In the wake of Sri Lanka's tsunami: The Health for the South Capacity‐Building Project

In response to the Indian Ocean tsunami of December 2004, the Health for the South Project was developed for Sri Lanka. The capacity‐building component of this project involves the provision of trauma and emergency care training to the staff of Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka. A principal objective of this training for THK is an increased capacity to respond to future disasters in the south of Sri Lanka. Key elements of the capacity‐building programme include the on‐site emergency care training by teams of Australian emergency physicians and emergency nurses, working alongside the staff of the Emergency Treatment Unit in THK. It is expected that the programme will continue for at least 2 years, during which time a new Emergency and Trauma Centre will be constructed.     

Emergency medicine in the Netherlands, the necessity for changing the system: results from two questionnaires.

OBJECTIVE: To obtain information about patient, staff and organization characteristics of Emergency Departments in the Netherlands, and evaluate the changes between 1996 and 1999. METHODS: The heads of the Emergency Departments of all hospitals in the Netherlands were sent a questionnaire concerning patient, staff, and organization characteristics, as well as questions about intended future developments. The results were compared with data obtained from a comparable questionnaire in 1996. RESULTS: In the Netherlands, 113 hospitals (113/126) have an Emergency Department; 105/113 returned the questionnaire (93%). Ninety-two percent of the hospitals reported an increase in annual Emergency Department census and in the number of self-referred patients. The number of Emergency Departments staffed by only surgical residents decreased (52% in 1996 versus 41% in 1999), whereas the number of hospitals employing emergency physicians increased (24% in 1996 versus 45% in 1999). In 92% of the hospitals, nurses who work in the Emergency Department receive specific training. For emergency physicians, a specific training programme is not available, and in fact 30% of the physicians did not have any specific emergency medicine training. Therefore, none of the emergency physicians were fully trained in emergency medicine. According to 88% of all responders, there is a future for emergency medicine as an independent speciality in the Netherlands, and 35% of all hospitals intend to initiate a training programme for emergency physicians in the future. CONCLUSION: Almost all hospitals in the Netherlands reported an increase in the number of patients visiting the Emergency Department, especially in the number of self-referred patients. A majority of the Emergency Departments are now staffed by emergency physicians instead of surgical residents. Developing specific training programmes for emergency physicians should be a priority for the Netherlands in the future.     

Ultrasound-diagnosed cardiac tamponade after blunt abdominal trauma-treated with emergent thoracotomy

Ultrasound imaging enhances the physician's ability to evaluate, diagnose, and treat emergency department (ED) patients. Because ultrasound imaging is often time-dependent in the acutely ill or injured patient, the emergency physician is in an ideal position to use this technology. Focused ultrasound examinations provide immediate information and can answer specific questions about the patient's physical condition. We report a case in which blunt trauma to the abdomen and pre-existing pericardial fluid, due to human immunodeficiency virus (HIV), caused pericardial tamponade, diagnosed by bedside ultrasonography, and subsequent cardiac arrest. An ED thoracotomy released this tamponade, and spontaneous cardiac activity returned. The indications for and efficacy of ED thoracotomy have been debated for many years. Multiple studies have shown that patients with isolated penetrating chest trauma have the best outcome and that patients with blunt trauma without signs of life at the scene or in the ED have the poorest. We demonstrate the importance of ultrasound use by emergency physicians to assess trauma patients with pulseless electrical activity and suggest that in specific clinical situations after blunt trauma, an ED thoracotomy can be life saving.     

Emergency department thoracotomy for trauma: a collective review

A decade of experience with resuscitative thoracotomy for the trauma victim in extremis has been gained since the pioneering efforts of Mattox and his associates in 1974. It appears, from a review of the various reports from different trauma centers, that there is an emergence of a consensus as to the best indications for the procedure. It is generally agreed upon that ERT is fruitless in the patient with severe head trauma or when vital signs were absent at the scene of the injury. In the absence of penetrating thoracic injuries ERT yields a very poor survival in patients without vital signs on admission to the emergency center. It is widely accepted that the best results for ERT are in patients with cardiac tamponade. The prognosis is hopeless in patients without vital signs after sustaining blunt trauma.     

A Novel Low‐Cost Ultrasound‐Guided Pericardiocentesis Simulation Model: Demonstration of Feasibility

Pericardiocentesis is a rare life‐saving procedure for patients with cardiac tamponade. Due to the infrequency of this procedure, simulation models are often used for training. Commercial models are generally expensive. Proposed homemade models offer a lower‐cost alternative but can be labor and time intensive. The purpose of this study was to determine the feasibility of a limited use, low‐cost ultrasound‐guided pericardiocentesis model as a training tool for emergency physicians. Our model proved to be a practical, easily implemented, and acceptable model for training emergency physicians, including residents and students, in ultrasound‐guided pericardiocentesis.     

