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1.
Crit Care ; 23(Suppl 1): 149, 2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31200777

RESUMO

Catecholamines are used to increase cardiac output and blood pressure, aiming ultimately at restoring/improving tissue perfusion. While intuitive in its concept, this approach nevertheless implies to be effective that regional organ perfusion would increase in parallel to cardiac output or perfusion pressure and that the catecholamine does not have negative effects on the microcirculation. Inotropic agents may be considered in some conditions, but it requires prior optimization of cardiac preload. Alternative approaches would be either to minimize exposure to vasopressors, tolerating hypotension and trying to prioritize perfusion but this may be valid as long as perfusion of the organ is preserved, or to combine moderate doses of vasopressors to vasodilatory agents, especially if these are predominantly acting on the microcirculation. In this review, we will discuss the pros and cons of the use of catecholamines and alternative agents for improving tissue perfusion in septic shock.


Assuntos
Catecolaminas/efeitos adversos , Perfusão/normas , Pressão Arterial/fisiologia , Débito Cardíaco/efeitos dos fármacos , Catecolaminas/farmacologia , Catecolaminas/uso terapêutico , Humanos , Microcirculação/efeitos dos fármacos , Perfusão/métodos , Perfusão/tendências , Ressuscitação/métodos , Ressuscitação/tendências
2.
Physiol Res ; 68(4): 675-679, 2019 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-31177801

RESUMO

Chemokine (C-X-C motif) receptor 4 (CXCR4) agonists have been shown to protect lung endothelial barrier function in vitro. In vivo effects of CXCR4 modulation on lung endothelial permeability are unknown. Here we tested the effects of the CXCR4 agonist ubiquitin and the antagonist AMD3100 on lung vascular permeability and cytokine concentrations in a rat hemorrhage model. Animals were hemorrhaged (mean arterial blood pressure 30 mmHg for 30 min), treated with vehicle, ubiquitin (0.7 and 3.5 µmol/kg) or AMD3100 (3.5 µmol/kg), and resuscitated with crystalloids. Evans blue extravasation was employed to quantify lung vascular permeability. Ubiquitin dose-dependently reduced Evans blue extravasation into the lung. AMD3100 increased Evans blue extravasation. With AMD3100, TNFalpha levels in lung homogenates were increased; while TNFalpha levels were lower with ubiquitin, these differences did not reach statistical significance. Our findings suggest that CXCR4 regulates lung vascular permeability and further point towards CXCR4 as a drug target to confer lung protection during resuscitation from traumatic-hemorrhagic shock.


Assuntos
Permeabilidade Capilar/fisiologia , Receptores CXCR4/fisiologia , Mucosa Respiratória/metabolismo , Ressuscitação , Choque Hemorrágico/metabolismo , Choque Hemorrágico/terapia , Animais , Permeabilidade Capilar/efeitos dos fármacos , Relação Dose-Resposta a Droga , Compostos Heterocíclicos/farmacologia , Mediadores da Inflamação/antagonistas & inibidores , Mediadores da Inflamação/metabolismo , Masculino , Ratos , Ratos Sprague-Dawley , Receptores CXCR4/agonistas , Receptores CXCR4/antagonistas & inibidores , Mucosa Respiratória/efeitos dos fármacos , Ressuscitação/tendências , Ubiquitina/farmacologia
3.
Emerg Med J ; 36(6): 364-368, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30940715

RESUMO

Resuscitation lacks a place in the hospital to call its own. Specialised intensive care units, though excellent at providing longitudinal critical care, often lack the flexibility to adapt to fluctuating critical care needs. We offer the resuscitative care unit as a potential solution to ensure that patients receive appropriate care during the most critical hours of their illnesses. These units offer an infrastructure for resuscitation and can meet the changing needs of their institutions.


