Annals of emergency medicine
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Randomized Controlled Trial Comparative Study Clinical Trial
Randomized study of epinephrine versus methoxamine in prehospital ventricular fibrillation.
Experimental data suggest that a pure alpha-agonist, such as methoxamine, may improve the outcome of patients in ventricular fibrillation. A double-blind, randomized, prospective study was conducted in a paramedic system comparing the use of methoxamine with epinephrine in enhancing conversion of ventricular fibrillation while otherwise following American Heart Association protocols. One hundred two patients in ventricular fibrillation not responding to initial defibrillations with a pulsatile rhythm were randomized into one of two groups, each containing 51 patients. ⋯ Conversion rate, defined as the percentage of patients who developed a pulse during resuscitation, was 27.5% for the methoxamine group and 49.0% for the epinephrine group (P less than or equal to .03). Successful resuscitation, defined as the conveyance of a patient to an emergency department with a pulse and rhythm, was 17.7% for the methoxamine group and 39.2% for the epinephrine group (P less than or equal to .02). Save rate, defined as the percentage of patients discharged alive after hospitalization, was 7.8% for the methoxamine group and 19.6% for the epinephrine group (P less than or equal to .07).(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Access to emergency departments: a survey of HMO policies.
An unresolved question related to the practice of health maintenance organizations' (HMOs) controlling access to medical care is whether such screening of patients seeking emergency department treatment impairs efficient patient care or endangers patients. A preliminary study was undertaken to determine whether so-called gatekeeping of access to EDs was common practice. Medical directors of HMOs in 39 states and the District of Columbia were surveyed by a mail questionnaire to assess policies regarding ED access. ⋯ Thirty-nine percent of the 98 respondents limited their members to using the EDs of certain hospitals only. Ninety-four of 98 (96%) reviewed all ED visits prior to making any payment. We discuss here the implications of these gatekeeping policies.
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We conducted a retrospective study of the interventions performed by physicians in 191 transfers by our pediatric critical care transport team. Currently, the team always includes a pediatrician or pediatric resident, a pediatric emergency department nurse, and a pediatric respiratory therapist. Procedures performed during transport were divided into those done only by physicians in our institution and those also performed by nurses or respiratory therapists. ⋯ In 91% of the transports, no procedures were performed that required a physician. In 66%, no medications were used that required physician presence. In at least 46%, the physician believed his expertise was not required for the transport's success.(ABSTRACT TRUNCATED AT 250 WORDS)
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We determined the frequency of certain disagreeable physical characteristics (presence of vomitus, dentures, blood and/or alcohol on the breath) of a cardiac arrest patient and the effect these characteristics have on a bystander's willingness to perform CPR. Data were collected prospectively on 121 nontraumatic cardiac arrest patients, of whom 35 received bystander-initiated CPR involving a total of 42 bystanders. Seventy-one (59%) patients had one or more disagreeable characteristics identified. ⋯ No bystander interviewed indicated hesitancy in performing CPR when encountering disagreeable characteristics. Seven bystanders stated they felt inadequately prepared to handle patients who vomited. Because of the high incidence of disagreeable characteristics, notably vomitus, in patients suffering a cardiac arrest, specific training in handling such characteristics seems justified.