Resuscitation
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Randomized Controlled Trial Multicenter Study Clinical Trial
Conducting research using the emergency exception from informed consent: the Public Access Defibrillation (PAD) Trial experience.
The Public Access Defibrillation (PAD) Trial, a prospective, multicenter, randomized clinical trial comparing two prehospital resuscitation strategies, was conducted under the regulations for exception from informed consent (21CFR50.24) in 24 communities in North America. These regulations place additional requirements for human subject protection on investigators and Institutional Review Boards (IRBs), including conducting community consultation (CC) and public disclosure (PD). ⋯ The length of time to obtain IRB approval and the extent of community consultation and public disclosure varied greatly among trial sites in meeting the current regulations for conducting emergency research with exception from informed consent. This suggests that more specific guidance may be useful and that determination of effective strategies for community consultation and public disclosure is needed.
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The severity of airway obstruction varies in infants with Pierre-Robin syndrome (PRS). Some have severe upper airway obstruction that results in respiratory failure and even death. We report a case of neonate with isolated PRS who had a severe airway obstruction and respiratory failure after birth. ⋯ The laryngeal mask airway was left inserted for 6 days. It was successful in this patient and eliminated the need for invasive surgical procedures. In conclusion, the relatively long term use of a laryngeal mask airway, which has not been reported before, could be an alternative therapy for patients with PRS with airway obstruction.
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Emergency medicine service (EMS) systems in the five Nordic countries have more similarities than differences. One similarity is the involvement of anaesthesiologists as pre-hospital physicians and their strong participation for all critically ill and injured patients in-hospital. ⋯ Main problems and challenges emphasized by the authors are: (1) Denmark: the dispatch centres are presently not under medical control and are without a national criteria based system. Access to on-line medical advice of a physician is not available; (2) Finland: the autonomy of the individual municipalities and their responsibility to cover for primary and specialised health care, as well as the EMS, and the lack of supporting or demanding legislation regarding the EMS; (3) Iceland is the only country that has emergency medicine (EM) as a recognised speciality but there is a need for more fully trained specialists in EM; (4) Norway: the ordinary ground ambulance is pointed out as the weakest link in the EM chain and a health reform demands extensive co-operation between the new health enterprises to re-establish a nation-wide air ambulance service; (5) Sweden: to create evidence based medicine standards for treatment in emergency medicine, a better integration of all part of the chain of survival, a formalised education in EM and a nation wide physician staffed helicopter EMS (HEMS) cover.
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Randomized Controlled Trial Comparative Study Clinical Trial
Trials of teaching methods in basic life support (4): comparison of simulated CPR performance at unannounced home testing after conventional or staged training.
This study compares the retention of basic life support (BLS) skills after 6 and 12 months by lay persons trained either in a conventional manner, or using a staged approach. Three classes, each of 2h, were offered to volunteers over a period of 4 months. For the conventional group, the second and third classes consisted of review of skills. ⋯ At 12 months, those taught by the staged method were significantly better at shouting for help (P = 0.005), time to first compression (P < 0.0001), and compression depth (P = 0.003). Those taught conventionally were significantly better at checking for a carotid pulse at both 6 and 12 months (P < 0.0001). These results suggest that training lay persons in basic life support skills using a staged approach leads to overall better skill retention at 6 and 12 months, and has other advantages including a greater willingness to re-attend follow-up classes.
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When ventilating an unintubated patient with a standard adult self-inflating bag, high peak inspiratory flow rates may result in high peak airway pressures with subsequent stomach inflation. In a previous study we have tested a newly developed mouth-to-bag-resuscitator (max. volume, 1500 ml) that limits peak inspiratory flow, but the possible advantages were masked by excessive tidal volumes. The mouth-to-bag-resuscitator requires blowing up a balloon inside the self-inflating bag that subsequently displaces air, which then flows into the patient's airway. ⋯ In comparison with the adult self-inflating bag, there was significantly (P < 0.05) less gastric inflation (3943 +/- 4896 ml/min versus 149 +/- 495 ml/min versus 128 +/- 278 ml/min, respectively) with both devices, but the standard adult self-inflating bag had significantly higher lung tidal volumes (566 +/- 77 ml), peak airway pressure (13 +/- 1 cm H2O), and peak inspiratory flow rate (0.8 +/- 0.11 l/s). In conclusion, comparing the mouth-to-bag-resuscitator with small tidal volumes versus the paediatric self-inflating-bag during simulated ventilation of an unintubated patient in respiratory arrest resulted in comparable marginal stomach inflation, but significantly reduced the likelihood of gastric inflation compared to the adult self-inflating-bag. Lung tidal volumes were improved from approximately 250 ml with the paediatric self-inflating-bag to approximately 300 ml with the mouth-to-bag-resuscitator.