P ARAMEDIC U SE OF E NDOTRACHEAL T UBE I NTRODUCERS FOR THE D IFFICULT A IRWAY

Objective. To evaluate the ability of paramedics to learn and apply the skill of introducer-aided oral intubation in the setting of the simulated “difficult airway.” The authors hypothesized that, following a brief introduction to the device, intubation success rates would not differ for traditional and introducer-aided intubations of an immobilized airway mannequin. Methods. During a paramedic recertification class, experienced paramedics were given a brief didactic introduction to the “bougie-like” Flex Guide endotracheal tube introducer (ETTI). The participants were then asked to intubate adult mannequins immobilized in the head-neutral position, with and without the ETTI. “Successful placement” was defined as completion of the procedure within 30 seconds and endotracheal tube position confirmed by the investigator with direct visualization. Results. For both traditional and ETTI intubations, 34 (97%) of the 35 paramedics successfully intubated within 30 seconds. The two unsuccessful intubation attempts were recognized by the paramedic as esophageal intubations, and correct tube placement was obtained within an additional 30 seconds. Conclusion. In this study, use of the ETTI was mastered by the participants after only a brief didactic introduction to the device, with their ability to intubate an immobilized mannequin using the ETTI being equal to their ability to perform traditional intubation. These results suggest that use of the ETTI is easily learned, and may support the device's role in the prehospital management of the difficult airway.     

基层医院急诊科心肺脑复苏的院内急救

目的：探讨基层医院心、肺、脑复苏的院内急救护理最佳配合。方法对本院2010年5月～2013年5月19例心肺脑复苏成功患者的急救与护理配合进行回顾性分析。结果19例患者经瞬间评估判断、畅通气道、人工呼吸、胸外心脏按压、电击除颤、合理给药、脑部降温等急救措施的实施，复苏成功。结论积极有效的急救护理配合是保证复苏成功的关键。     

两种液体复苏方法在创伤失血性休克患者中的应用研究

【目的】比较延迟液体复苏和即刻液体复苏对创伤失血性休克（HTS）患者的救治效果。【方法】回顾性分析2006年5月-2011年10月我院急诊经院前急救收治的63例有HTS患者，根据患者人院前纠正平均动脉压（MAP）水平分为即刻液体复苏组（A组，MAP90～110mmHg，32例）和延迟液体复苏组（B组，MAP70—89mmHg，31例），对两组患者复苏前后的3个时间节点检测血红蛋白（Hh）、红细胞压积（Hct）、血小板（Pit）、碱缺失（BE）、动脉血PH（BpH）、谷丙转氨酶（ALT），统计两组患者输入液体量、MAP、并发症发生率及死亡率。【结果】两组在建立静脉通路前（即液体复苏前）Hb、Hct、Plt、BE、BpH、AIJT比较无统计学差异（P〉0．05）。在院前急救期，A组较B组Hb、Hct、Ph、BE、BpH均下降，有统计学意义（P〈0．05），在院内救治期，A组较B组Hb、Hct、Plt、BE、BpH均下降，差异有统计学意义（P〈0．05）。两组MAP在充分液体复苏前各自稳定在90～110mmHg和70～90mmHg，A组液体输入量（3250±457）ml，B组液体输入量（1080±514）ml，两组在MAP和输液量比较差异有统计学意义（P〈0．05），本研究发生并发症20例，死亡5例，两组患者并发症发生率和死亡率比较差异无统计学意义（P〉0．05）。【结论】对活动性出血的HTS患者院前延迟性液体复苏，维持适当的MAP水平，可在一定程度上改善休克期组织脏器的灌注和氧供。     

Comparison of Effects of Levobupivacaine and Ropivacaine Infiltration on Cutaneous Wound Healing in a Rat Model

ABSTRACT

Purpose: To compare the effects of fluid resuscitation with lactated Ringer's solution (LR) and saline-based 6% hydroxyethyl starch 130/0.4 (HES) on the inflammatory response and oxidative stress in the small intestine as well as on bacterial translocation to the liver. Methods: Sprague–Dawley rats were subjected to blood pressure-controlled hemorrhagic shock and then resuscitated with LR or HES. At 1, 3, 6, 12, and 24 hr after resuscitation, liver tissues were collected to count the bacterial colonies, and small intestines were harvested to analyze the levels of inflammatory (TNF-α and HO-1) and oxidative stress (MPO) mediators as well as the intestinal injury by immunohistochemistry, colorimetry and hematoxylin &; eosin staining, respectively. Results: The expression level of TNF-α in the LR group was stable from 1 to 6 hr but decreased at 12 hr and then abruptly increased at 24 hr. The expression level of TNF-α in the LR group was significantly lower than that in the HES group, especially during the first 12 hr post-fluid infusion. MPO activity decreased to its lowest level at 3 hr but increased from 6 to 12 hr, with no difference at 24 hr between the two groups. Although a decreasing tendency was observed from 6 hr, HO-1 expression levels remained higher in the LR group than in the HES group at 12 and 24 hr, particularly at 12 hr. During the initial 12 hr, the LR group exhibited significantly lower colony-forming units in the liver tissues than the HES group. Chiu's score in the intestine decreased regardless of which resuscitative fluids were used. Conclusions: During early resuscitation (within 12 hr), LR may be superior to HES in reducing intestinal injuries by suppressing inflammatory and oxidative mediators.     