Early Diagnosis and Rescue Pericardiocentesis for Acute Cardiac Tamponade during Radiofrequency Ablation for Arrhythmias. Is Fluoroscopy Enough?

Background: With the number of complex catheter ablation procedures increasing, procedure‐related acute cardiac tamponade is encountered more frequently in the cardiac catheterization laboratory. Survival depends on prompt recognition and rescue pericardiocentesis. Objective: The aim of this report was to validate fluoroscopic heart silhouette characteristics associated with cardiac tamponade as a diagnostic method, and evaluate the safety and effectiveness of fluoroscopy‐guided pericardiocentesis during catheter ablation. Methods: All cases of acute cardiac tamponade that occurred in the cardiac catheterization laboratory during radiofrequency catheter ablation from March 2004 to November 2009 were reviewed retrospectively. Results: Of 1,832 catheter ablation procedures performed during a 5‐year period, 10 (0.55%) were complicated by cardiac tamponade. Fluoroscopic examination confirmed the diagnosis in all 10 patients and demonstrated effusions before hypotension in four patients. All patients were stabilized by fluoroscopy‐guided pericardiocentesis with placement of an indwelling catheter and autologous transfusion. The time interval between recognition of cardiac tamponade and completion of pericardiocentesis was 6.0 ± 1.8 minutes (range 3–9 minutes). The mean aspirated blood volume was 437 mL (range 110–1,400 mL), and the mean autotransfused blood volume was 425 mL (range 100–1,384 mL). Surgical repair of the cardiac perforation was needed in one patient. No procedure‐related death occurred. Conclusion: A reduction in the excursion of cardiac silhouette on fluoroscopy is an early diagnostic sign of cardiac tamponade during radiofrequency ablation. Fluoroscopy‐guided pericardiocentesis is a safe and effective management strategy for cardiac tamponade developed in the cardiac catheterization laboratory. (PACE 2011; 9–14)     

On scene thoracotomy: a case report.

We report a case of on scene resuscitative thoracotomy performed by an anaesthetist on a patient in cardiac arrest following a stab wound to the chest. The patient made a good recovery and was discharged from hospital within 2 weeks. The rationale for performing resuscitative thoracotomy and who should perform this procedure are discussed.     

A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage

An 81-year-old woman became unconsciousness after complaining of a backache, and then, an ambulance was called. She was suspected to have an aortic dissection by the emergency medical technicians and was transferred to our department. On arrival, she was in shock. Emergency cardiac ultrasound disclosed good wall motion with cardiac tamponade but no complication of aortic regurgitation. Computed tomography of the trunk revealed a type A aortic dissection with cardiac tamponade. During performance of pericardial drainage, she lapsed into cardiopulmonary arrest. Immediately after sterilization of the patient's upper body with compression of the chest wall, we performed a thoracotomy and dissolved the cardiac tamponade by pericardiotomy and obtained her spontaneous circulation. Fortunately, blood discharge was ceased immediately after controlling her blood pressure aggressively. As she complicated pneumonitis, conservative therapy was performed. Her physical condition gradually improved, and she finally could feed herself and communicate. In cases of acute cardiac tamponade, simple pericardiocentesis often is not effective due to the presence of the clot, and a cardiac tamponade by a Stanford type A aortic dissection is highly possible to complicate cardiac arrest, so emergency physicians should be ready to provide immediate open cardiac massage to treat such patients.     

The effect of healthcare provider education on diabetes management of hospitalised patients

Background: The importance of optimising blood glucose (BG) control in hospitalised patients is widely accepted. To determine whether focused education of physicians and nurses would result in measurable changes in glycaemic control, the effect of a diabetes‐focused educational programme on point of care (POC) BG measures was monitored. Methods: This programme included 2 h symposium and 2 h interactive session. The POC BG measures were determined at 2‐month period prior to implementing the programme and the ensuing 7 months after. Outcome parameters included the mean BG values, the incidence of hyperglycaemia (BG > 180 mg/dl) and hypoglycaemia (BG < 60 mg/dl). The outcome parameters were analysed by comparing the Internal Medicine (target service) to other such as Neurology and Surgical Trauma where no programme was offered. Results: On Internal Medicine, the mean BG decreased soon after implementing the programme and stayed lower than the baseline values over 7 months. The changes were significant at the third, fourth, seventh and the ninth month of the study. Hyperglycaemia decreased significantly (p < 0.05) on the third, fourth, seventh and eighth month, while hypoglycaemia increased following the education programmes. On Neurology and Surgical Trauma, the mean BG values were significantly higher, and hypoglycaemia was significantly lower during the same time frame. Conclusions: Implementing an educational programme for healthcare providers had significant effects on the lowering of mean BG values and the incidence of hyperglycaemia, but increased the risk of hypoglycaemia. The merits of such programmes need to be tested before their widespread implementation.     

