nearly 30% of errors committed in EDs are due to deficiencies in knowledge and skills, and between 60% and 70% of errors occur due in part from communication breakdowns. The goal of this project was to examine whether in situ simulation will increase health care providers' knowledge of how to perform during a disaster, improve competency in skills related to those actions, and to improve communication regarding the special circumstances inherent to a disaster in the ED. A mixed-methods pilot project analyzed the effects of in situ simulation. Results of the project demonstrate that in situ simulation can improve knowledge and communication during a disaster situation.


Assuntos
Planejamento em Desastres , Serviço Hospitalar de Emergência/organização & administração , Erros Médicos/prevenção & controle , Treinamento por Simulação , Competência Clínica , Comunicação , Humanos , Inquéritos e Questionários
9.
Am J Emerg Med ; 33(1): 76-9, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25455046

RESUMO

INTRODUCTION: Intramuscular ketamine has become increasingly popular for prehospital chemical restraint of severely agitated or violent patients because of its favorable adverse effect profile, rapid onset, and wide therapeutic window. However, there is currently no literature quantifying the need for intubation or hospital admission for these patients once they reach the emergency department. METHODS: Medical records for patients receiving prehospital ketamine who were transported to a single level 1 trauma center were abstracted. Ketamine dose, patient weight, final disposition, and presence of intubation were recorded. Exclusion criteria were missing dose or weight and ketamine given for an indication other than chemical restraint. Statistical analysis was preformed with unadjusted Student t test. Statistical significance was defined as P < .05. RESULTS: A convenience sample of 51 consecutive patients was identified with 2 excluded because of missing data, leaving 49 for analysis. Ketamine dosing ranged from 2.25 to 9.42 mg/kg (mean, 5.26 ± 1.65 mg/kg). Significant differences were noted between those who required intubation (n = 14) and those who did not (n = 35) (6.16 ± 1.62 mg/kg vs 4.90 ± 1.54 mg/kg, P = .02). No patients were intubated prehospital. There was an increased dose in patients admitted to a medical ward (57%, 28/49) that approached statistical significance (5.62 ± 1.80 vs 4.78 ± 1.31, P = .06). CONCLUSION: Intubation was observed in our emergency department in 29% of patients administered intramuscular ketamine for prehospital chemical restraint. There was a positive association between higher ketamine doses and both endotracheal intubation and hospital admission. Future research should aim to define the minimum effective ketamine dose for successful chemical restraint.


Assuntos
Anestésicos Dissociativos/administração & dosagem , Tratamento de Emergência , Hospitalização/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Ketamina/administração & dosagem , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Injeções Intramusculares , Masculino , Estudos Retrospectivos , Fatores de Risco
11.
Prehosp Emerg Care ; 18(2): 231-8, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24400965

RESUMO

OBJECTIVES: The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. METHODS: This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC™ video laryngoscopes and six King Vision™ (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience. RESULTS: Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices. CONCLUSION: The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.


Assuntos
Manuseio das Vias Aéreas/instrumentação , Competência Clínica , Serviços Médicos de Emergência/estatística & dados numéricos , Auxiliares de Emergência/educação , Intubação Intratraqueal/instrumentação , Laringoscopia/instrumentação , Adulto , Idoso , Manuseio das Vias Aéreas/efeitos adversos , Manuseio das Vias Aéreas/métodos , Estudos Cross-Over , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Auxiliares de Emergência/normas , Auxiliares de Emergência/estatística & dados numéricos , Feminino , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Laringoscopia/efeitos adversos , Laringoscopia/métodos , Masculino , Manequins , Pessoa de Meia-Idade , Estudos Prospectivos , Gravação em Vídeo
12.
Am J Emerg Med ; 32(6): 692.e3-4, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24440591

RESUMO

Venous access is essential to providing emergency care for critically ill or injured patients. Obtaining peripheral or central access can be problematic and time consuming. Intraosseous (IO) fluid administration provides similar flow rates and central circulation times compared to central lines, but use of these devices to monitor blood pressure has not been explored. We report a case of successful IO pressure (IOP) monitoring through an IO during the resuscitation of a 31-year-old male. This is the first report of monitoring IOP in a clinical setting and comparing it to traditional measures of central pressure.


