Search

Introduction: Telephone-cardiopulmonary resuscitation (CPR) advice aims to increase the quality and quantity of bystander CPR, one of the few interventions shown to improve outcome in cardiac arrest. We evaluated a current paediatric telephone protocol (AMPDS v11.1) to assess the effectiveness of verbal CPR instructions in paediatric cardiac arrest., Methods: Consecutive emergency calls classified by the AMPDS as cardiac arrests in children <8 years old, over an 11 month period, were compared with their corresponding patient report forms (PRFs) to confirm the diagnosis. Audio recordings and PRFs were then evaluated to assess whether bystander CPR was given, and when it was, the time taken to perform CPR interventions, before paramedic arrival., Results: Of the 42 calls reviewed, 19 (45.2%) were confirmed as cardiac arrest. CPR was already underway in two cases (10.5%). Of the remaining callers, 11 (64.7%) agreed to attempt T-CPR, resulting in an overall bystander-CPR rate of 68.4%. The median time to open the airway was 126s (62-236s, n=11), deliver the first ventilation was 180s (135-360s, n=11), and perform the first chest compression was 280s (164-420s, n=9)., Conclusion: Although current telephone-CPR instructions improve the numbers of children in whom bystander CPR is attempted, effectiveness is likely to be limited by the significant delays in actually delivering basic life support.

Introduction: Traditionally, anaesthetists have provided airway management skills on resuscitation teams. Because advanced life support (ALS) courses teach practical airway management, some UK hospitals have dropped anaesthetists from cardiac arrest teams. Does the ALS course give non-anaesthetists adequate skills to manage an airway during a cardiac arrest?, Methods: We recruited adult surgical patients undergoing general anaesthesia and laryngeal mask airway (LMA) insertion as part of their routine care. Patients were randomly assigned to airway management by a junior doctor; either an ALS-qualified anaesthetist or an ALS-qualified non-anaesthetist. After induction of anaesthesia, five manual ventilations were delivered using a self-inflating bag-mask device before insertion of a LMA. We recorded the quality of manual ventilation (adequate, partially adequate or inadequate), the time to LMA insertion, and any complications., Results: Twenty anaesthetists and 16 non-anaesthetist ALS graduates participated. Of the anaesthetists, 18 (90%) demonstrated adequate and 2 (10%) demonstrated partially adequate manual ventilation skills, compared with non-anaesthetists of whom 5 (31.25%) demonstrated adequate, 5 (31.25%) demonstrated partially adequate, and 6 (37.5%) demonstrated inadequate manual ventilation skills (p<0.001). Eighteen anaesthetists (90%) and 4 non-anaesthetists (25%) met the ALS LMA insertion guideline time of 30s (p<0.0001). Median time for LMA insertion by anaesthetists and non-anaesthetists was 20.5s (range 16-40s, n=20) and 35.0 s (range 18-168, n=10) respectively (p<0.05). Six of the 16 non-anaesthetists failed to insert the LMA (37.5%). There were four complications (laryngospasm, vomiting, and SaO(2)<90%) in the non-anaesthetic group (25% of patients), compared with none in the anaesthetic group (p=0.01)., Conclusions: The airway component of an ALS course alone does not give adequate practical skills for non-anaesthetists to manage an airway in an anaesthetised patient. Airway management at a cardiac arrest is unlikely to be any better., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Ambulance paramedics are now trained routinely in advanced airway skills, including tracheal intubation. Initial training in this skill requires the insertion of 25 tracheal tubes, and further ongoing training is attained through clinical practice and manikin-based practice. In contrast, training standards for hospital-based practitioners are considerably greater, requiring approximately 200 tracheal intubations before practice is unsupervised. With debate growing regarding the efficacy of paramedic intubation, there is a need to assess current paramedic airway practice in order to review whether initial training and maintenance of skills provide an acceptable level of competence with which to practice advanced airway skills., Methods: All ambulance patient report forms (anonymised) for the period 1 January 2007 to 31 December 2007 were reviewed, and data relating to airway management were collected. Paramedic and technician identification codes were used to determine the number of airway procedures undertaken on an individual basis., Results: Of the 269 paramedics, 128 (47.6%) had undertaken no intubation and 204 (75.8%) had undertaken one or less intubation in the 12-month study period. The median number of intubations per paramedic during the 12-month period was 1.0 (range 0-11). A total of 76 laryngeal mask insertion attempts were recorded by 41 technicians and 30 paramedics. The median number of laryngeal mask insertions per paramedic/technician during the 12-month period was 0 (range 0-2). A survey of ongoing continuing professional development across all ambulance trusts demonstrated no provision for adequate training to compensate for the lack of clinical exposure to advanced airway skills., Conclusion: Paramedics use advanced airway skills infrequently. Continuing professional development programmes within ambulance trusts do not provide the necessary additional practice to maintain tracheal intubation skills at an acceptable level. Advanced airway management delivered by ambulance crews is likely to be inadequate with such infrequent exposure to the skill.