New therapeutic approach to aortic dissection complicated by cardiac tamponade

The management of aortic dissection with cardiac tamponade may result in increased blood pressure and thereby itself make the aortic dissection worse. Nevertheless, it is important to prevent cardiac failure caused by cardiac tamponade. We describe a case of aortic dissection with cardiac tamponade. Echocardiography and aortography showed DeBakey IIIb-type aortic dissection with retrograde dissection, complicated by cardiac tamponade and aortic insufficiency. To treat this condition, a new therapeutic approach was undertaken. A vasodilator was administered, then pericardiocentesis guided by echocardiography was performed. To prevent abrupt elevation of blood pressure in response to the relief of cardiac tamponade, the pericardial aspiration was carried out slowly--it took four hours for the complete drainage of 415 ml of blood--and a vasodilator, sodium nitroprusside, was administered. After drainage, cardiac function was reversed fully, and the systolic pressure was controlled under 140 mmHg. Then, using extra-corporeal circulation, the surgical procedure was performed successfully. We conclude that it is useful to treat cardiac tamponade by controlling blood pressure with slow drainage and use of a vasodilator in preparation for performing the surgical procedure.     

Cardiac tamponade as complication of active-fixation atrial lead perforations: proposed mechanism and management algorithm

BACKGROUND: Cardiac tamponade is a rare complication after implantation of dual chamber pacemaker or defibrillator systems. Its pathophysiology and optimal management are not currently well established. METHODS: Three cases of cardiac tamponade following successful implantation of transvenous dual chamber pacemakers with active-fixation atrial leads were identified. RESULTS: All three patients with post-implant cardiac tamponade were suspected to have the same etiology of bleeding into the pericardial space. This was due to protrusion of the helix of the active-fixation atrial pacing lead through the atrial wall with subsequent abrasion of visceral pericardial layer and bleeding from the atrium through the perforation. In two patients, the perforation sites were visualized and repaired during open thoracotomy in the operating room. The third patient underwent lead repositioning under fluoroscopic guidance in the electrophysiology laboratory. CONCLUSION: Based on the reviewed cases, we describe the pathophysiology of, and recommend a safe conservative algorithm for, the management of cardiac tamponade after successful transvenous lead implantation. Percutaneous pericardiocentesis with placement of the pericardial drain followed by lead repositioning under fluoroscopic guidance with surgical backup appears to be safe and effective.     

Definitive management of acute cardiac tamponade secondary to blunt trauma

Blunt cardiac injuries are a leading cause of fatalities following motor-vehicle accidents. Injury to the heart is involved in 20% of road traffic deaths. Structural cardiac injuries (i.e. chamber rupture or perforation) carry a high mortality rate and patients rarely survive long enough to reach hospital. Chamber rupture is present at autopsy in 36-65% of death from blunt cardiac trauma, whereas in clinical series it is present in 0.3-0.9% of cases and is an uncommon clinical finding. Patients with large ruptures or perforations usually die at the scene or in transit--the rupture of a cardiac cavity, coronary artery or intrapericardial portion of a major vein or artery is usually instantly fatal because of acute tamponade. The small, rare, remaining group of patients who survive to hospital presentation usually have tears in a cavity under low pressure and prompt diagnosis and surgery can now lead to a survival rate of 70-80% in experienced trauma centres. As regional trauma systems evolve, patients with severe, but potentially survivable cardiac injury are surviving to ED. Two distinct syndromes are apparent--haemorrhagic shock and cardiac tamponade. Any patient with severe chest trauma, hypotension disproportionate to estimated loss of blood or with an inadequate response to fluid administration should be suspected of having a cardiac cause of shock. For patients with severe hypotension or in extremis, the treatment of choice is resuscitative thoracotomy with pericardotomy. Closed chest cardiopulmonary resuscitation is ineffective in these circumstances. Blunt traumatic cardiac injury presenting with shock is associated with a poor prognosis. The majority of survivors of blunt or penetrating cardiac injury present to the ED/trauma centre with vital signs. The main pathophysiologic determinant for most survivors is acute pericardial tamponade. The presence of normal clinical signs or normal ECG studies does not exclude tamponade. In recent years the widespread availability and use of ultrasound for the initial assessment of severely injured patients has facilitated the early diagnosis of cardiac tamponade and associated cardiac injuries. Two cases of survival from blunt traumatic cardiac trauma are described in the present paper to demonstrate survivability in the context of rapid assessment and intervention.     

