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1.
About 50% of the trauma victims die at the scene mostly because of exsanguinating haemorrhage. Most trials of resuscitation fail in face of the ongoing bleeding. Ongoing research/studies to save these victims by inducing rapid hypothermia using cardiopulmonary bypass as an emergency initial measure along with delayed resuscitation show improved outcomes. A comprehensive review of this research and analysis of studies showed that rapid induction of hypothermia within 5 min of cardiac arrest is associated with better survival and improved neurological outcome. This led us to conclude that suspended animation is a lifesaving modality for the treatment of trauma victims, otherwise hurtling towards certain death. This should be integrated into regular clinical practice. The US Food and Drug Administration has given its approval for clinical trials on such an intervention.  相似文献   

2.
Therapeutic hypothermia in traumatology   总被引:13,自引:0,他引:13  
Despite its proven clinical application for protection-preservation of the brain and heart during cardiac surgery, hypothermia research has fallen in and out of favor many times since its inception. Since the 1980s, there has been renewed research and clinical interest in therapeutic hypothermia for resuscitation of the brain after cardiac arrest or TBI and for preservation-resuscitation of extracerebral organs, particularly the abdominal viscera in low-flow states such as HS. Although some of the fears regarding the side effects of hypothermia are warranted, others are not. Without further laboratory and clinical studies, the significance of these effects cannot be determined and ways to overcome these problems cannot be developed. Currently, at the turn of the century, there are significant data demonstrating the benefit of mild-to-moderate hypothermia in animals and humans after cardiac arrest or TBI and in animals during and after HS. The clinical implications of uncontrolled versus controlled hypothermia in trauma patients and the best way to assure poikilothermia for cooling without shivering are still unclear. It is time to consider a prospective trial of therapeutic, controlled hypothermia for patients during traumatic HS and resuscitation. The authors believe that the new millennium will witness remarkable advantages of the use of controlled hypothermia in trauma. Starting in the prehospital phase, mild hypothermia will be induced in hypovolemic patients, which will not only decrease the immediate mortality rate but perhaps also will protect cells and reduce the likelihood of secondary inflammatory response syndrome, multiple organ failure, and late deaths. The most futuristic applications will be hypothermic strategies to achieve prolonged suspended animation for delayed resuscitation in traumatic exsanguination cardiac arrest.  相似文献   

3.
In emergency medicine accidental hypothermia (<35 degrees C) is a common epiphenomenon of many medical conditions. In contrast, severe hypothermia (<28 degrees C) occurs very seldom and presents a difficult medical situation. Here we present a female patient with severe urban hypothermia (core temperature of 20.7 degrees C) and circulatory arrest. An overview of the emergency treatment, rewarming strategy with extracorporeal circulation and the clinical course will be given. The survival of the patient and the favorable neurological outcome will be discussed considering the current literature. Due to the paucity of treatment guidelines or clear prognostic criteria of withholding or withdrawing treatment in severe hypothermia, the decision of prolonged resuscitation and rewarming strategy is solely dependent on the individual judgement and medical experience of the physician. The positive clinical outcome which can be gleaned from case reports or single retrospective studies should encourage the emergency physician to selectively rewarm a severe hypothermic patient with extracorporeal circulation under prolonged CPR.  相似文献   

4.
5.
On the basis of a case report the prehospital management of severely burned patients is discussed. The prevention of hypovolemia, hypothermia or hypoxemia are the primary targets. It is necessary to estimate the burn size and depth. The burn shock fluid resuscitation, prevention of hypothermia, pain- and airway management are described as well as the transport from the scene of accident to a proximal emergency unit or to a specialized burn intensive care unit.  相似文献   

6.
PURPOSE OF REVIEW: The new International Liaison Committee on Resuscitation documents, published in 2005, include important changes in pediatric resuscitation. Some issues that were left pending have since been supplemented with new studies. Their impact will be discussed here. RECENT FINDINGS: Studies on oxygen use for neonatal resuscitation have consistently found room air to be superior to 100% oxygen. Prospective studies indicate that intubation by first responders in preclinical resuscitation of children is dangerous and should probably be avoided. New studies point to a better neurological outcome with hypothermia in neurologically depressed neonates after perinatal asphyxia. SUMMARY: Resuscitation of 'depressed' near-term neonates should be started with an oxygen content of less than 100%, and only change to 100% if the child remains bradycardic and cyanotic. A neonate who can be resuscitated with room air will receive no benefit from 100% oxygen and may even have a worse outcome. If the first responder in a pediatric emergency is out of training with pediatric intubation he or she should feel reassured that resuscitation without an attempt at endotracheal intubation is acceptable. Presently, hypothermia in neonates after birth asphyxia should be used within controlled studies, or at least follow the protocols of published studies and be performed in specialized centers.  相似文献   