Introduction: Sequential monophasic defibrillation reduces transthoracic impedance (TTI) and progressively increases current flow for any given energy level. The effect of sequential biphasic shocks on TTI is unknown. We therefore studied patients undergoing elective cardioversion using a biphasic waveform to establish whether this is a phenomenon seen in the clinical setting., Methods: Adults undergoing elective DC cardioversion for atrial flutter or fibrillation received sequential transthoracic shocks using an escalating protocol (70J, 100J, 150J, 200J, and 300J) with a truncated exponential biphasic waveform. TTI was calculated through the defibrillator circuit and recorded electronically. Successful cardioversion terminated further defibrillation shocks., Results: A total of 58 patients underwent elective cardioversion. Cardioversion was successful in 93.1% patients. First shock TTI was 92.2 [52.0-126.0]Omega (n=58) and decreased significantly with each sequential shock. Mean TTI in patients receiving five shocks (n=5) was 85.0Omega., Conclusion: Sequential biphasic defibrillation decreases TTI in a similar manner to that seen with monophasic waveforms. The effect is likely during defibrillation during cardiac arrest by the quick succession in which shocks are delivered and the lack of cutaneous blood flow which limits the inflammatory response. The ability of biphasic defibrillators to adjust their waveform according to TTI is likely to minimise any effect of these findings on defibrillation efficacy.

Clinical diagnosis in pre-hospital care is challenging. It aims to identify life-threatening pathology that requires immediate treatment prior to evacuation to hospital. This case report present two elderly patients injured in a road traffic accident who presented with signs consistent with acute life-threatening pathology. Subsequent investigations in hospital revealed that in both patients, the underlying pathology was secondary to chronic malignancy and not as a result of any injury sustained during the accident. The importance of past medical history and the incidence of co-morbidity in relation to pre-hospital care are discussed.

Introduction: Bystander cardiopulmonary resuscitation (CPR) has been shown to significantly improve outcome in sudden cardiac arrest in children. In view of this, most emergency medicine services deliver telephone instructions for carrying out CPR to laypeople who call the emergency services. Little is known as to whether laypeople carrying out these instructions deliver effective CPR., Methods: Adult volunteers who had no previous experience of CPR were recruited. They were presented with a scenario and asked to perform CPR for 3 min on a training manikin according to the instructions they were given by telephone. Tidal volume, compression rate and depth, time to the beginning of CPR and hand positioning were recorded., Results: Fifty-five volunteers were recruited; three were excluded (two had previous CPR training and one refused to perform CPR). None of the subjects identified correctly that the manikin was not breathing and achieved a level of CPR performance that was consistent with all of the current guidelines. Median tidal volume of rescue breaths was 38 mL. Only 23% of subjects delivered rescue breaths of optimal volume (40-50 mL) and 23% delivered no effective breaths at all. Chest compressions were performed at a median rate of 95 min(-1) with 37% delivering compressions at the optimum rate of 90-110 min(-1)., Conclusion: None of our volunteers performed telephone-CPR at a level consistent with current guidelines. Further investigation is necessary to determine whether the instructions can be improved to optimise CPR performance.

This case report describes the first reported successful UK pre-hospital thoracotomy performed outside the London HEMS system. Continuous ECG monitoring during the procedure has allowed presentation of sequential ECGs recorded during the procedure.

Introduction: The need for rescue breaths in bystander CPR has been questioned after several studies have shown that omitting ventilation does not worsen outcome. Chest compression may produce passive tidal volumes large enough to provide adequate ventilation in animal studies, but no recent clinical studies have examined this phenomenon. We measured passive ventilation during optimal chest compression to determine whether compression-only CPR provides adequate gas exchange during cardiac arrest., Methods: Adult cardiac arrest patients were treated according to European Resuscitation Council guidelines. Chest compressions were performed using a mechanical chest compression device (LUCAS) with active decompression disabled to mimic manual compression. Respiratory variables were measured during periods of compression-only CPR., Results: Emergency Department data were collected during compression-only CPR from 17 patients (11 male) aged 47-82 years who had suffered an out-of-hospital cardiac arrest. Median tidal volume per compression was 41.5 ml (range 33.0-62.1 ml), being considerably less than measured deadspace in all patients. Maximum end-tidal CO2 was 0.93 kPa (range 0.0-4.6 kPa). Minute volume CO2 was 19.5 ml (range 15.9-33.8; normal range 150-180 ml)., Conclusions: At an advanced stage of cardiac arrest, passive ventilation during compression-only CPR is limited in its ability to maintain adequate gas exchange, with gas transport mechanisms associated with high frequency ventilation perhaps generating a very limited gas exchange. The effectiveness of passive ventilation during the early stages of CPR, when chest and lung compliance is greater, remains to be investigated.