Successful Therapeutic Hypothermia in Patients with Congenital Long QT Syndrome

Therapeutic hypothermia has been shown to improve neurological outcomes in patients who remain comatose following resuscitation from cardiac arrest. While there are numerous reports of patients who have had a successful course after induction of therapeutic hypothermia, such therapeutic intervention has not been described in patients with congenital long QT syndrome (LQTS). We report outcomes in two patients with LQTS who had therapeutic hypothermia following a ventricular fibrillation arrest. Careful and routine monitoring of the QT interval in this patient population is necessary due to the potential for worsening electrical instability during induced hypothermia. Ann Noninvasive Electrocardiol 2011;16(1):100–103     

Obstetric emergencies

For more than 60 years the Confidential Enquiries into Maternal Deaths triennial reports have helped build a picture of maternity care within the UK, highlighting not only our successes but failures in caring for women within the puerperal period. Despite most obstetric emergencies being well described and having clear management strategies and guidance, there continues to be substandard management with poor outcomes recorded and this has been highlighted within the latest triennium report. This article describes some common obstetric emergencies with which the anaesthetist will become involved. It emphasizes management related to some deficiencies identified in the Centre for Maternal and Child Enquiries report as well as highlighting a multidisciplinary approach throughout. Good communication between team members is paramount in all aspects of medical care, but this approach should be fostered routinely to ensure that rapid and appropriate decisions are made in a safe and timely manner.     

Socioeconomic Status Is Associated with Provision of Bystander Cardiopulmonary Resuscitation

Objective. Although socioeconomic status (SES) has been linked to multiple health outcomes, there have been few studies of the effect of SES on the provision of bystander cardiopulmonary resuscitation (CPR) during cardiac arrest events and no studies that we know of on the effect of SES on the provision of dispatcher-assisted bystander CPR. This study sought to define the relationship between SES and the provision of bystander CPR in an emergency medical system that includes dispatcher-provided CPR instructions. Methods. This study was a retrospective, cohort analysis of cardiac arrests due to cardiac causes occurring in private residences in King County, Washington, from January 1, 1999, to December 31, 2005. We used the tax-assessed value of the location of the cardiac arrest as an estimate of the SES of potential bystanders as well as multiple measures from 2000 Census data (education, employment, median household income, and race/ethnicity). We also examined the effect of patient and system characteristics that may affect the provision of bystander CPR. Logistic regression models were used to analyze the association of these factors with two outcomes: the provision of bystander CPR with and without dispatcher assistance. Results. Forty-four percent (1,151/2,618) of cardiac arrest victims received bystander CPR. Four hundred fifty-seven people (17.5% of the entire study population, 39.7% of those who received any bystander CPR) received CPR without telephone instructions. A total of 694 people received dispatcher-assisted bystander CPR (25.6% of the entire population, 60.4% of those receiving any bystander CPR). After adjusting for demographic and care factors, we found a strong association between the tax-assessed value of the cardiac arrest location and increased odds of the provision of bystander CPR without dispatcher instructions and bystander CPR with dispatcher assistance compared with no bystander CPR. Conclusions. This study suggests that higher bystander SES is associated with increased rates of bystander CPR with and without dispatcher instructions. CPR training programs that target lower-SES communities and assessment of these training methods may be warranted.     

Out-of-Hospital Cardiac Arrest –Optimal Management

Out-of-hospital cardiac arrest (OHCA) has attracted increasing attention over the past years because outcomes have improved impressively lately. The changes for neurological intact outcomes has been poor but several areas have achieved improving survival rates after adjusting their cardiac arrest care. The pre-hospital management is certainly key and decides whether a cardiac arrest patient can be brought back into a spontaneous circulation. However, the whole chain of resuscitation including the in-hospital care have improved also. This review describes aetiologies of OHCA, risk and potential protective factors and recent advances in the pre-hospital and in-hospital management of these patients.     

Three Meals a Day is Passé at Progressive Hospital

Modern medical simulation technology (MST) debuted in 1960 with the development of Resusci Annie (Laerdal 2007), which assisted students in the acquisition of proper ventilation and compression techniques used during basic life support. Following a steady stream of subsequent technological advances and innovations, MST manufacturers are now able to offer training aids capable of facilitating innovative learning in such diverse areas as human patient simulators, simulated clinical environments, virtual procedure stations, virtual medical environments, electronic tutors, and performance recording. The authors list a number of the most popular MSTs presently available while citing evaluative efforts undertaken to date regarding the efficacy of MST to the medical profession. They conclude by proposing a variety of simulation innovations of prospective interest to both medical and technology personnel while offering healthcare administrators a series of recommended considerations when planning to integrate MST into existing medical systems.