Annals of emergency medicine
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Although endotracheal intubation is still the most definitive technique for airway management in patients with cardiac or respiratory arrest, in some emergency care systems, use of endotracheal intubation by prehospital care personnel has been restricted by policy or statute. Therefore, alternative airway devices have been developed. These alternative airway devices include the Esophageal Obturator Airway (EOA) and Esophageal Gastric Tube Airway (EGTA), the Pharyngeotracheal Lumen Airway (PTL), and the Esophageal-Tracheal Combitube (ETC). ⋯ Therefore, proper training and expert medical supervision probably have more influence on the successful use and impact of these devices than any other factors related to the devices themselves. Future training efforts would be most useful if directed at proper endotracheal intubation training and development of improved basic ventilatory skills. Nevertheless, additional controlled, direct-comparison studies of the PTL and ETC devices are recommended and should be conducted in properly supervised emergency medical services systems.
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Submersion injury is so often lethal because it inflicts severe hypoxia. To prevent hypoxic end-organ damage to the heart and brain, the goals of resuscitation are immediate ventilation and oxygenation. Issue 1: Should submersion victims receive the Heimlich maneuver? The pathophysiologic assumptions for this intervention are that water in the airway is obstructive, thus precluding ventilation, and that aspiration of water is the major injury. ⋯ With inadequate data to support benefit from the Heimlich maneuver and concern that the Heimlich maneuver would delay initiation of ventilation, basic life support procedures are recommended in managing the airway of the submersion victim. Issue 2: What is the role of prehospital care? Outcomes of submersion victims treated with rapid, aggressive prehospital care show that the window for medical intervention for the submersion victim is in the prehospital setting, not in the emergency department or intensive care unit. The submersion victim should be provided advanced cardiac life support, including intubation as needed, as soon as possible.
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Emphasis on a clear airway is a primary requisite for effective CPR. Airway control in the trauma victim needs special consideration of the possibility of associated cervical vertebrae and spinal cord injury; thus, modification of the patient positioning for transport is essential. Emphasis on visualization of chest movement is the most important factor in assessing adequacy of ventilation. ⋯ Methods to measure end-tidal CO2 as a valuable check for tube position is a useful adjunct but must not be relied upon. Foreign body management continues to be controversial and remains unchanged for the present; ie, the infant < 1 year of age the recommendations are back blows followed by chest thrusts. Above 1 year of age, abdominal thrusts (Heimlich maneuver) is recommended.
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Cardiac arrest from electrical shock or lightning strike is associated with significant mortality and requires modification and extension of standard advanced life support measures to achieve successful resuscitation. Patients who experience electrical shock or lightning strike may sustain cardiac and respiratory arrest secondary to the direct effects of current. However, the majority of victims have associated multisystem involvement, including neurologic complications, cutaneous burns, and associated blunt trauma. ⋯ Unique considerations include vigorous fluid resuscitation and spinal immobilization for victims of electrical shock and reversal of normal multiple casualty triage priorities when managing several lightning strike victims. Because the majority of victims are relatively young and seldom have significant underlying cardiac disease, the chance for successful resuscitation may be greater for patients who experience sudden death from electrical shock or lightning strike than for those with other causes of cardiac arrest, even among patients with initial rhythms traditionally unresponsive to therapy. Although numerous specialized aspects are required for the successful management of victims of electrical shock and lightning strike, the following article focuses on the unique considerations necessary for immediate care of cardiac arrest victims, with emphasis on the underlying mechanisms of sudden death and currently recommended guidelines for resuscitation.