Introduction: Supplementary oxygen is used routinely during cardiopulmonary resuscitation (CPR). High ambient oxygen levels from ventilation circuits have caused fatal fires and explosions. The Lund University Cardiopulmonary Assist System (LUCAS) device is driven by > 70 l min(-1) oxygen which is also likely to increase ambient oxygen concentrations and cause similar risk of fire and explosion. This study used simulated CPR with a LUCAS device to measure resulting ambient oxygen concentrations and assess safety of the device., Material and Methods: Simulated manikin CPR using a LUCAS device was performed outdoors, inside an ambulance (ventilation off and ventilation on full power), and in a resuscitation bay. Ambient oxygen concentrations were measured over the apical and sternal defibrillation sites and midway between the two, at the head and 1m horizontally above the head. Recordings were made for 5 min when the LUCAS device was turned on and for a further 5 min when turned off., Results: Ambient oxygen concentration increased quickly in all four scenarios. Peak oxygen levels over the chest were highest in the resuscitation bay (36.7%) and lowest in the ambulance with ventilation on full power (33.8%). Oxygen levels decreased to baseline within 5 min of turning off the LUCAS device., Conclusion: The use of oxygen to drive the LUCAS device results in a rapid increase in ambient oxygen concentration to levels likely to risk injury or death from fire. Ambulance services and hospitals using the device must be alerted to these dangers immediately.

Prehospital cervical spine (c-spine) immobilisation is common, despite c-spine injury being relatively rare. Unnecessary immobilisation results in a significant burden on limited prehospital and emergency department (ED) resources. This study aimed to determine whether the incidence of unnecessary c-spine immobilisation by ambulance personnel could be safely reduced through the implementation of an evidence-based algorithm. Following a training programme, complete forms on 103 patients were identified during the audit period, of which 69 (67%) patients had their c-spines cleared at scene. Of these, 60 (87%) were discharged at scene, with no clinical adverse events reported, and 9 (13%) were taken to the local ED with non-distracting minor injuries, all being discharged home the same day. 34 (33%) patients could not have their c-spines safely cleared at scene according to the algorithm. Of these, 4 (12%) patients self-discharged at scene and 30 (88%) were conveyed to an ED as per the normal procedure. C-spine clearance at scene by ambulance personnel may have positive impacts on patient care, efficient use of resources and cost to healthcare organisations.

Introduction: Telephone cardiopulmonary resuscitation (CPR) advice aims to increase the quality and quantity of bystander CPR, one of the few interventions shown to improve outcome in cardiac arrest. We evaluated a current telephone protocol (based on 2000 ILCOR guidelines) to assess the effectiveness of verbal CPR instructions., Methods: Emergency calls were identified from AMPDS codes for cardiac arrest and checked against the ambulance patient record form to confirm the diagnosis. Calls over a seven month period were analysed retrospectively, and the time taken to perform interventions calculated., Results: 176 calls were analysed; of those 145 (82.4%) were confirmed cases of cardiac arrest. CPR was already underway in 11 cases (7.5%), 101 callers (69.7%) agreed to attempt CPR with telephone instructions. The median time to open the airway was 128s (62-482s), to perform the first ventilation was 247s (80-633s), and to perform the first chest compression was 315s (153-750s). Of those attempting CPR, 21 (20.8%) stopped because they were unable to move the patient onto a hard surface, and 28 (27.7%) required multiple attempts to perform effective ventilations. In the telephone CPR group 42/101 (40.6%) did not receive any chest compressions before the arrival of the ambulance crew., Conclusions: Although current telephone-CPR instructions significantly improve the numbers of patients in whom bystander CPR is attempted, significant delays and poor quality CPR are likely to limit any benefits.

Introduction: Defibrillation of patients connected to medical equipment that is not defibrillation proof risks ineffective defibrillation and harm to the operator as a result of aberrant electrical pathways taken by the defibrillation current. Many renal dialysis systems are not currently defibrillation proof. Although national and international safety standards caution against defibrillating under this circumstance, it appears to be an area of confusion that we have investigated in more detail., Methods: Thirty renal dialysis units across the UK were invited to participate in a telephone survey of current practice from 1 October 2004 to 1 October 2005. The Medical Healthcare Regulatory Agency and renal dialysis machine manufacturers were contacted for advice, and current safety standards were reviewed., Results: Twenty-eight renal dialysis units completed the survey. Seven (25%) units would not disconnect patients from dialysis equipment during defibrillation, collectively reporting 14 patients who had required defibrillation during dialysis. Eighteen (64.3%) units would disconnect patients from dialysis equipment during defibrillation, collectively reporting 29 patients who had required defibrillation during dialysis. No complications were identified by this survey, through the MHRA or through a literature search., Conclusion: Defibrillation of patients while undergoing renal dialysis is common practice in the UK. Although no adverse events have been reported, this practice risks injury to the patient and clinical staff, and equipment damage if the dialysis equipment is not defibrillation proof. It is in breach of national and international safety standards and should not be practiced.

