Current opinion in critical care
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Curr Opin Crit Care · Jun 2002
ReviewAlternative ventilation strategies in cardiopulmonary resuscitation.
The introduction of the 2000 Guidelines for Cardiopulmonary Resuscitation emphasizes a new, evidence-based approach to the science of ventilation during cardiopulmonary resuscitation (CPR). New laboratory and clinical science underemphasizes the role of ventilation immediately after a dysrhythmic cardiac arrest (arrest primarily resulting from a cardiovascular event, such as ventricular defibrillation or asystole). However, the classic airway patency, breathing, and circulation (ABC) CPR sequence remains a fundamental factor for the immediate survival and neurologic outcome of patients after asphyxial cardiac arrest (cardiac arrest primarily resulting from respiratory arrest). ⋯ Prompt recognition of supraglottic obstruction of the airway is fundamental for the management of patients in cardiac arrest when ventilation and oxygenation cannot be provided by conventional methods. "Minimally invasive" cricothyroidotomy devices are now available for the professional health care provider who is not proficient or comfortable with performing an emergency surgical tracheotomy or cricothyroidotomy. Finally, a recent device that affects the relative influence of positive pressure ventilation on the hemodynamics during cardiac arrest has been introduced, the inspiratory impedance threshold valve, with the goal of maximizing coronary and cerebral perfusion while performing CPR. Although the role of this alternative ventilatory methodology in CPR is rapidly being established, we cannot overemphasize the need for proper training to minimize complications and maximize the efficacy of these new devices.
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Immediate defibrillation is the single most effective therapy to reverse ventricular fibrillation cardiac arrest today. The once physician-only skill of defibrillation has entered mainstream society and is saving the lives of many sudden cardiac arrest (SCA) victims in a variety of settings. The automated external defibrillator (AED) and the concept of public access defibrillation (PAD) are a result of collaborative efforts between the American Heart Association (AHA) and medical manufacturers. ⋯ The success of these programs has ignited a trend in public safety and subsequently marketed the worth of AEDs in the home. Although optimal placement of AEDs remains uncertain, PAD is showing great promise in reducing the death rate from SCA. The lay public, both trained and untrained, is emerging as the next level of emergency care responders able to use a defibrillator.
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Curr Opin Crit Care · Jun 2002
Review Comparative StudyLithium dilution measurement of cardiac output and arterial pulse waveform analysis: an indicator dilution calibrated beat-by-beat system for continuous estimation of cardiac output.
Lithium dilution cardiac output (LiDCO trade mark; LiDCO, London, UK) is a minimally invasive indicator dilution technique for the measurement of cardiac output. It was primarily developed as a simple calibration for the PulseCO trade mark (LiDCO, London, UK) continuous arterial waveform analysis monitor. The technique is quick and simple, requiring only an arterial line and central or peripheral venous access. ⋯ The nominal stroke volume is converted to actual stroke volume by calibration of the algorithm with LiDCO trade mark. Initial studies indicate good fidelity, and the results from centers in the United States and the United Kingdom are extremely encouraging. The PulseCO trade mark monitor incorporates software for interpretation of the hemodynamic data generated and provides a real-time analysis of arterial pressure variations (ie, stroke volume variation, pulse pressure variation, and systolic pressure variation) as theoretical guides to intravascular and cardiac filling.
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Curr Opin Crit Care · Jun 2002
ReviewTermination of resuscitation: the art of clinical decision making.
Despite all of the progress in reanimating patients in cardiac arrest over the last half century, resuscitation attempts usually fail to restore spontaneous circulation. Thus, the most common of all resuscitation decisions after initiation remains the decision to stop. ⋯ However, this most central decision is often left open to chance, provider preference, family wishes, futility judgments, and resource concerns-a host of subjective considerations at the bedside and beyond. This article sheds light on these considerations, acknowledging the pivotal role that resuscitation science and guidelines can play in the multifactorial decision to discontinue resuscitative efforts.
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Distributive shock is a common problem in intensive care. Systemic hypotension is a medical emergency and will cause end-organ injury if not reversed. There are relatively few medications available to treat distributive shock. ⋯ Thus, the appropriate therapeutic endpoints for vasopressor therapy are not uniform for all patients. Similarly, the available evidence comparing vasopressor agents in terms of safety and efficacy is limited. When used at doses necessary to reverse distributive shock, less potent vasoconstrictors (eg, dopamine) do not appear to be safer than more potent ones (eg, norepinephrine) and do not appear to be as effective.