Assuntos
Serviço Hospitalar de Emergência , Infusões Intraósseas/métodos , Monitorização Fisiológica/métodos , Adulto , Pressão Sanguínea , Monitores de Pressão Arterial , Evolução Fatal , Humanos , Masculino , Monitorização Fisiológica/instrumentação , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Parada Cardíaca Extra-Hospitalar/terapia
13.
Air Med J ; 32(2): 93-7, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23452368

RESUMO

INTRODUCTION: This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls. SETTING: Rotor-wing division of a single critical care transportation company METHODS: 53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO2, ETCO2 at 2 minutes after placement, and complications were also analyzed. RESULTS: 38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR = 0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12-46). Pre- and post-insertion SaO(1)2 values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO2 at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patient's airway was the most frequently reported complication (46%). CONCLUSION: Success rates with the King LTS-D were not significantly different from historical control ETI data. Time to placement was comparable to previous reports.


Assuntos
Manuseio das Vias Aéreas/instrumentação , Serviços Médicos de Emergência/métodos , Intubação Intratraqueal/instrumentação , Adolescente , Adulto , Idoso , Resgate Aéreo , Manuseio das Vias Aéreas/métodos , Pessoal Técnico de Saúde , Feminino , Humanos , Intubação Intratraqueal/métodos , Masculino , Manequins , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Tempo para o Tratamento , Recursos Humanos , Adulto Jovem
14.
J Med Toxicol ; 9(2): 172-8, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23494844

RESUMO

New groups of synthetic "designer drugs" have increased in popularity over the past several years. These products mimic the euphoric effects of other well-known illicit drugs but are advertised as "legal" highs and are sold over the internet, at raves and night clubs, and in head shops. The 2C series drugs are ring-substituted phenethylamines that belong to a group of designer agents similar in structure to 3,4-methylenedioxy-N-methylamphetamine (MDMA, Ecstasy). Understanding the pharmacology and toxicology of these agents is essential in order to provide the best medical care for these patients. This review focuses on the pharmacology, pharmacokinetics, clinical effects, and treatment of 2C drug intoxication based on available published literature. Multiple names under which 2C drugs are sold were identified and tabulated. Common features identified in patients intoxicated with 2Cs included hallucinations, agitation, aggression, violence, dysphoria, hypertension, tachycardia, seizures, and hyperthermia. Patients may exhibit sympathomimetic symptoms or symptoms consistent with serotonin toxicity, but an excited delirium presentation seems to be consistent amongst deaths attributed to 2C drugs; at least five deaths have been reported in the literature in patients intoxicated with 2C drugs. 2C drugs are a group of designer intoxicants, many of which are marketed as legal, but may carry risks that consumers are unaware of. These drugs may be characterized by either serotonergic toxicity or a sympathomimetic toxidrome, but a presentation consistent with excited delirium is consistent amongst the reported 2C-related deaths. Treatment of 2C intoxication is primarily supportive, but immediate action is required in the context of excited delirium, hyperthermia, and seizure activity.


Assuntos
Estimulantes do Sistema Nervoso Central/farmacologia , Drogas Desenhadas/farmacologia , Alucinógenos/farmacologia , Fenetilaminas/farmacologia , Animais , Estimulantes do Sistema Nervoso Central/química , Estimulantes do Sistema Nervoso Central/farmacocinética , Estimulantes do Sistema Nervoso Central/toxicidade , Drogas Desenhadas/química , Drogas Desenhadas/farmacocinética , Drogas Desenhadas/toxicidade , Overdose de Drogas/fisiopatologia , Overdose de Drogas/terapia , Febre/etiologia , Febre/prevenção & controle , Alucinógenos/química , Alucinógenos/farmacocinética , Alucinógenos/toxicidade , Humanos , Fenetilaminas/química , Fenetilaminas/farmacocinética , Fenetilaminas/toxicidade
15.
Prehosp Emerg Care ; 17(3): 379-85, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23410104