Background: Prompt ambulance attendance is aimed at improving patient care. With finite resources struggling to meet performance targets, unforeseen demand precludes the ability to tailor resources to cope with increased call volumes, and can have a marked detrimental effect on performance and hence patient care. The effects of the 2006 World Cup football matches on call volumes and profiles were analysed to understand how public events can influence demands on the ambulance service., Methods: All emergency calls to the Hampshire Ambulance Service NHS Trust (currently the Hampshire Division of South Central Ambulance Service, Winchester, UK) during the first weekend of the 2006 World Cup football matches were analysed by call volume and classification of call (call type)., Results: On the day of the first football match, call volume was over 50% higher than that on a typical Saturday, with distinct peaks before and after the inaugural match. Call profile analysis showed increases in alcohol-related emergencies, including collapse, unconsciousness, assault and road traffic accidents. The increase in assaults was particularly marked at the end of each match and increased again into the late evening., Conclusion: A detailed mapping of call volumes and profiles during the World Cup football shows a significant increase in overall emergency calls, mostly alcohol related. Mapping of limited resources to these patterns will allow improved responses to emergency calls.

Introduction: Hyperventilation during cardiopulmonary resuscitation is detrimental to survival. Several clinical studies of ventilation during hospital and out-of-hospital cardiac arrest have demonstrated respiratory rates far in excess of the 10 min(-1) recommended by the ERC. We observed detailed ventilation variables prospectively during manual ventilation of 12 cardiac arrest patients treated in the emergency department of a UK Hospital., Methods: Adult cardiac arrest patients were treated according to ERC guidelines. Ventilation was provided using a self-inflating bag. A COSMOplus monitor (Respironics Inc.) was inserted into the ventilation circuit at the beginning of the resuscitation from which ventilation data were downloaded to a laptop., Results: Data were collected from 12 patients (7 male; age 47-82 years). The maximum respiratory rate was 9-41 breaths per minute (median 26). The median tidal volume was 619 ml (374-923 ml) and the median respiratory rate was 21 min(-1) (7-37 min(-1)). The corresponding median minute volume was 13.0 l/min (4.6-21.3 min(-1)). Median peak inspiratory pressures were 60.6 cmH(2)O (range 46-106). Airway pressure was positive for 95.3% of the respiratory cycle (range 87.9-100%)., Conclusions: Hyperventilation was common, mostly through high respiratory rates rather than excessive tidal volumes. This is the first study to document tidal volumes and airway pressures during resuscitation. The persistently high airway pressures are likely to have a detrimental effect on blood flow during CPR. Guidelines on respiratory rates are well known, but it would appear that in practice they are not being observed.

Introduction: Bystander cardiopulmonary resuscitation (CPR) significantly improves the outcome from sudden cardiac arrest (SCA) and is therefore encouraged by offering telephone instructions to the bystander. The effectiveness of this technique was examined in a manikin-based study., Methods: Subjects performed CPR on an instrumented adult manikin by following Advanced Medical Priority Dispatch System v11.1 (AMPDS) instructions given by telephone from a different room., Results: Fifty-one volunteers (26 males, median age 56, range 27-76 years) with no previous experience of CPR were recruited. No volunteers followed the entire instructions correctly. Forty percent were unable to open the airway, only 18% achieved a median inspiration time of 2 s or greater and only 30% delivered tidal volumes within the range 700-1000 ml. Chest compressions were performed at a median rate of 52 min-1 with only 4% of subjects achieving a rate of 100 min-1. Depth of compression was also inadequate in 88% of subjects and hand positioning was incorrect in a third of subjects. The median duty cycle was 46% and there were significant delays between the commencement of the AMPDS protocol and the delivery of the first breath (123 s) and first chest compression (163 s)., Discussion: Few bystanders perform CPR satisfactorily and further work is necessary to improve the effectiveness of telephone CPR instructions.