7.
In Germany 100,000–160,000 people suffer from out-of-hospital cardiac arrest (OHCA) annually. The incidence of cardiopulmonary resuscitation (CPR) after OHCA varies between emergency ambulance services but is in the range of 30–90 CPR attempts per 100,000 inhabitants per year. Basic life support (BLS) involving chest compressions and ventilation is the key measure of resuscitation. Rapid initiation and quality of BLS are the most critical factors for CPR success. Even healthcare professionals are not always able to ensure the quality of CPR measures. Consequently in recent years mechanical resuscitation devices have been developed to optimize chest compression and the resulting circulation. In this article the mechanical resuscitation devices currently available in Germany are discussed and evaluated scientifically in context with available literature. The ANIMAX CPR device should not be used outside controlled trials as no clinical results have so far been published. The same applies to the new device Corpuls CPR which will be available on the market in early 2014. Based on the current published data a general recommendation for the routine use of LUCAS? and AutoPulse® CPR cannot be given. The preliminary data of the CIRC trial and the published data of the LINC trial revealed that mechanical CPR is apparently equivalent to good manual CPR. For the final assessment further publications of large randomized studies must be analyzed (e.g. the CIRC and PaRAMeDIC trials). However, case control studies, case series and small studies have already shown that in special situations and in some cases patients will benefit from the automatic mechanical resuscitation devices (LUCAS?, AutoPulse®). This applies especially to emergency services where standard CPR quality is far below average and for patients who require prolonged CPR under difficult circumstances. This might be true in cases of resuscitation due to hypothermia, intoxication and pulmonary embolism as well as for patients requiring transport or coronary intervention when cardiac arrest persists. Three prospective randomized studies and the resulting meta-analysis are available for active compression-decompression resuscitation (ACD-CPR) in combination with an impedance threshold device (ITD). These studies compared ACD-ITD-CPR to standard CPR and clearly demonstrated that ACD-ITD-CPR is superior to standard CPR concerning short and long-term survival with good neurological recovery after OHCA.  相似文献   

8.
Multiple trauma patients frequently demonstrate a hypothermic core temperature, defined as a temperature below 35°C, already at admission in the emergency room. As a drop of the core temperature below 34°C has been shown to be associated with a significant increase in post-traumatic complications, this limit is considered to be critical in these patients. Multiple trauma patients with hypothermia demonstrate a markedly increased mortality rate compared to normothermic patients with the same injury severity. Therefore effective rewarming measures are essential for adequate bleeding control and successful resuscitation. If and to what extent the induction of controlled hypothermia in the early phase of treatment on the intensive care unit after resuscitation and operative bleeding control can contribute to an improved post-traumatic outcome, has to be clarified in further experimental and clinical studies.  相似文献   

9.
Various new techniques have been developed in recent years to improve the emergency management of children. Practice concepts have been tested for efficiency and unwanted effects in animal experiments and clinical studies. An electrical hand-held drill has been developed which allows rapid and efficient placement of an intraosseous vascular access. The early use of a laryngeal mask for airways in children who are difficult to ventilate with a bag and mask is now recommended in the current guidelines of the European Resuscitation Council for personnel trained in this method. The laryngeal tube (which is very effective and easy to place in adults) has been reported to be less efficient in children in these circumstances. The chest compression-ventilation ratio has been changed to 15:2 for children to achieve better training efficiency and better coronary perfusion. High dose adrenalin should not be used in the resuscitation of children. The application of hypothermia may be considered in children who remain comatose after resuscitation but the data are less clear in children than in adults, as its use in children has resulted in adverse outcomes and the cause and sequence of cardiac arrest differs between children and adults. Until further research can clarify the situation, a decision to use hypothermia must be made in an individualized manner. Decisive for the treatment of septic shock is the early and aggressive use of volume therapy.  相似文献   

