The American journal of emergency medicine
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Cardiac pacing has been used successfully in patients with asystole or bradycardia compromising hemodynamics when it was applied soon after the onset of the event. An external cardiac pacemaker was used as part of initial resuscitative efforts for patients in primary, out-of-hospital, cardiac arrest who arrived in the emergency department in asystole, agonal rhythm, pulseless idioventricular rhythm, or bradycardia with hemodynamic compromise. A pulse was successfully generated in only one of twelve patients. ⋯ The interval between arrest and application of the pacemaker was prolonged because of long periods for ambulance response, field resuscitation, and transport. It is concluded that the external cardiac pacemaker is a useful instrument for the treatment of bradyarrhythmias. While it may also be useful in the first few minutes after development of asystole, pulseless idioventricular rhythm, or agonal rhythm, it is of no benefit if applied long after the event.
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Comparative Study
Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation.
Records on 1,297 people with witnessed out-of-hospital cardiac arrest, caused by heart disease and treated by both emergency medical technicians (EMTs) and paramedics, were examined to determine whether or not early cardiopulmonary resuscitation (CPR) initiated by bystanders independently improved survival. Bystanders initiated CPR for 579 patients (bystander CPR); for the remaining 718 patients, CPR was delayed until the arrival of EMTs (delayed CPR). Survival was significantly better (P less than 0.05) in the bystander-CPR group (32%) than in the delayed-CPR group (22%). ⋯ The authors conclude that early initiation of CPR by bystanders significantly improves survival from out-of-hospital cardiac arrest, and they suggest that it may do so by prolonging the duration of VF after collapse and by increasing cardiac susceptibility to defibrillation. The benefit of this early CPR, however, appears to exist within a rather narrow window of effectiveness. It must be started within 4-6 minutes from the time of collapse and must be followed within 10-12 minutes of the collapse by advanced life support in order to be effective.
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Currently, the American Heart Association (AHA) recommends that physicians be certified in cardiopulmonary resuscitation (CPR) every two years. This study was undertaken to determine the effects of time since training on retention of CPR skills of physicians and to identify at what point performance deteriorates to a level requiring retraining with supervised practice. The physicians' performance of CPR one year or less after training was compared with that of more than one year after training. ⋯ Deterioration of skills may reflect the fact that senior residents do not actually perform CPR, but become team leaders and thereby lose their skills, or that poor performance is not corrected in actual "code" situations. If a two-year certification standard is maintained, CPR skill testing at least every 12 months should be considered. If skills have deteriorated, hands-on-practice should be undertaken at that time.
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Randomized Controlled Trial Clinical Trial
The use of antibiotics in the initial management of recent dog-bite wounds.
The use of antibiotics in the initial management of dog-bite wounds presented within eight hours of injury was studied. Of 211 wounds occurring in 150 patients seen during the study period, 66 wounds occurring in 33 patients comprised the study sample. All wounds were managed according to a strict protocol that included cleaning, debridement, and pressure irrigation. ⋯ There was no significant difference in outcome between antibiotic and placebo groups. Hand wounds became infected significantly more often than other wounds. The administration of a penicillinase-resistant antibiotic is not indicated in the initial management of dog-bite wounds presented within eight hours of injury.
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A five-year retrospective study of pediatric salicylate intoxications (serum level greater than 300 micrograms/ml) revealed that 2/20 patients developed salicylate induced pulmonary edema. These patients had significantly higher initial anion gaps (P less than 0.02) and serum salicylate determinations (P less than 0.001) and tended to be younger with lower initial serum potassium and arterial carbon dioxide measurements. ⋯ Unlike other reports, these data suggest that pulmonary edema is not rare in severe pediatric salicylate ingestion and correlates with high serum salicylate levels and anion gaps. Early, aggressive detoxification, supportive therapy, and hemodynamic monitoring would appear to be indicated in these patients.