Introduction: Current Advanced Medical Priority Dispatch System (AMPDS) V.11.1 telephone instructions are limited in their ability to produce correctly performed basic life support. The current telephone instructions were modified in an attempt to improve areas of poor CPR performance., Methods: Fifty subjects performed CPR on an instrumented adult manikin by following instructions modified from AMPDS V.11.1 instructions. Instructions were given by telephone from a different room., Results: No improvements were seen with opening the airway or delivering rescue breaths. The rate of chest compression improved from 52 to 81 min-1 (P=0.004), although the depth of chest compression fell to 2.0 cm compared with 3.2 cm documented with the original AMPDS instructions (P=0.004). Instructions to put the telephone down while performing CPR improved all aspects of CPR., Discussion: The effective delivery of telephone-directed CPR to untrained bystanders is a complex process. Changing verbal instructions to improve the quality of CPR is not easy. Further work is urgently needed to strengthen this important link in the chain of survival.

Objective: Cutaneous burns are a common cause of morbidity following direct current (DC) cardioversion. We designed a prospective randomised double-blinded controlled study to determine the effect of biphasic or monophasic waveform on the pain and inflammation occurring after elective cardioversion., Materials and Methods: One hundred and thirty nine patients undergoing elective DC cardioversion were randomised to receive monophasic (HP Codemaster XL; 100, 200, 300, 360, and 360 J) or biphasic (Welch Allyn-MRL PIC defibrillator; 70, 100, 150, 200, and 300 J) waveforms. Two hours after DC cardioversion, skin temperature, erythema index and sensory threshold to light and sharp touch was measured at the centre and edge of paddle sites. Visual analogue pain score (VAS) was recorded at 2 and 24 h., Results: There was significantly less pain following biphasic cardioversion as assessed by VAS at both 2 h (p < 0.001; 95% confidence intervals of difference of medians (CI) 0.2-0.8 cm) and 24 h (p = 0.004; 95% CI 0.0-0.4 cm). There was significantly less erythema in patients receiving biphasic cardioversion at the edge of the sternal site (p = 0.046; 95% CI 0.41-4.5). There was no difference in any other variable at any site between biphasic and monophasic cardioversion., Conclusion: The use of a biphasic waveform for DC cardioversion reduces the inflammation and pain of burns as measured by erythema index and visual analogue scale.

Objective: Biphasic waveforms have similar or greater efficacy at cardioverting atrial and ventricular arrhythmias at lower energy levels than monophasic waveforms, and cause less ST depression following defibrillation of ventricular fibrillation. No studies have investigated this effect on ST change with atrial arrhythmias. We studied the efficacy of the Welch Allyn-MRL PIC biphasic defibrillator., Methods: One hundred and thirty-nine patients undergoing elective DC cardioversion for atrial arrhythmias were randomised to cardioversion by monophasic (Hewlett Packard Codemaster XL; 100, 200, 300, 360 and 360J) or biphasic (Welch Allyn-MRL PIC; 70, 100, 150, 200 and 300J) defibrillator. We analysed success of cardioversion after 0 and 30min, cumulative energy, number of shocks and energy at successful cardioversion. The ST change in the recorded electrocardiogram was measured at 15s after all shocks using electronic callipers., Results: Immediately after cardioversion 59/68 (86.8%) of the monophasic group versus 56/60 (93.3%) of the biphasic group were in sinus rhythm. Of the monophasic group, 55/67 (82.1%) remained in sinus rhythm at 30min versus 53/58 (91.4%) of the biphasic group. These differences were not significant at 0min (P=0.35) or 30min (P=0.21). The biphasic group required significantly fewer shocks (P=0.006), less cumulative energy (P<0.0001) and required lower total energy for successful cardioversion (P<0.0001). Of the 102 patients with electrocardiogram recordings suitable for analysis, ST segment change was greater in the monophasic group (P=0.037)., Conclusions: The Welch Allyn-MRL biphasic waveform for DC cardioversion results in fewer shocks, with less cumulative energy delivered and less post shock ST change than with a Hewlett Packard Codemaster XL damped sine wave monophasic waveform.

Introduction: The National Service Framework for Coronary Heart Disease requires identification of patients with an acute coronary syndrome (ACS) to enable prompt identification of those who may subsequently require pre-hospital thrombolysis. The Advanced Medical Priority Dispatch System (AMPDS) with Department of Health (DH) call prioritisation is now the common triage tool for emergency ('999') calls in the UK. We retrospectively examined patients with ACS to identify whether this triage tool had been able to allocate an appropriate emergency response., Methods: All emergency calls to Hampshire Ambulance Service NHS Trust (HAST) from the Southampton area over an 8 month period (January to August 2004) were analysed. The classification allocated to the patient by AMPDS (version 10.4) was specifically identified. Data from the Myocardial Infarct National Audit Project) were obtained from the receiving hospital in Southampton to identify the actual number of patients with a true ACS., Results: In total, 42 657 emergency calls were made to HAST from the Southampton area. Of these, 263 patients were subsequently diagnosed in hospital as having an ACS. Of these 263 patients, 76 presented without chest pain. Sensitivity of AMPDS for detecting ACS in this sample was 71.1% and specificity 92.5%. Positive predictive value was 5.6% (95% confidence interval 4.8 to 6.4%), and 12.5% (33/263) of patients with confirmed ACS were classified as non-life threatening (category B) incidents., Conclusion: Only one of approximately every 18 patients with chest pain has an ACS. AMPDS with DH call prioritisation is not a tool designed for clinical diagnosis, and its extension into this field does not enable accurate identification of patients with ACS.