RESUMO

OBJECTIVES: The primary aims of this study were to determine whether the frequency of placement, type of advanced airway, and settings of advanced airway placement (clinical vs. field) have changed for paramedic students over the last 11 years, and to describe regional differences regarding the same set of variables. METHODS: This study was a retrospective review of prospectively reported airway procedures documented by paramedic students in Fisdap ( http://www.fisdap.net ). Students were included if they graduated from a paramedic program, had procedure entries verified by a preceptor, and provided consent for research. Exclusion criteria included students who had a total number of airway placements ≥2 standard deviations from the mean or had 0 airway placements recorded, and programs with <10 graduating students total over the study period. Airway device types and educational settings were descriptively compared over the 11-year study period by year and region. RESULTS: A total of 8,934 paramedic student records were reviewed, with 2,811 excluded based on a priori criteria, leaving 6,123 records for analysis. In each year, the median number of airway devices placed per student was greater in the clinical setting. Endotracheal intubation (ETI) was more common than alternative airway placement in both the field and clinical settings. The median number of clinical ETIs per student has remained relatively constant at 7. The median number of field ETIs per student ranged from 0 to 1 over the study period, with a median alternative airway placement rate of 0 for both clinical and field settings. For all regions, the majority of procedures were performed in a clinical environment. The median number of clinical alternative airway device placements was 0 for all regions. The number of clinical ETIs ranged from 5 to 11 per student, with the highest number of ETIs per student in the West North Central and New England regions and the lowest in the West South Central and East South Central regions. CONCLUSION: Paramedic students gain the majority of their advanced airway experience in the clinical setting. ETI remains more common than alternative airway placement, although there is significant geographic variation in the number of ETIs per student. High rates of clinical intubations do not correlate with high rates of field intubations.


Assuntos
Manuseio das Vias Aéreas/normas , Auxiliares de Emergência/educação , Medicina de Emergência/educação , Adulto , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos
16.
Am J Emerg Med ; 31(3): 589-92, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23347722

RESUMO

OBJECTIVE: The aim of this study was to compare first-attempt and overall success rates and success rates in relation to placement time among 5 different airway management devices: Storz CMAC, Glidescope GVL, AirTraq, King LTS-D, and direct laryngoscopy (DL). METHODS: Emergency medical technician basic (EMT-B), EMT-paramedics (EMT-P), and emergency medicine residents and staff physicians placed each of the 5 devices in a random order into an AirSim (TruCorp, Belfast, UK) part-task training manikin. The difficult airway scenario was created by fixing the manikin head to a stationary object and introducing simulated emesis into the hypopharynx. First-attempt and overall success and success in relation to placement time were compared. Provider feedback about device performance was also evaluated. RESULTS: Ninety-four providers (16 EMT-basics, 54 EMT-paramedics, and 24 emergency department doctors of medicine) consented to participation. First-attempt and overall success rates for DL, King LTS-D, GVL, and CMAC were not statistically different. Compared with DL, the AirTraq was 96% less likely to be placed successfully (odds ratio, 0.04; 95% confidence interval [CI], 0.01-0.14). When time was factored into the model, the odds of successful placement of the King LTS-D were higher compared with DL (hazard ratio [HR], 1.80; 95% CI, 1.34-2.42) and lower for GVL (HR, 0.59; 95% CI, 0.44-0.80) and AirTraq (HR, 0.228; 95% CI, 0.16-0.325). Providers ranked the CMAC first in terms of performance and preference for use in their practice setting. CONCLUSION: Overall success rates for DL, King-LTS-D, and both video laryngoscope systems were not different. When time was factored into the model, the King LTS-D was more likely to be placed successfully.