Assuntos
Unidades de Terapia Intensiva/tendências , Ressuscitação/métodos , Centros Médicos Acadêmicos/organização & administração , Medicina de Emergência/métodos , Planejamento Ambiental/normas , Planejamento Ambiental/tendências , Humanos , Unidades de Terapia Intensiva/organização & administração , Maryland , Michigan , Pennsylvania , Ressuscitação/tendências
4.
Crit Care ; 23(1): 124, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30992045

RESUMO

The mainstay of hemodynamic treatment of septic shock is fluid resuscitation followed by vasopressors where fluids alone are insufficient to achieve target blood pressure. Norepinephrine, a catecholamine, is the first-line vasopressor used worldwide but given that all routinely used catecholamines target the same adrenergic receptors, many clinicians may add a non-catecholamine vasopressor where refractory hypotension due to septic shock is present. However, the timing of this additional intervention is variable. This decision is based on three key factors: availability, familiarity, and safety profile. In our opinion, further consideration should be potential vasopressor response because following appropriate volume resuscitation, the response to different vasopressor classes is neither uniform nor predictable. Critically ill patients who are non-responders to high-dose catecholamines have a dismal outcome. Similarly, patients have a variable response to non-catecholamine agents including vasopressin and angiotensin II: but where patients exhibit a blood pressure response the outcomes are improved over non-responders. This variable responsiveness to vasopressors is similar to the clinical approach of anti-microbial sensitivity. In this commentary, the authors propose the concept of "broad spectrum vasopressors" wherein patients with septic shock are started on multiple vasopressors with a different mechanism of action simultaneously while the vasopressor sensitivity is assessed. Once the vasopressor sensitivities are assessed, then the vasopressors are 'de-escalated' accordingly. We believe that this concept may offer a new approach to the treatment of septic shock.


Assuntos
Ressuscitação/métodos , Choque Séptico/tratamento farmacológico , Fatores de Tempo , Vasoconstritores/uso terapêutico , Catecolaminas/uso terapêutico , Humanos , Norepinefrina/uso terapêutico , Ressuscitação/tendências
5.
J Clin Neurophysiol ; 36(5): 349-357, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31033654

RESUMO

PURPOSE: We aimed to determine which early EEG features and feature combinations most accurately predicted short-term neurobehavioral outcomes and survival in children resuscitated after cardiac arrest. METHODS: This was a prospective, single-center observational study of infants and children resuscitated from cardiac arrest who underwent conventional EEG monitoring with standardized EEG scoring. Logistic regression evaluated the marginal effect of each EEG variable or EEG variable combinations on the outcome. The primary outcome was neurobehavioral outcome (Pediatric Cerebral Performance Category score), and the secondary outcome was mortality. The authors identified the models with the highest areas under the receiver operating characteristic curve (AUC), evaluated the optimal models using a 5-fold cross-validation approach, and calculated test characteristics maximizing specificity. RESULTS: Eighty-nine infants and children were evaluated. Unfavorable neurologic outcome (Pediatric Cerebral Performance Category score 4-6) occurred in 44 subjects (49%), including mortality in 30 subjects (34%). A model incorporating a four-level EEG Background Category (normal, slow-disorganized, discontinuous or burst-suppression, or attenuated-flat), stage 2 Sleep Transients (present or absent), and Reactivity-Variability (present or absent) had the highest AUC. Five-fold cross-validation for the optimal model predicting neurologic outcome indicated a mean AUC of 0.75 (range, 0.70-0.81) and for the optimal model predicting mortality indicated a mean AUC of 0.84 (range, 0.76-0.97). The specificity for unfavorable neurologic outcome and mortality were 95% and 97%, respectively. The positive predictive value for unfavorable neurologic outcome and mortality were both 86%. CONCLUSIONS: The specificity of the optimal model using a combination of early EEG features was high for unfavorable neurologic outcome and mortality in critically ill children after cardiac arrest. However, the positive predictive value was only 86% for both outcomes. Therefore, EEG data must be considered in overall clinical context when used for neuroprognostication early after cardiac arrest.