Introduction: Compared with monophasic defibrillation, biphasic defibrillation is associated with less myocardial stunning and earlier activation of sodium channels. We therefore hypothesised that earlier sodium channel activation would result in earlier restoration of the first sinus beat following elective DC cardioversion., Methods: Adults undergoing elective DC cardioversion were randomised to receive either monophasic or biphasic escalating transthoracic shocks. The ECG was recorded electronically during defibrillation and the time from delivery of the shock to restoration of the first sinus beat, measured from the beginning of the 'P' wave, was calculated., Results: Seventy four patients were studied. Data were unavailable from 18 patients. There was no demographic difference between groups. Median time to the first sinus beat following monophasic defibrillation (n=25) was 3.66 s (95% CI 2.55-4.61 s) and following biphasic defibrillation (n=33) was 2.21s (95% CI 1.76-2.56 s; P

Venous access and fluid therapy should still be considered to be essential elements of pre-hospital advanced life support (ALS) in the critically injured patient. Initiation of fluid therapy should be based on a clinical assessment, most importantly the presence, or otherwise, of a radial pulse. The goal in penetrating injury is to avoid hypovolaemic cardiac arrest during transport, but at the same time not to delay transport, or increase systolic blood pressure. The goal in blunt injury is to secure safe perfusion of the injured brain through an adequate cerebral perfusion pressure, which generally requires a systolic blood pressure well above 100 mmHg. Patients without severe brain injury tolerate lower blood pressures (hypotensive resuscitation). Importantly, using systolic blood pressure targets to titrate therapy is not as easy as it seems. Automated (oscillometric) blood pressure measurement devices frequently give erroneously high values. The concept of hypotensive resuscitation has not been validated in the few studies done in humans. Hence, the suggested targeted systolic blood pressures should only provide a mental framework for the decision-making. The ideal pre-hospital fluid regimen may be a combination of an initial hypertonic solution given as a 10-20 minutes infusion, followed by crystalloids and, in some cases, artificial colloids. This review is intended to help the clinician to balance the pros and cons of fluid therapy in the individual patient.

Introduction: Cutaneous burns are a common cause of morbidity following direct current (DC) cardioversion. We designed a prospective double-blinded controlled study to determine whether the application of steroid cream prior to cardioversion reduces their incidence and severity., Materials and Methods: Two hours before elective DC cardioversion, we applied betamethasone 0.1% cream or placebo cream over sternal and apical pad sites in 56 patients, with patients acting as their own controls. Two hours after cardioversion, a separate blinded observer measured the visual analogue pain score (VAS), sensory and pain detection thresholds, skin temperature and erythema index at sternal and apical pad sites., Results: The study had an 80% power to detect a 50% difference in VAS at 2 h, accepting an alpha error of 0.05. There was no difference between pain at 2 or 24 h, skin temperature, erythema index, sensory and pain detection thresholds at pad sites treated with steroid cream or control., Conclusion: Topical betamethasone 0.1% cream applied 2 h before elective DC cardioversion is no more effective than placebo at reducing the pain and inflammation from cardioversion burns.

Introduction: Cutaneous burns are a common cause of morbidity following direct current (DC) cardioversion. We designed a study to determine whether the application of non-steroidal anti-inflammatory cream prior to cardioversion reduces their incidence and severity., Materials and Methods: Two hours before elective DC cardioversion, we randomised 55 patients to receive ibuprofen 5% cream or placebo cream over sternal and apical pad sites, with patients acting as their own controls. Two hours after cardioversion an independent blinded observer measured skin temperature, erythema index, and minimum sensory and pain detection thresholds at sternal and apical pad sites. Visual analogue pain score (VAS) for each site was recorded at 2 h and 24 h post-cardioversion., Results: There was a statistically significant difference between pain measured by VAS, skin temperature and pain detection threshold measured at pad sites with pre-applied ibuprofen 5% cream and those with pre-applied aqueous cream, after elective DC cardioversion., Conclusion: Prophylactic application of topical ibuprofen 5% cream 2h prior to elective DC cardioversion reduces pain and inflammation. Consideration should be given to use of prophylactic application of topical ibuprofen as routine treatment for elective DC cardioversion.