Assuntos
Intubação Intratraqueal/instrumentação , Laringoscópios , Adulto , Atitude do Pessoal de Saúde , Competência Clínica , Auxiliares de Emergência , Feminino , Humanos , Intubação Intratraqueal/métodos , Masculino , Manequins , Pessoa de Meia-Idade , Razão de Chances , Médicos , Estudos Prospectivos , Fatores de Tempo
18.
Prehosp Emerg Care ; 16(4): 553-9, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22809253

RESUMO

BACKGROUND: There are no published reports examining the effects that ketamine administered prior to hospital arrival has on patients after their transfer to the emergency department (ED). OBJECTIVE: In order to better understand the risk-benefit ratio for the prehospital use of ketamine, we examined the ED courses of 13 patients to whom emergency medical services (EMS) had administered ketamine for chemical restraint. METHODS: This project was undertaken as part of our EMS system's continuous quality improvement (CQI) process. Data were collected retrospectively. All patients who were given ketamine by EMS providers under our medical direction were identified by prehospital care report queries. The treating paramedic and emergency physician were provided a CQI form after disposition of the patient from their care. The data were tabulated and descriptive statistics were calculated. RESULTS: Thirteen patients were given ketamine by EMS providers, with 13 of 13 having EMS records and 12 of 13 having ED records available for review. Time from ketamine administration to peak sedation was <5 minutes in 11 patients and 20 minutes for two patients. On emergency physician examination, five of 12 patients had Richmond Agitation Sedation Scale (RASS) scores of -5 (unarousable), one of 12 had a RASS score of -4 (deep sedation), four of 12 had RASS scores of -3 (moderate sedation), and two of 12 had RASS scores of -2 (light sedation). Three patients developed hypoxia, two in the ED and one prior to hospital arrival. Two of these patients required intubation and one was treated with jaw thrust. Indications for intubation were recurrent laryngospasm and intracranial bleeding. One additional patient experienced a single episode of hypersalivation, which was successfully treated with suctioning of the oropharynx. Of the nonintubated patients, three of 10 were diagnosed with an emergence reaction and five of 10 required additional sedation. The primary diagnosis on ED disposition was drug/ethanol intoxication (3), psychosis (4), intracranial bleeding (1), seizure (1), suicidal ideation (1), agitation (1), and altered mental status (1). Five patients were discharged from the ED, seven were admitted (two to the intensive care unit, four to medicine, and one to psychiatry), and one patient's disposition was unknown. CONCLUSIONS: In this series of 13 patients, ketamine administered by EMS produced moderate or deeper sedation. Respiratory complications included hypoxia, laryngospasm, and hypersalivation. Emergence reactions occurred in 30% of nonintubated patients, but they were successfully treated with small doses of benzodiazepines.


Assuntos
Anestésicos Dissociativos/administração & dosagem , Serviços Médicos de Emergência/métodos , Serviço Hospitalar de Emergência/organização & administração , Ketamina/administração & dosagem , Adulto , Anestésicos Dissociativos/efeitos adversos , Feminino , Humanos , Intubação Intratraqueal , Ketamina/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
20.
Resuscitation ; 83(8): 1021-4, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22445865

RESUMO

OBJECTIVES: This study examines the effects of IV epinephrine administration on carotid blood flow (CBF) and end tidal CO(2) (ETCO(2)) production in a swine model of active compression-decompression CPR with an impedance threshold device (ACD-CPR+ITD). METHODS: Six female swine (32 ± 1 kg) were anesthetized, intubated and ventilated. Intracranial, thoracic aorta and right atrial pressures were measured via indwelling catheters. CBF was recorded. ETCO(2), SpO(2) and EKG were monitored. V-fib was induced and went untreated for 6 min. Three minutes each of standard CPR (STD), STD-CPR+impedance threshold device (ITD) and active compression-decompression (ACD)-CPR+ITD were performed. At minute 9 of the resuscitation, 40 µg/kg of IV Epinephrine was administered and ACD-CPR+ITD was continued for 1 min. Statistical analysis was performed with a paired t-test. p values of <0.05 were considered statistically significant and all values are reported in mmHg unless otherwise noted. RESULTS: Aortic pressure, cerebral and coronary perfusion pressures increased from STD

Assuntos
Agonistas de Receptores Adrenérgicos alfa 1/efeitos adversos , Reanimação Cardiopulmonar/instrumentação , Epinefrina/efeitos adversos , Parada Cardíaca/terapia , Hemodinâmica/efeitos dos fármacos , Animais , Impedância Elétrica , Feminino , Parada Cardíaca/tratamento farmacológico , Parada Cardíaca/fisiopatologia , Suínos
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