Termination of Resuscitative Efforts for Out-of-hospital Cardiac Arrests

OBJECTIVE: To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC). METHODS: This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-of-hospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC. RESULTS: Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p < 0.0001); incidence at base hospital B was 14% (odds ratio, 3.3; 95% confidence interval = 1.9 to 5.5; p < 0.0001), and incidence at all other base hospitals was 5%. Cardiac arrest patients handled by base hospital A were more likely to be found in ventricular fibrillation; those patients handled by base hospital B had shorter emergency medical services response times and were more likely to be found in an extended care facility. All other characteristics of cardiac arrest patients were not significantly different among the base hospitals. CONCLUSIONS: There is significant variability in Los Angeles, depending on the particular base hospital that provides OLMC, in pronouncement of death and termination of resuscitative efforts for medical cardiac arrest in the field. Given potential ethical, logistical, and economic concerns, efforts to assure consistency in the practice of discontinuing resuscitative efforts in the field is warranted.     

Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers

Cardiac arrest presenting as pulseless electrical activity (PEA) currently has a very low survival rate. Many of the conditions underlying PEA (cardiac tamponade, hypovolemia, and pulmonary embolus) are associated with specific cardiac ultrasound findings. The aim of this study was to evaluate a rapid cardiac ultrasound assessment performed by trained nonexpert sonographers integrated into the ACLS response system at a major medical center. METHODS: An emergency sonography system was created and deployed to each inpatient cardiac arrest occurring at Dartmouth Hitchcock Medical Center between November 1, 2003 and April 30, 2004. Thirteen internal medicine house officers received training to perform a limited subcostal cardiac ultrasound examination designed to diagnose cardiac tamponade, pulmonary embolus, severe hypovolemia, and lack of cardiac motion. Time from arrest alert to sonographic result, and correlation with over-reading by blinded echocardiography physicians were assessed. RESULTS: A complete emergency ultrasound examination was performed in five PEA arrests. The average time from arrest alert to interpretation was 7.75 min. (95% CI 2.8-18.3 min). Three of these examinations (60%, 95% CI 14.7-94.7%) were adequate for interpretation. Agreement between the nonexpert sonographer and echocardiography physician occurred in four of five (kappa=0.706) cases. CONCLUSION: Rapid cardiac sonography can be successfully integrated in the ACLS response. Nonexpert sonographers may be able to provide useful interpretive information when sufficiently trained.     

Societal opinions regarding CPR

Resuscitative measures are traditionally undertaken for most patients with cardiac arrest, unless an advance directive exists. This long-standing default presumption of patients' wishes to undergo resuscitation has never been proven. This study was undertaken to determine societal preferences of the general public regarding resuscitation. A cross-sectional survey was administered at community events to 724 volunteer participants over a 16-month period. For 6 hypothetical clinical scenarios (previously piloted and validated), respondents indicated personal preferences regarding resuscitation attempts for themselves. Most respondents indicated preferences for resuscitative efforts in a scenario depicting a young, healthy patient (96%), whereas few would desire resuscitative efforts for an elderly, debilitated patient (27%) (P <.01, Fisher's exact test). Nearly all (98%) respondents showed a trend (by scalogram analysis) toward refusal of resuscitative efforts in scenarios depicting more elderly, debilitated patients. Respondents had inaccurate perceptions of survival rates after cardiac arrest; the mean estimated survival rate was 50% (range 0%-100%). Although the majority of respondents had a personal physician (82%), only 10% of respondents had ever discussed death or resuscitation with their physicians. This study shows a trend in personal opinion among the general public toward refusal of resuscitative efforts in clinical scenarios with poor prognoses. Because so few patients have completed advance directives, physician awareness of such public opinions may be useful in decision-making in end-of-life care, particularly when caring for patients without advance directives. These public opinions support the feasibility of establishing societal consensus regarding resuscitation preferences, which may be useful in the development of federal and local guidelines and policies.     