Assuntos
Eletroencefalografia/métodos , Parada Cardíaca/diagnóstico , Parada Cardíaca/fisiopatologia , Criança , Pré-Escolar , Estado Terminal/terapia , Eletroencefalografia/mortalidade , Eletroencefalografia/tendências , Feminino , Parada Cardíaca/mortalidade , Humanos , Lactente , Masculino , Prognóstico , Estudos Prospectivos , Ressuscitação/métodos , Ressuscitação/mortalidade , Ressuscitação/tendências , Resultado do Tratamento
6.
Curr Opin Anaesthesiol ; 32(2): 163-168, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817389

RESUMO

PURPOSE OF REVIEW: Sepsis-3 guidelines have implications in a deeper understanding of the biopathology of the disease. Further, the review focuses on timely topics and new literature on fluid resuscitation, the value of steroids in sepsis, and new therapeutic options such as angiotensin II, vitamin C, and thiamine as well as the emerging role of procalcitonin (PCT) in managing antibiotics. RECENT FINDINGS: Traditional therapies such as type of crystalloid fluid administration and steroid therapy for sepsis are currently under re-evaluation. Angiotensin II is investigated for reversing vasodilatory shock. The role of capillary endothelium leak and cellular metabolism can be affected by vitamin C and thiamine levels. Biomarker level trends, specifically PCT, can aid clinical suspicion of infection. SUMMARY: Sepsis-3 shifts the focus from a noninfectious inflammatory process and an emphasis on a dysregulated host response to infection. Hyperchloremic crystalloid resuscitation is associated with poor clinical outcomes. Steroid administration can reverse shock physiology; however, mortality benefits remain uncertain. Angiotensin II, vitamin C, and thiamine are novel treatment options that need further validation. PCT assays can help discern between infectious and noninfectious inflammation.


Assuntos
Cuidados Críticos/normas , Hidratação/normas , Ressuscitação/normas , Sepse/terapia , Angiotensina II/uso terapêutico , Antibacterianos/uso terapêutico , Ácido Ascórbico/uso terapêutico , Biomarcadores/sangue , Terapia Combinada/métodos , Terapia Combinada/normas , Terapia Combinada/tendências , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Hidratação/métodos , Hidratação/tendências , Glucocorticoides/uso terapêutico , Humanos , Guias de Prática Clínica como Assunto , Pró-Calcitonina/sangue , Ressuscitação/métodos , Ressuscitação/tendências , Sepse/diagnóstico , Sepse/mortalidade , Tiamina/uso terapêutico , Resultado do Tratamento
7.
Pediatrics ; 143(2)2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30602545

RESUMO

BACKGROUND AND OBJECTIVES: Avoidance of delivery room intubation (DRI) reduces death or bronchopulmonary dysplasia (BPD) in preterm neonates. Our objective with this quality improvement project was to decrease DRI rates by improving face mask positive pressure ventilation (Fm-PPV) among infants born ≤29 weeks' gestation. METHODS: Key drivers of change were identified from a retrospective review of resuscitation records. A resuscitation bundle to optimize Fm-PPV including the use of a small round mask and end-tidal CO2 detectors, increasing peak inspiratory pressure when indicated, and debriefing after each intubation were implemented in consecutive plan-do-study-act cycles. The DRI rate was tracked by using a control chart. Resuscitation practice and outcomes of pre-quality improvement cohort (QIC) (January 2014-September 2015) were compared with post-QIC (October 2015-December 2016). RESULTS: Of the 314 infants who were resuscitated, 180 belonged to the pre-QIC and 134 to the post-QIC. The antenatal steroid administration rate was higher in the post-QIC (54% vs 88%). More infants in the post-QIC had resolution of bradycardia after Fm-PPV (56% vs 77%, P = .02). Infants in the post-QIC had lower DRI rates (58% vs 37%, P < .01), lower need for mechanical ventilation (85% vs 70%, P < .01), lower rates of BPD (26% vs 13%, P < .01), and severe retinopathy of prematurity (14% vs 5%, P = .01). Rates of DRI, BPD, and severe retinopathy of prematurity remained lower even after controlling for the potential confounders. CONCLUSIONS: Implementation of a resuscitation bundle decreased the DRI rate and improved outcomes of preterm infants.