10.
BACKGROUND: Although hypothermia often occurs after trauma and has protective effects during ischemia and organ preservation, it remains unknown whether maintenance of hypothermia or restoring the body temperature to normothermia during resuscitation has any deleterious or beneficial effects on heart performance and organ blood flow after trauma-hemorrhage. METHODS: Male rats underwent laparotomy (i.e., induced trauma) and were exsanguinated to and maintained at a mean arterial pressure of 40 mm Hg until 40% of the maximum shed volume was returned in the form of Ringer's lactate. Body temperature decreased from approximately 36.5 degrees C to below 32 degrees C. The animals were then resuscitated with four times the volume of maximal bleedout with Ringer's lactate. In one group, body temperature was rewarmed to 37 degrees C during resuscitation. In another group, body temperature was maintained at hypothermia (32 degrees C) for 4 hours after resuscitation. In an additional group, the body temperature was kept at 37 degrees C during hemorrhage as well as during resuscitation. Left ventricle performance parameters such as maximal rate of left ventricular pressure increase and decrease (+/-dP/dt(max)) were measured up to 4 hours. Cardiac output and regional blood flow were determined by radioactive microspheres at 4 hours after the completion of resuscitation. RESULTS: The maintenance of normothermia during hemor. rhage or prolonged hypothermia after resuscitation depressed the left ventricular performance parameters, cardiac output, and regional blood flow in various organs. Rewarming the body to normothermia during resuscitation, however, significantly increased heart performance, cardiac output (from hypothermia 16.2 +/- 1.4 to 22.3 +/- 1.4 mL/min per 100 g body weight,p < 0.05) and total hepatic blood flow (from hypothermia 117.5 +/- 5.3 to 166.0 +/- 9.3 mL/min per 100 g tissue, p < .05). CONCLUSION: Our data indicate that restoration of normothermia during resuscitation improves cardiac function and hepatic blood flow compared with hypothermia.  相似文献   

11.
Gaining vascular access in a neonate during cardiopulmonary resuscitation is crucial and challenging. Intraosseous (IO) access can offer a fast and reliable method for achieving emergency access for fluids and drugs when venous access fails in a critically ill child. IO access can however result in rare, but serious adverse events including compartment syndrome and amputation. We describe a case resulting in leg amputation due to IO infusion in a neonate after resuscitation and therapeutic hypothermia. We compared 10 tibia X‐rays in three age groups. The mean medullary diameter of the proximal tibia at the recommended site for IO access was 7 mm in neonate, 10 mm in 1‐ to 12‐month‐old infants, and 12 mm in 3‐ to 4‐year‐old children. This provides a narrow margin of safety for the correct positioning and the avoidance of dislodgement of the IO needle. The correct position of the IO needle should be confirmed by bone marrow aspiration and fluid bolus. Unnecessary touching of the IO needle after fixing it in place should be avoided by inserting a luer‐lock catheter with a three‐way stop‐cock for IO drug and fluid administration. Regular observation of the circulation and possible swelling of the leg should be performed. The IO administration of inotropic infusions should also be avoided after the initial resuscitation phase. When treating with therapeutic hypothermia, it may be wise to remove the IO needle much earlier than the currently recommended 24 h because of the problems in peripheral circulation and its monitoring.  相似文献   

12.
Therapeutich hypothermia (TH) has been shown to improve neurological outcome and survival after witnessed cardiac arrest (CA) that is due to ventricular fibrillation. Although TH is widely used following witnessed CA as well as all forms of initial rhythm, the mortality rate after CA remains unacceptably high, and additional study is needed to understand when and how to implement hypothermia in the post-resuscitation phase. Experimental studies have emphasized the importance of initiating cooling soon after the return of spontaneous circulation (ROSC) or even during cardiopulmonary resuscitation (CPR). Clinical studies have shown that pre-hospital induction of hypothermia is feasible and has no major adverse events-even when used intra-arrest-and may provide some additional benefits compared to delayed in-hospital cooling. Thus, hypothermia use should not be limited to the Intensive Care Unit but can be initiated in the field/ambulance or in the Emergency Department, then continued after hospital admission- even during specific procedures such as coronary angiography-as part of the global management of CA patients. Various methods (both non-invasive and invasive) are available to achieve and maintain the target temperature; however, only some of these methods-which include cold fluids, ice packs, iced pads and helmet and trans-nasal cooling- are easily deployed in the pre-hospital setting.  相似文献   