Primary health care resources for rehabilitation and secondary prevention after myocardial infarction – a questionnaire survey

Scand J Caring Sci; 2013; 27; 260–266 Primary health care resources for rehabilitation and secondary prevention after myocardial infarction – a questionnaire survey Background: During the first year after a cardiac event, many patients are offered participation in a cardiac rehabilitation programme, after which the patients are often not given the opportunity to continue to attend rehabilitation and secondary prevention programmes. Aim: This study describes the primary health care centres’ (PHCC) resources regarding cardiac rehabilitation/secondary prevention programmes for coronary heart disease (CHD) patients in a southern Swedish region. Method: A questionnaire containing 26 dichotomous or multiple choice questions was sent to the responsible manager of all 137 public and private PHCCs in Region Skåne. Questionnaires from 91 (66%) of the PHCCs were completed and returned. Result: Few nurses at the PHCCs had special training regarding CHD (10%), cardiac rehabilitation (8%) or heart failure (32%). Twenty‐one per cent of the physicians had special training regarding CHD. One third of the PHCCs did not offer long‐term secondary prevention programmes, and few (6%) had any routines for offering socio‐economic support to CHD patients. Comparison of private and public PHCCs showed that the private centres could not offer a physiotherapist (61 vs. 84%) or dietician (32 vs. 73%; p = 0.03) to the same extension as the public ones. Furthermore, the majority (91%) of PHCCs had no cooperation with patient organizations. Conclusions: The PHCCs need to improve the strategies and long‐term rehabilitation programmes. Furthermore, they need to focus on education programme for the staff. The result revealed that the PHCCs lack resources, strategies and long‐term care programmes for CHD patients.     

心内直视术后出血再次开胸手术常见原因及临床防治

【目的】探讨体外循环心内直视术后出血和心脏压塞的临床特点。[方法】回顾性分析湘雅二医院因心脏直视术后出血和心脏压塞再次开胸手术87例病例,采集相关数据,进行统计学分析。【结果】术后活动性出血21例,急性心脏压塞63例,延迟性心脏压塞3例,死亡11例（活动性出血组3例,急性心脏压塞8例）。活动性出血组术后动脉收缩压、舒张压、中心静脉压、尿量进行性下降,心率增快,引流量显著增多（P〈0．05）。急性心脏压塞组术后pH值、动脉收缩压和舒张压突然快速降低及尿量显著减少,中心静脉压及心率很快增高,引流量突然减少（P〈0．05）。术后活动性出血以心脏切口、胸腺、骨膜及骨髓腔、剑突血管、心包切缘、钢丝穿孔点等多见。【结论】术前心功能不全及继发多脏器功能失调,体外循环凝血机制紊乱,术中止血不彻底,术后处理不及时是心内直视术后出血或心脏压塞的主要原因。调整术前脏器功能,加强血液保护,止血彻底,术后严密监护,必要时及时开胸止血是防治术后出血的关键。     

Organization of anesthesiological and resuscitative care delivered to the wounded and patients in the large specialized hospital

On the basis of an analysis of the specific features of organization of anesthesiological and resuscitative care, the authors formulate a number of points that are of great importance for the quality of work. They give the optimal recommendations for organizing the professional activities of physicians of intensive care units and consultants. The paper presents conceptual sketches of the training of anesthesiologists working in a specialized center are presented. The authors show it necessary to follow the principle in the gradation of anesthesiological and resuscitative care.     

Delayed perforation of right ventricle with cardiac tamponade: a complication of pacemaker implantation.

We report a case of delayed cardiac tamponade that resulted from pacemaker implantation in the emergency room of a large urban hospital. A 19-year-old male patient with a pacemaker implanted 10 days earlier suffered from delayed perforation of the right ventricle with cardiac tamponade. A review of the literature revealed that cardiac tamponade is a rare complication of pacemaker implantation. Pacemakers should only be implanted by physicians with relevant experience, and emergency room physicians should be aware of the possibility of the associated complications and be prepared to treat them.     

心脏直视手术中心脏复苏困难的处理

目的：为提高心脏直视手术中心脏复苏率。方法：总结２０例心脏直视手术中心脏复苏困难的处理经验。结果：胸内心脏挤压和中等剂量心脏兴奋剂有利于心脏手术中的心脏复苏；心肌出现粗颤即应尽早除颤，不宜片面追求较高的心脏自动复跳率。对复苏困难病例，依其不同情况，在常规复苏方法的基础上，可采用一些特殊复苏措施，包括消除导致复苏困难的原因、长时间心脏挤压和长时间体外循环辅助、采用外科手段等。结论：有多种因素影响心脏直视手术中的心脏复苏，正确分析判断复苏困难的特殊原因，恰当地采用综合性措施（包括外科手段）进行复苏可收到良好效果。