Assuntos
Salas de Parto/normas , Recém-Nascido Prematuro/fisiologia , Melhoria de Qualidade/normas , Ressuscitação/normas , Adulto , Displasia Broncopulmonar/diagnóstico , Displasia Broncopulmonar/epidemiologia , Displasia Broncopulmonar/terapia , Estudos de Coortes , Salas de Parto/tendências , Feminino , Humanos , Recém-Nascido , Doenças do Prematuro/diagnóstico , Doenças do Prematuro/epidemiologia , Doenças do Prematuro/terapia , Masculino , Gravidez , Melhoria de Qualidade/tendências , Ressuscitação/métodos , Ressuscitação/tendências , Estudos Retrospectivos
8.
Arch Dis Child Fetal Neonatal Ed ; 104(3): F324-F325, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30355782

RESUMO

BACKGROUND: Previous surveys have demonstrated that neonatal resuscitation practices on the delivery suite vary between UK units, particularly according to the hospital's neonatal unit's level. Our aim was to determine if recent changes to the Resuscitation Council guidelines had influenced clinical practice. METHODS: Surveys of resuscitation practices at UK delivery units carried out in 2012 and 2017 were compared. RESULTS: Comparing 2017 with 2012, initial resuscitation using air was more commonly used in both term (98% vs 75%, p<0.001) and preterm (84% vs 34%, p<0.001) born infants. Exhaled carbon dioxide monitoring was more frequently employed in 2017 (84% vs 19%, p<0.001). There were no statistically significant differences in practices according to the level of neonatal care provided by the hospital. CONCLUSION: There have been significant changes in neonatal resuscitation practices in the delivery suite since 2012 regardless of the different levels of neonatal care offered.


Assuntos
Salas de Parto/tendências , Assistência Perinatal/tendências , Ressuscitação/tendências , Salas de Parto/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal/normas , Unidades de Terapia Intensiva Neonatal/tendências , Monitorização Fisiológica/métodos , Monitorização Fisiológica/normas , Monitorização Fisiológica/tendências , Assistência Perinatal/métodos , Assistência Perinatal/normas , Guias de Prática Clínica como Assunto , Prática Profissional/normas , Prática Profissional/tendências , Ressuscitação/métodos , Ressuscitação/normas , Medicina Estatal/normas , Medicina Estatal/tendências , Reino Unido
11.
F1000Res ; 72018.
Artigo em Inglês | MEDLINE | ID: mdl-30416707

RESUMO

Effective mask ventilation is an essential skill for any practitioner engaged in airway management. Recent methods to objectively describe mask ventilation using waveform capnography help practitioners to monitor and communicate the effectiveness of mask ventilation. Gentle mask ventilation is now considered acceptable during rapid sequence induction/intubation after loss of consciousness, hence reducing the incidence of hypoxia prior to tracheal intubation. Mask ventilation can be enhanced with muscle relaxation, a double C-E grip, and jaw thrust. This is particularly relevant for patients with reduced apnoea time. An awareness of the complications associated with mask ventilation may help reduce the morbidity associated with this technique. Effective ventilation technique and optimum device selection are important aspects for resuscitation of the newborn. Teaching correct establishment and maintenance of mask ventilation is essential for safe patient care. This review will examine some of the latest developments concerning mask ventilation for adult and paediatric patients.


Assuntos
Manuseio das Vias Aéreas/métodos , Máscaras , Ventilação/métodos , Adulto , Manuseio das Vias Aéreas/tendências , Criança , Humanos , Máscaras/efeitos adversos , Máscaras/tendências , Guias de Prática Clínica como Assunto , Ressuscitação/educação , Ressuscitação/métodos , Ressuscitação/tendências , Ventilação/normas
12.
Mil Med ; 183(suppl_2): 92-97, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-30189054

RESUMO

Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.