13.
The success of the patient’s hospital treatment depends to a large extent on the primary care, which in the case of cardiopulmonary resuscitation takes place largely outside of the hospital (preclinical management). It is just as important to coordinate treatment measures in the sense of a rescue chain as to elaborate “clinical pathways” and “standard operating procedures” and to implement them into everyday clinical practice. In terms of quality of structure, treatment, and outcome of patient care, particularly after cardiopulmonary resuscitation there is still a need for implementing application of mild therapeutic hypothermia as well as early defibrillation for in-hospital circulatory arrest due to ventricular fibrillation or pulse-less ventricular tachycardia. More importance should be attached to early recognition of patients with imminent disturbances of vital functions. Establishing such structures (cardiac alarm team, medical emergency team) is associated with in-hospital expenditures for personnel, material, and organization. The costs for these have to be calculated by the providers with regard to avoiding incidents and ultimately the patients’ outcome and thus the accumulated costs for each case.  相似文献   

14.
背景 失血性休克(hemorrhagic shock,HS)是导致人类死亡和致残的重要原因,与患者转归密切相关,目前尚缺乏理想的复苏方案.目的 综述损伤控制性复苏(damage control resuscitation,DCR)研究进展.内容 DCR是较新的整合性复苏策略,已被广泛应用于创伤急救、心脏外科、妇产科等多个手术领域.由于凝血机制的破坏,HS患者常伴有创伤性凝血病、低体温和酸中毒.DCR推荐对HS患者进行允许性低压复苏、止血复苏和损伤控制性手术的处理.DCR不仅可以提高复苏效果,还能减少休克相关并发症.趋向 DCR在HS处理中有良好应用前景,然而尚需进一步研究使其完善.  相似文献   

15.
Post‐resuscitation care has changed in the last decade, and outcome after cardiac arrest has improved, thanks to several combined measures. Induced hypothermia has shown a treatment benefit in two randomized trials, but some doubts remain. General care has improved, including the use of emergency coronary intervention. Assessment of neurological function and prognosis in comatose cardiac arrest patient is challenging, especially when treated with hypothermia. In this review, we evaluate the recent literature and discuss the available evidence for prognostication after cardiac arrest in the era of temperature management. Relevant literature was identified searching PubMed and reading published papers in the field, but no standardized search strategy was used. The complexity of predicting outcome after cardiac arrest and induced hypothermia is recognized in the literature, and no single test can predict a poor prognosis with absolute certainty. A clinical neurological examination is still the gold standard, but the results need careful interpretation because many patients are affected by sedatives and by hypothermia. Common adjuncts include neurophysiology, brain imaging and biomarkers, and a multimodal strategy is generally recommended. Current guidelines for prediction of outcome after cardiac arrest and induced hypothermia are not sufficient. Based on our expert opinion, we suggest a multimodal approach with a continuous evaluation of prognosis based on repeated neurological examinations and electroencephalography. Somatosensory‐evoked potential is an established method to help determine a poor outcome and is recommended, whereas biomarkers and magnetic resonance imaging are promising adjuncts. We recommend that a decisive evaluation of prognosis is performed at 72 h after normothermia or later in a patient free of sedative and analgetic drugs.  相似文献   

16.
A case report is described with successful outcome of prolonged cardiopulmonary resuscitation in a 30-year-old man suffering from acute deep hypothermia. His lowest temperature recorded was 23 degrees C. Continuous external cardiac massage was required for a total of 4.5 h whilst rewarming was instituted. The patient eventually left hospital with no permanent sequelae. A review of hypothermia follows, emphasising some important management principals and pitfalls.  相似文献   