Background: The transfusion of allogeneic red blood cells and allogeneic coagulation products is associated with risk to the patient and the depletion of an increasingly scarce resource. This prospective, randomized, double-blind, placebo-controlled trial investigated practices to avoid transfusion in patients undergoing first-time cardiac surgery., Methods: Patients were randomized to one of three treatment groups: an aprotinin group, a tranexamic acid group, and a control group receiving normal saline. Intra-operative cell salvage was used for all patients. The primary outcomes were the number of patients exposed to allogeneic red blood cells, allogeneic coagulation products or any allogeneic transfusion (allogeneic red blood cells and/or allogeneic coagulation products)., Results: Patients were 2.5 times more likely to receive any allogeneic transfusion in the tranexamic group than in the aprotinin group (21 patients out of 60 compared with nine out of 60, respectively). The relative risk of any allogeneic transfusion comparing aprotinin with tranexamic acid was 0.43 (95% confidence interval 0.21-0.86; P=0.019). Patients in the control group were four times more likely to receive any allogeneic transfusion when compared with the aprotinin group (37 patients out of 60 compared with nine out of 60, respectively). The relative risk of any allogeneic transfusion comparing aprotinin with control was 0.24 (95% confidence interval 0.13-0.46; P<0.001)., Conclusions: When used in addition to intra-operative cell salvage, aprotinin is the most efficacious pharmacological therapy for reducing patient exposure to any allogeneic transfusion during first-time cardiac surgery.

Objectives: The recent introduction of a disposable laryngeal mask airway has provided paramedics with an alternative to endotracheal intubation. Time taken to secure the airway with each device was compared in patients undergoing elective surgery., Methods: Patients undergoing general anaesthesia were studied. Paramedics trained in laryngeal mask use and endotracheal intubation participated in the study. A Portex disposable laryngeal mask was inserted and removed, followed by a Portex endotracheal tube. Time taken from beginning of the procedure to ventilation of the patient was recorded., Results: Laryngeal mask insertion and endotracheal intubation was attempted on 52 patients. Median age was 63.5 years (range 39-83). Laryngeal mask insertion was successful in 88.5% (46 of 52) patients; endotracheal intubation was successful in 71.2% (37 of 52) patients (after no more than two attempts), p = 0.049. Intubation success was related to laryngoscopic view (87.5% grade 1, 56.3% grade 2, 0.0% grade 3. p<0.0001). When laryngeal mask/endotracheal tube insertion were both successful (n = 35 of 52), there was no significant difference in median time to secure the airway (laryngeal mask 47.0 seconds (range 24-126) compared with endotracheal tube 52.0 seconds (range 27-148) p = 0.22). Laryngeal mask insertion was successful in 80.0% (12 of 15) patients in whom endotracheal intubation had failed., Conclusions: Even under optimal conditions, 30% of attempts at intubation by paramedics were unsuccessful. A disposable laryngeal mask has a higher success rate in securing the airway and overall, secures the airway more reliably than endotracheal intubation.

Introduction: Firm paddle force during defibrillation lowers transthoracic impedance (TTI) and increases transmyocardial current, increasing the chances of successful cardioversion. Current protocols recommend that if defibrillation using the anterior-apical (AA) paddle position fails, the anterior-posterior (AP) position should be used. This generally requires the patient to be placed in the left lateral position with the operator leaning over the patient. Avoiding physical contact with the patient during defibrillation subjectively makes application of firm paddle force difficult in the AP position. We compared TTI between the AA and AP positions and between manual paddles and self-adhesive pads to establish if the AP position precludes firm paddle force and to compare TTI between paddles and self-adhesive pads., Methods: Twenty-one consecutive patients undergoing elective cardioversion (age 39-82) were studied. TTI was measured between pairs of manually held paddles and self-adhesive pads using AA placement with the patient supine, and AP placement with the patient left lateral position., Results: Mean TTI using the AP electrode position was lower using manual paddles (66.5 Omega; 95% CI 60.2-72.9 Omega) than that using self-adhesive pads (92.1 Omega; 95% CI 81.5-102.7 Omega; 95% CI between the mean =15.8-35.5 Omega; P <0.0001). TTI was significantly less using the manual paddles compared with self-adhesive pads in both AA and AP positions (P <0.0001)., Conclusion: Despite the subjective difficulties of defibrillating patients in the AP position whilst leaning over them, use of manual paddles achieves a lower TTI than that achieved with self-adhesive pads.