Assuntos
Ressuscitação/métodos , Toracotomia/métodos , Humanos , Escala de Gravidade do Ferimento , Militares , Ressuscitação/tendências , Estudos Retrospectivos , Análise de Sobrevida , Toracotomia/tendências , Guerra
13.
Mil Med ; 183(suppl_2): 172-179, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-30189074

RESUMO

Highly skilled swimmers and aquatically adaptable service members such as U.S. Navy Divers, Sea, Air and Land (SEAL) Teams, and Explosive Ordnance Disposal (EOD) technicians, die every year from drowning. Drowning is the cause of over 500,000 deaths annually across the globe. This Clinical Practice Guideline (CPG) provides an overview of drowning and associated conditions based on the best available current medical evidence. Unlike basic life support and advanced cardiac life support protocols, rescue breathing should be initiated prior to chest compressions to re-expand water-filled alveoli. These guidelines should be used as a standardized framework to guide first responders, prehospital emergency medical service personnel, and medical department personnel in evaluating, diagnosing, and managing common in water pathologies.


Assuntos
Afogamento/prevenção & controle , Ressuscitação/métodos , Gerenciamento Clínico , Afogamento/epidemiologia , Afogamento/fisiopatologia , Serviços Médicos de Emergência/métodos , Guias como Assunto , Humanos , Edema Pulmonar/etiologia , Ressuscitação/tendências , Natação/lesões , Água/efeitos adversos
14.
World Neurosurg ; 118: e166-e174, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29959068

RESUMO

OBJECTIVE: Patients from contemporary populations with traumatic brain injury (TBI) resulting from epidural hematoma (EDH) may differ regarding age, comorbidities, and coagulation status. We therefore analyzed predictors for the clinical outcome of patients with EDH treated surgically regarding modern approaches to resuscitation and trauma care. METHODS: A retrospective observational analysis was carried out. All patients included underwent surgery. The indication for surgery followed international guidelines. Retrospective data evaluation considered data reflecting the effectiveness of trauma care, baseline characteristics, and radiologic findings. In this analysis, we divided patients into 2 groups (isolated EDH vs. EDH plus other intracranial traumatic injuries). The neurologic outcome was assessed at discharge using the Glasgow Outcome Scale. RESULTS: Two hundred and sixty-eight patients with epidural hematoma, of whom 131 underwent surgery, were treated between January 1997 and December 2012 in our level-1 trauma center. The overall mortality was 6.8% (mortality for patients with Glasgow Outcome Scale score <9, 15%). As expected, factors with a highly significant (P < 0.01) impact on outcome were concomitant with other intracranial injuries, brain midline shift, and higher Injury Severity Score. Alcohol intoxication was a significant (P < 0.05) predictor of an unfavorable outcome. Anticoagulants and Glasgow Coma Scale score at admission had no significant impact on the outcome. CONCLUSIONS: The outcome for EDH is more favorable than decades ago, most probably reflecting a well-established chain of trauma care. Therefore, EDH is a treatable disease with a high probability of a favorable outcome.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Lesões Encefálicas Traumáticas/cirurgia , Hematoma Epidural Craniano/diagnóstico por imagem , Hematoma Epidural Craniano/cirurgia , Ressuscitação/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Intoxicação Alcoólica/diagnóstico por imagem , Intoxicação Alcoólica/epidemiologia , Intoxicação Alcoólica/cirurgia , Lesões Encefálicas Traumáticas/epidemiologia , Criança , Pré-Escolar , Feminino , Seguimentos , Escala de Resultado de Glasgow/tendências , Hematoma Epidural Craniano/epidemiologia , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
15.
Physiol Res ; 67(Suppl 1): S199-S214, 2018 06 27.
Artigo em Inglês | MEDLINE | ID: mdl-29947540

