Annals of emergency medicine
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To determine whether family members accept field termination of unsuccessful out-of-hospital cardiac arrest resuscitation. ⋯ Family members accept termination of unsuccessful out-of-hospital cardiac arrest resuscitation in the field.
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Brain damage accompanying cardiac arrest and resuscitation is frequent and devastating. Neurons in the hippocampus CA1 and CA4 zones and cortical layers III and V are selectively vulnerable to death after injury by ischemia and reperfusion. Ultrastructural evidence indicates that most of the structural damage is associated with reperfusion, during which the vulnerable neurons develop disaggregation of polyribosomes, peroxidative damage to unsaturated fatty acids in the plasma membrane, and prominent alterations in the structure of the Golgi apparatus that is responsible for membrane assembly. ⋯ Growth factors--in particular, insulin--have the potential to reverse phosphorylation of elF-2 alpha, promote effective translation of the mRNA transcripts generated in response to ischemia and reperfusion, enhance neuronal defenses against radicals, and stimulate lipid synthesis and membrane repair. There is now substantial evidence that the insulin-class growth factors have neuron-sparing effects against damage by radicals and ischemia and reperfusion. This new knowledge may provide a fundamental basis for a rational approach to "cerebral resuscitation" that will allow substantial amelioration of the often dismal neurologic outcome now associated with resuscitation from cardiac arrest.
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Laboratory research should have clinical relevance. Topics should be selected according to need, gaps in knowledge, and opportunities; the investigator's background, expertise, interests, and ambitions; scientific, clinical, and socioeconomic importance; and feasibility of successful performance and conclusion. The current explosion of knowledge and sophistication of methods will require research by multidisciplinary teams. ⋯ In cardiac arrest research, hearts and brains "too good to die" offer many challenges. In trauma research, particular challenges include protection-preservation during uncontrolled hemorrhagic shock, suspended animation for delayed resuscitation in exsanguination, and prevention of brain swelling after traumatic brain injury. Emergency physicians have the unique opportunity to initiate clinical resuscitation research in unexplored territory: the prehospital arena.
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In the United States debate continues about the necessity of ventilation during CPR because of fear of contracting infectious diseases. Three questions will be considered in this article. First, is ventilation necessary for the treatment of cardiac arrest? Second, is mouth-to-mouth ventilation any better than no ventilation at all? Third, are other techniques of ventilation as effective or more effective than mouth-to-mouth ventilation during basic life support CPR? Although research is still inconclusive with regard to the need for ventilation during CPR, recent findings have clarified the effect of ventilation during low blood flow states and how ventilation influences resuscitation. ⋯ Chest compression alone provides some pulmonary ventilation and gas exchange. Active chest compression-decompression may improve gas exchange better than does standard chest compression. Other forms of manual ventilation may also have a role in CPR.