Objectives: Most emergency department (ED) intubations are to prevent gastric contents aspiration. The incidence of aspiration is unknown and intubation has complications. Balancing these risks requires an idea of the incidence of aspiration. This study assessed one technique for investigating the aspiration risk in ED patients. Cricoid pressure is used to reduce this risk and the technique may also examine this manoeuvre., Methods: Cohorts of unconscious adult ED and elective surgical patients were recruited. The posterior pharyngeal wall pH was measured immediately before and after intubation. Pharyngeal pH was used to indicate risk of aspiration, and pH change to assess the efficacy of cricoid pressure., Results: Eight ED and 48 control patients were recruited. In the ED cohort, pH ranged from 6.0 to 8.0 before intubation and 4.7 to 8.0 after intubation: a mean decrease of 0.3 (95% CI 1.5 decrease to 0.9 increase). In the control cohort pH ranged from 5.8 to 8.0 before intubation and 6.0 to 8.0 after intubation: a mean increase of 0.4 (95% CI 0.1 to 0.6 increase)., Conclusions: This is a simple, cheap, and repeatable technique for assessing aspiration risk in emergency intubations. A larger study is required to assess the efficacy of cricoid pressure.

Background: End-tidal carbon dioxide (Petco2) concentration is a marker of the pathophysiologic state because it is a reflection of cardiac output. Petco2 correlates with outcome after prehospital primary cardiac arrest, but association with outcome from prehospital trauma has not been established., Methods: Between 1998 and 2001, Petco2 was recorded in 191 blunt trauma patients requiring prehospital intubation. Rapid sequence intubation was performed using suxamethonium (1 mg/kg) and etomidate (0.2-0.3 mg/kg). Initial Petco2 after endotracheal intubation (t0) and Petco2 at 20 minutes after endotracheal intubation (t20) were recorded, together with survival to discharge., Results: Median Petco2 at t20 was 4.10 kPa in survivors and 3.50 kPa in nonsurvivors (95% confidence interval of difference between medians, 0.40 to 0.90 kPa; p < 0.0001). Petco2 at t20 was a better predictor of outcome than at t0., Conclusion: Only 5% patients with Petco2 < 3.25 kPa survived to discharge. Petco2 at t20 is of value in predicting outcome from major trauma.

Introduction: Cutaneous burns are a common cause of morbidity following direct current (DC) cardioversion, but the incidence and severity have never been quantified., Materials and Methods: Two hours after elective DC cardioversion in 83 sequential patients, we measured skin temperature, erythema index, and minimum sensory and pain detection thresholds at paddle sites and control sites on the contralateral side. Visual analogue pain score (VAS) was recorded at 2 and 24h post-cardioversion., Results: Values for areas over paddle sites were higher (P < 0.05) than control site for all variables measured at 2h. Eighty-four percent patients experienced some pain and 23% patients experienced moderate to severe pain as assessed by VAS. Burns were greater at the edge than the centre of sternal sites and greater at sternal than apical sites. There were positive correlations between transthoracic impedance (TTI) and total energy delivered (r(2) = 0.048; P = 0.04); total energy and pain at 2 h (r(2) = 0.38; P < 0.0001) and 24 h (r(2) = 0.23; P < 0.0001); and number of shocks and pain at 2 h (r(2) = 0.36; P < 0.0001) and 24 h (r(2) = 0.19; P < 0.0001)., Conclusion: Elective DC cardioversion causes burns as measured by skin temperature, erythema index and sensory threshold to sharp touch. Pain experienced is related to the total energy and number of shocks delivered. To reduce burns, operators should apply optimal paddle force equally to both paddles, with the paddles applied so as to provide even contact along their edges. Burns may also be minimised by starting with lower energy shocks.

Background: Two mechanisms by which firm external paddle force decreases transthoracic impedance (TTI) have been proposed. Decreased impedance at the paddle-skin interface has been assumed to be the primary mechanism, but expulsion of air from the lungs, reducing lung volume is also likely to contribute. The relative contribution of each mechanism is unknown., Methods and Results: Thirty five intubated patients undergoing general anaesthesia for cardiac surgery were studied. TTI across external defibrillation paddles was measured as paddle force was increased to 12kgf. Measurements were performed twice; once allowing the volume of the lungs to change and once with lung volume held at functional residual capacity. TTI with constant lung volume was significantly higher at (P< 0.001), confirming that a reduction in lung volume contributes to the decrease in TTI. At an optimal paddle force of 8kg, the reduction in lung volume contributed to 16.2% of the overall decrease in TTI., Conclusion: The decrease in TTI seen with increasing external paddle force is due primarily to improved electrical contact at the paddle-skin interface, with a decrease in thoracic volume accounting for no more than 16% of the overall decrease at forces used clinically.