DC shock? I want my blankie!

Posted on February 4, 2010 by Cliff Reid

A blanket made of nonconducting material was used to allow CPR to continue during defibrillation of arrested swine. Coronary perfusion pressure was maintained when the blanket was used

but fell when there was a hands-off interruption for defibrillation. Also, the defibrillation threshold was significantly lower when the blanket was used. A good idea, although even the authors point out that “Thus far, medical literature has not reported any rescuer or bystander serious injury from receiving an inadvertent shock while in direct or indirect contact with a patient while performing CPR“

The resuscitation blanket: A useful tool for “hands-on” defibrillation
Resuscitation. 2010 Feb;81(2):230-23

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Precordial thump

Posted on February 4, 2010 by Cliff Reid

The precordial thump is recommended for witnessed and monitored ventricular fibrillation/ventricular tachycardia (VF/VT) cardiac arrest when a defibrillator is not immediately available.

Haman et al investigated the precordial thump in patients in whom VT or VF was initiated during an electrophysiological study, applying a single thump after initiation of ventricular arrhythmia in 155 patients. This terminated the tachycardia in two (1.3%) patients.

Pellis et al investigated the precordial thump as an initial measure by paramedics in 144 patients in out-of-hospital cardiac arrest, irrespective of the initial rhythm. Three patients had return of spontaneous circulation and two were discharged alive.

Precordial thump efficacy in termination of induced ventricular arrhythmias
Resuscitation 2009;80:14–6

Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study
Resuscitation 2009;80:17–23

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Naloxone in cardiac arrest

Posted on February 4, 2010 by Cliff Reid

Previous case reports and animal studies have suggested a possible role for naloxone in cardiac arrest even in the absence of opioid overdose.

Possible mechanisms include reducing the myocardial depressant effect of endogenous opioids, stimulating catecholamine release, and providing antiarryhthmic effects through an effect on cardiomyocyte ion channels.

A retrospective review of 32,544 out of hospital cardiac arrests over 5 years revealed 36 to have received pre-hospital naloxone. Of these, only one survived to hospital discharge, who tested positive for opiates in a urine toxicology screen in the emergency department.

No need to change the guidelines yet then.

Naloxone in cardiac arrest with suspected opioid overdoses
Resuscitation. 2010 Jan;81(1):42-6

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Thoracostomy in blunt traumatic arrest

Posted on December 21, 2009 by Cliff Reid

37 patients with blunt traumatic cardiac arrest underwent attempted resuscitation by a HEMS crew over a four year period. Chest decompression was performed in 18 cases (17 thoracostomy, one needle decompression). The procedure revealed evidence of chest injury in 10 cases (pneumothorax, haemothorax, massive air leak) and resulted in return of circulation and survival to hospital in four cases. All four cases died of associated major head injury, although one became a heart beating organ donor. Only half of the cases found to have pneumothorax demonstrated clinical signs of one prior to chest decompression.
The authors state: ‘Relying on clinical signs of the thorax alone will not identify all patients with these injuries, and our data support extending the practice into all patients with a suitable mechanism of injury together with external evidence of chest injury.’
Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest
Emerg Med J. 2009 Oct;26(10):738-40

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Not such a B.I.G. success in the field?

Posted on December 21, 2009 by Cliff Reid

Success rates with the bone injection gun were 71% (10 out of 14) in children <16 years and 73% (19 out of 26) in adults. Less encouraging data than that seen with the EZ-IO device, and consistent with the experience of some other services.

Prehospital Intraosseus Access With the Bone Injection Gun by a Helicopter-Transported Emergency Medical Team
J Trauma. 2009 Jun;66(6):1739-41

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Ballistic penetrating neck injury and the risk of immobilisation

Posted on December 21, 2009 by Cliff Reid

British military physicians reported the outcomes of patients sustaining penetrating neck injury from the Iraq and Afghanistan conflicts. Three quarters were injured in explosions, one quarter from gunshots.

Of 90 patients, only 1 of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. The authors conclude that penetrating ballistic trauma to the neck is associated with a high mortality rate, and their data suggest that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk, and cervical collars may hide potential life-threatening conditions.

Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma
Injury. 2009 Dec;40(12):1342-5

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Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury

Posted on December 21, 2009 by Cliff Reid

Patients admitted to a level 1 trauma centre with traumatic brain injury whose end-tidal CO2 was kept with the Brain Trauma Foundation recommended limits of 30-35 mmHg (3.9-4.6 kPa) had a lower mortality than those whose CO2 was outside this range. The group in which the target was not achieved had a greater injury severity, which may have contribute to the difficulty in optimising ETCO2.

Prehospital Hypocapnia and Poor Outcome After Severe Traumatic Brain Injury
J Trauma. 2009 Jun;66(6):1577-82

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No benefit from drugs in pre-hospital cardiac arrest

Posted on December 17, 2009 by Cliff Reid

A Norwegian randomised controlled trial over five years compared out-of-hospital nontraumatic cardiac arrest outcomes between ACLS protocols with and without access to intravenous drugs (epinephrine/adrenaline, atropine, amiodarone).

Patients randomised to the drug group had a higher rate of hospital admission with return of spontaneous circulation, but there was no significant difference in survival to discharge, survival with favourable neurological outcome, or one year survival.

Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest
JAMA. 2009 Nov 25;302(20):2222-9

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Characteristic ECG signs of LAD occlusion without ST elevation

Posted on December 14, 2009 by Cliff Reid

In a single centre observational study over 10 years of patients undergoing acute PCI of the left anterior descending (LAD) artery, 35 of 1890 (2%) had a distinct non-ST elevation ECG pattern.

The ECG showed ST-segment depression at the J-point of at least 1 mm in the precordial leads with upsloping ST-segments continuing into tall, symmetrical T-waves. Patients also showed a mean J-point elevation of approximately 0.5 mm in lead aVR.

This novel ECG pattern resolved after reperfusion in all included patients.

The authors caution that these electrocardiographic changes may be missed or misdiagnosed as reversible ischaemia, which might substantially delay the transportation to a PCI centre or the start of reperfusion therapy

The authors conclude: “It is important for cardiologists and emergency care physicians to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy.”

Image from Dr Smith's ECG Blog

Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion
Heart. 2009 Oct;95(20):1701-6

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Is cervical spine protection always necessary following penetrating neck injury?

Posted on December 10, 2009 by Cliff Reid

This short cut review in the Best Bets format attempted to answer the question: “is cervical spine protection always necessary following penetrating neck injury?”

From the available evidence they draw the following conclusions:

  1. In stab wounds to the neck (with or without neurological deficit) an unstable spinal injury is very unlikely and c-spine immobilisation is not needed
  2. In gunshot wounds the value of cspine immobilisation is limited: for gunshot wounds without neurological deficit no immobilisation is required, while in cases of gunshot wounds with neurological deficit, or where the diagnosis cannot be made (ie, altered mental status), a collar or sandbag is advised once ABCs are stable, with close observation and intermittent removal to inspect and reassess.
  3. In the rare event of penetrating injury with combined blunt force trauma, a collar or sandbag is advised if possible, once ABCs are stable, with intermittent removal to reassess.

Emerg Med J. 2009 Dec;26(12):883-7

Full text at BestBets.org

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