The American journal of emergency medicine
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Randomized Controlled Trial Comparative Study Clinical Trial
Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study.
A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. ⋯ Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.
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Review Case Reports
Hypoglycemia presenting as acute respiratory failure in an infant.
Hypoglycemia, a common metabolic abnormality seen in the pediatric population, is most often easily diagnosed and rapidly treated with satisfactory outcome. If not recognized and treated in prompt fashion, however, hypoglycemia may cause irreversible central nervous system injury or expose the patient to unnecessary procedures; it rarely results in death. The classic emergency department (ED) presentation of hypoglycemia, the diabetes mellitus patient using hypoglycemic therapy, is frequently encountered and adequately managed with excellent outcome. ⋯ His mental status improved and his respiratory insufficiency resolved after glucose therapy. No other explanation for the respiratory failure was found during the hospital admission. It is imperative that the emergency physician consider hypoglycemia in all patients with any degree of mental status abnormality, even when the findings seem to be explained initially by other etiologies.
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Standards of care are devised by juries in courts of law. They "evolve," in part, according to public expectations as those expectations are honed by the profession in its literature, its forums, and as reported in the popular press and media. ⋯ A significant number of deaths from sudden cardiac arrest can be prevented by using automatic external defibrillators in the out-of-hospital setting. These devices have become cost effective, reliable, and readily available and the standard of care requiring their use in the out-of-hospital setting has arrived.
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Randomized Controlled Trial Clinical Trial
Continuous flumazenil infusion in preventing complications arising from severe benzodiazepine intoxication.
A prospective, randomly controlled study was conducted to test the effect of continuous flumazenil infusion in preventing complications arising from severe benzodiazepine (BZ) intoxication. Patients who were believed to be suffering benzodiazepine intoxication and whose Glasgow Coma Scale (GCS) score was below 10 were enrolled after showing a clear-cut response to flumazenil 0.5 or 1 mg (an improvement by 4 or more on the GCS). The patients were consecutively enrolled and randomized into two groups: a continuous infusion group (CI, n = 50) who were immediately given flumazenil 0.5 mg/h for 5 hours, and a control group (CIN, n = 50). ⋯ A greater incidence of underlying disease and an older age seemed to contribute to the higher complication rates in both groups. Several patients (in both groups) resedated into deeper coma after showing an initial response to flumazenil or after the cessation of flumazenil infusion. For severe BZ intoxication, treatment with flumazenil infusion should still be considered skeptically and should not be recommended as routine management BZ-intoxicated patients with an underlying disease, an older age, and resedation into a deep comatose state after showing an initial response to flumazenil should be treated in an intensive care unit.
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Some cases of difficult airway intubation can be managed by using the Endotrol (trigger) endotracheal tube. This report describes such a case, in which the management of a difficult airway was facilitated initially by using the Endotrol tube; however, significant occlusion occurred approximately 16 hours later when the tube "kinked," leading to its partial collapse. The Endotrol tube has been used to maintain airways in critical and difficult situations, but its use for longer periods of intubation may need to be further studied.