Resuscitation
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Measurements of plasma colloid osmotic pressure (COP) were made during and for 24 h after normothermic continuous flow cardiopulmonary bypass (CPB) in 20 adults exposed to sudden haemodilution by a crystalloid pump prime solution. Haematocrit, albumin and total protein were also measured. Within 5 min of starting bypass the mean COP fell to 45% pre-bypass value and remained at this level until bypass was discontinued. ⋯ This significant difference in fall between plasma protein concentration and directly measured COP is explained by their non-linear relationship. Three patients died soon after bypass. They all showed significantly lower values of COP than the mean for the group as a whole at some stage (P less than 0.05).
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Comparative Study
Treatment of postoperative respiratory distress syndrome.
We have studied 45 patients with postoperative adult respiratory distress syndrome (ARDS) who were treated by mechanical ventilation during the last four years. This period was divided into two periods, and the mortality and progress after treatment were analysed. The overall, mortality was 56%. ⋯ Patients of types 3 and 4 had extremely poor prognoses. Stricter management to avoid infection, specific treatment of multiple organ failure (which was seen frequently) seemed advantageous. High frequency positive pressure ventilation (HFPPV) may have some role in improving the respiratory function of the patients with ARDS.
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Of 125 patients who had no detectable cortical activity (DCA) in the electroencephalograph (EEG) immediately upon resuscitation from circulatory arrest of primary cardiovascular aetiology, 37 subsequently regained consciousness; these patients had their EEG and neurological status serially investigated until they expired or had survived one year. The orderly cerebral recovery during postischaemic unconsciousness was characterized by a sequential appearance of EEG configurations and related neurological signs. The absence of DCA was at first accompanied by miosis and all the cranial nerve reflexes except the caloric vestibular reflex (phase of exclusive presence of cranial nerve reflexes) and then by motor responsiveness, predominantly decerebrate posturing (phase of cephalic reactivity). ⋯ The EEG and neurological recovery occurred independently after awakening; but elementary motor, sensory and mental faculties were regained in a characteristic sequence. Initially, the alert patient had a phase of 'severe disability' seen as communicating motor responses, eye-orientation and a bilateral Babinski response; in the subsequent phase of 'moderate disability' speech, auto-orientation, locomotor control, and a normal plantar response were then restored; finally in the phase of slight- or no disability allo-orientation, retention and recall reappeared. Thirteen patients made a complete recovery of all faculties 83--2150 h after cardiopulmonary resuscitation.
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The treatment of head and spinal cord injuries must be directed towards prevention of secondary insults which will increase the extent of permanent disability. Improved extrication techniques at the scene of the accident, earlier recognition and treatment of complications and improved transfer management have all reduced the acute morbidity and mortality of injuries to the central nervous system. At the University of Virginia we have implemented a comprehensive training program in the acute care of the head and spinal cord injured patient for Emergency Medical Technicians (EMT), nurse, community referring physicians, and house staff within the medical center. ⋯ The greatest emphasis is placed on the history and physical examinations, which documentation of the extent of neurologic deficit, including the Glasgow coma scale. Data on 900 pre-hospital calls by volunteer EMTs demonstrate a 90% compliance in basic life support skills outlined in the educational program. A similar compliance has been achieved with referring physicians and house staff in the medical center, in the acute management of the CNS injured patient, due primarily to this educational program and increase in the optimal care of these patients has resulted.
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Sophisticated care of the head injury patient in the emergency department does not demand sophisticated knowledge of neurosurgery. Instead it depends upon: (1) Meticulous attention to the fundamental principles of resuscitation; (B) Prevention of secondary cardiopulmonary abnormalities which can further injure the traumatized brain; (C) Performance of serial neurologic examinations. (In the case of acute head injury, a simple neurologic examination performed repeatedly usually provides the physician with more useful information than a more elaborate examination performed only once). (D) Consultation with the neurosurgeon. ⋯ This can only be achieved through persons dedicated to training emergency medical technicians, nurses and physicians in the optimal care that can be afforded these patients. If advances are to be made in decreasing the morbidity and mortality of the CNS trauma patient, those actively involved in emergency medicine are going to have to take an active role in training programs, seminars and clinical practice for physicians, emergency department nurses, and emergency medical technicians.