17.
To define the part played by mild-to-moderate hypothermia in neuroprotection, it is necessary to take into account the thermoregulatory responses that occur in the normal human as the change in central temperature exceeds 0.2 °C. The mechanisms induced by cold are cutaneous vasoconstriction and shivering. They must be suppressed before starting controlled hypothermia. In these conditions, controlled moderate hypothermia between 32 and 35 °C dœs not seem to have deleterious side-effects, especially on coagulation. Caution is needed with the analysis of the numerous papers reporting experiments concerning the effects of moderate hypothermia in animals with induced cerebral ischaemia because of significant differences in the study designs. These differences concern mainly the time of onset of hypothermia, viz before or after ischaemia, the fact that the ischaemia is either global or focal, that it is caused by vascular occlusion posttraumatic or initiated by hypo or hyperglycemia. Some differences are also existing in the criteria used to appreciate the neuronal damage, as well as in the level of temperature and the site where it is measured. The mechanism of neuroprotectionfrom moderate hypothermia seems to be not only a decrease in cerebral metabolism, but also involves a specific action on some intra-cellular events such as the blocking of the release of glutamate and of lipid peroxydation in brain tissue. An indirect proof of the neuroprotective effect of moderate hypothermia is the increase in the neuronal damage induced by moderate hyperthermia. It is conceivable that moderate hypothermia could exert a better neuroprotective effect than the drugs having this reputation, such as barbiturates, isoflurane and propofol. The possible induction of hypothermia into experiments concerning barbiturate or isoflurane protection could even explain the protection observed, as this has been proven for anti NMDA, MK-801. The few clinical studies already published do not show obvious differences allowing to recommend moderate hypothermia as a standard technique among the therapeutic modalities used for cerebral protection for intracerebral vascular surgery or cerebral resuscitation after severe head trauma. However, the experimental results are strong enough to justify futur controlled clinical studies. The prevention of brain hyperthermia may also emerge as a major objective of resuscitative intervention.  相似文献   

18.
ILCOR hot topics     
Cardiovascular disease is the world’s leading cause of death. Extrapolation of a representative incidence and survival analysis from cardiac arrest in all rhythms treated by the emergency medical services (out-of-hospital cardiac arrest, OHCA) leads to numbers of 350,000 persons who experience OHCA in Europe [10]. The number mentioned above and the fact that the impact of single therapeutic measures on improvement of individual survival is unclear requires standard procedures that lead to the best possible outcome for as many patients as possible. Beyond the actions of basic life support, only a few advanced life support measures have definitely proven to be of value for ROSC (return of spontaneous circulation) and improved neurological outcome: defibrillation, some pharmacological interventions and hypothermia. ILCOR (International Liaison Committee on Resuscitation) is co-ordinating again an evidence-based review of resuscitation science, which will culminate in a Consensus Conference in February 2010. This will provide material for the ERC to write the new resuscitation guidelines. What changes can we expect?  相似文献   

19.
Seventy-four patients were admitted after cardiac resuscitation to a general intensive care unit; 19, of whom 14 were neurologically normal, were utimately discharged from hospital. It is suggested that elderly patients, those who have had prolonged resuscitation, and patients with a combination of hypothermia, coma, dilated pupils, and apnoea have a very poor prognosis. It is doubtful whether such patients benefit from admission to an intensive care unit.  相似文献   

20.
BackgroundSurvival benefits of mild hypothermia in animals suffering from uncontrolled hemorrhagic shock (HS) may be influenced by trauma severity. We hypothesized that mild hypothermia would improve early outcomes based on our rabbit model of severe traumatic HS.Materials and methodsFifty male New Zealand rabbits weighing between 1.6 and 2.2 kg were randomized into one of the five groups: group 1 (sham), group 2 (37°C/80 mm Hg), group 3 (37°C/40 mm Hg), group 4 (34°C/80 mm Hg), and group 5 (34°C/40 mm Hg). Under urethane anesthesia, animals that suffered fractures and uncontrolled HS received prehospital fluid resuscitation (aggressive or limited) with temperature controlled at normothermia or mild hypothermia, hemostasis, and hospital resuscitation followed by observation.ResultsMild hypothermia significantly improved cardiac systolic function and decreased lung wet-to-dry weight ratios and total injury score compared with normothermia. Group 5 manifested the best results in lung injury. The decreased base excess and pH and increased lactate levels during HS and limited fluid resuscitation were not exacerbated by mild hypothermia. Electrolytes including potassium and calcium and blood glucose levels as well as coagulation were not significantly influenced after mild hypothermia treatment. Seven-hour survival in the hypothermic groups was higher than that in the normothermic groups, although there was no significant difference in survival between groups 5 and 3.ConclusionsTherapeutic mild hypothermia improves early outcomes through improving lung and cardiac performance without causing evident homeostasis disturbances in the rabbit model of traumatic uncontrolled HS. Animals may benefit most under the combination treatment with mild hypothermia and limited fluid resuscitation.  相似文献   

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