RESUMO

Endothelin-1 (ET-1) acts on ET(A) and ET(B) receptors and has been implicated in hemorrhagic shock (shock). We determined effect of shock and resuscitation by hypertonic saline (saline) or centhaquin on ET(A) and ET(B) receptor expression. Rats were anesthetized, a pressure catheter was placed in the left femoral artery; blood was withdrawn from the right femoral artery to bring mean arterial pressure (MAP) to 35 mm Hg for 30 min, resuscitation was performed and 90 min later sacrificed to collect samples for biochemical estimations. Resuscitation with centhaquin decreased blood lactate and increased MAP. Protein levels of ET(A) or ET(B) receptor were unaltered in the brain, heart, lung and liver following shock or resuscitation. In the abdominal aorta, shock produced an increase (140 %) in ET(A) expression which was attenuated by saline and centhaquin; ET(B) expression was unaltered following shock but was increased (79 %) by centhaquin. In renal medulla, ET(A) expression was unaltered following shock, but was decreased (-61 %) by centhaquin; shock produced a decrease (-34 %) in ET(B) expression which was completely attenuated by centhaquin and not saline. Shock induced changes in ET(A) and ET(B) receptors in the aorta and renal medulla are reversed by centhaquin and may be contributing to its efficacy.


Assuntos
Piperazinas/uso terapêutico , Receptores de Endotelina/metabolismo , Ressuscitação/tendências , Choque Hemorrágico/metabolismo , Choque Hemorrágico/terapia , Animais , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Relação Dose-Resposta a Droga , Masculino , Piperazinas/farmacologia , Distribuição Aleatória , Ratos , Ratos Sprague-Dawley
16.
J Emerg Med ; 55(1): 141-142, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29776701

RESUMO

BACKGROUND: Critically ill or injured emergency department or prehospital patients who lack decision-making capacity sometimes present with a non-standard advance directive, such as a "Do Not Resuscitate" tattoo or medallion. Emergency clinicians must immediately address the question of whether to withhold treatment based on what may or may not be a valid patient directive. DISCUSSION: Advance directives have been standardized for a good reason. Emergency department or prehospital healthcare providers must be able to immediately interpret and act on them without needing a legal interpretation. When faced with non-standard directives, physicians can follow them, ignore them, or simply use them as an additional piece of information about the individual's wishes for some situations at one point in his or her life. Absent the patient's input or that of aknowledgeable surrogate, both the patient's initial reasons for their non-standard directive and his or her present wishes concerning resuscitation cannot be independently known. Therefore, healthcare providers must initiate treatment while they buy time, attempt to return the patient to lucidity, and search for probative information regarding their current wishes concerning medical treatment. Without such additional information, the moral weight will always favor initiating treatment, since withholding treatment is often irreversible and any treatment instituted can later be withdrawn.


Assuntos
Diretivas Antecipadas/tendências , Tomada de Decisões , Ressuscitação/ética , Diretivas Antecipadas/ética , Medicina de Emergência/métodos , Medicina de Emergência/tendências , Serviço Hospitalar de Emergência/organização & administração , Humanos , Ressuscitação/tendências , Tatuagem/efeitos adversos , Tatuagem/tendências
17.
J Emerg Med ; 54(4): 487-499.e6, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29501219

RESUMO

BACKGROUND: The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care. OBJECTIVE: We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality. METHODS: We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered. RESULTS: There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08). CONCLUSIONS: We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.


Assuntos
Serviços Médicos de Emergência/normas , Hidratação/normas , Ressuscitação/métodos , Ferimentos Penetrantes/terapia , Adolescente , Adulto , Idoso , Serviços Médicos de Emergência/tendências , Feminino , Hidratação/métodos , Hidratação/tendências , Hemodinâmica/fisiologia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Razão de Chances , Philadelphia , Sistema de Registros/estatística & dados numéricos , Ressuscitação/tendências , Ferimentos Penetrantes/mortalidade
19.
Mil Med ; 183(1-2): e45-e50, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-29401352

RESUMO

Introduction: Hemorrhage is the most common cause of death among Special Operations Force (SOF) soldiers. Bringing remote damage control resuscitation into the far-forward combat environment is logistically challenging, as it requires blood products that generally require a robust cold chain. Alternatively, lyophilized products such as fibrinogen concentrate, which does not require thawing or blood group compatibility testing before use, might be advantageous in damage control resuscitation in the battlefield. In this report, we review the evidence for the use of fibrinogen concentrate in the Canadian SOF environment. Materials and Methods: The literature on the use of fibrinogen concentrate in the trauma setting was reviewed by Canadian Forces Services Working Group, in three separate meetings. Multiple stakeholders were consulted to obtain authoritative perspectives from subject matter experts on the use of fibrinogen concentrate in the Canadian SOF environment. We also conducted a comparison review of fibrinogen content, pathogen risk, shelf life, and methods required for use for fresh frozen plasma, cryoprecipitate, and fibrinogen concentrate relevant to their application in the far-forward combat environment. Results: Indications and a protocol for the use of fibrinogen as an adjunct to fresh whole blood were formulated based on a literature review and clinical expert opinion. Alternative strategies and other lyophilized blood products were considered before selecting fibrinogen concentrate as the lyophilized blood product of choice. Fibrinogen concentrate is an ABO-universal blood product with an excellent safety profile. Training was conducted by subject matter experts within civilian trauma centers and at military training facilities. The clinical efficacy and safety were confirmed by monitoring the use of fibrinogen concentrate in deployed combat settings. Conclusion: Fibrinogen concentrate is a useful adjunct to remote damage control resuscitation in the SOF environment. Fibrinogen concentrate was found to be robust for transport into the SOF environment and is widely accepted among SOF operators and medics.


Assuntos
Fibrinogênio/administração & dosagem , Hemorragia/prevenção & controle , Militares , Ressuscitação/métodos , Guerra/tendências , Canadá , Fibrinogênio/uso terapêutico , Hemorragia/tratamento farmacológico , Humanos , Ressuscitação/tendências
20.
Emerg Med J ; 35(1): 39-45, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28855237

RESUMO

BACKGROUND: The Paediatric Research in Emergency Departments International Collaborative (PREDICT) performs multicentre research in Australia and New Zealand. Research priorities are difficult to determine, often relying on individual interests or prior work. OBJECTIVE: To identify the research priorities of paediatric emergency medicine (PEM) specialists working in Australia and New Zealand. METHODS: Online surveys were administered in a two-stage, modified Delphi study. Eligible participants were PEM specialists (consultants and senior advanced trainees in PEM from 14 PREDICT sites). Participants submitted up to 3 of their most important research questions (survey 1). Responses were collated and refined, then a shortlist of refined questions was returned to participants for prioritisation (survey 2). A further prioritisation exercise was carried out at a PREDICT meeting using the Hanlon Process of Prioritisation. This determined the priorities of active researchers in PEM including an emphasis on the feasibility of a research question. RESULTS: One hundred and six of 254 (42%) eligible participants responded to survey 1 and 142/245 (58%) to survey 2. One hundred and sixty-eight (66%) took part in either or both surveys. Two hundred forty-six individual research questions were submitted in survey 1. Survey 2 established a prioritised list of 35 research questions. Priority topics from both the Delphi and Hanlon process included high flow oxygenation in intubation, fluid volume resuscitation in sepsis, imaging in cervical spine injury, intravenous therapy for asthma and vasopressor use in sepsis. CONCLUSION: This prioritisation process has established a list of research questions, which will inform multicentre PEM research in Australia and New Zealand. It has also emphasised the importance of the translation of new knowledge.


Assuntos
Medicina de Emergência Pediátrica/métodos , Médicos/psicologia , Pesquisa/tendências , Austrália , Técnica Delfos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/tendências , Hidratação/métodos , Hidratação/tendências , Humanos , Nova Zelândia , Medicina de Emergência Pediátrica/tendências , Ressuscitação/métodos , Ressuscitação/tendências , Sepse/terapia , Inquéritos e Questionários
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