Resuscitation of the trauma patient: Restoration of hemodynamic functions using clinical algorithms

Two algorithms were developed for immediate fluid resuscitation and subsequent management of emergency trauma patients and critically ill postoperative patients. These algorithms were developed from decision rules based on objective physiologic values attained in patients surviving life-threatening shock and trauma. The improved mortality in prospective studies of these two algorithms supports the hypothesis that compensatory physiologic responses of survivors of life-threatening acute illness are major determinants of outcome. Therapy that supports these compensations and produces the survivor pattern was found to improve survival rates and reduce post-resuscitation complications. These prospective studies confirm the validity of an organized, coherent physiologic approach that has as its goal the achievement of optimal physiologic patterns in contrast to simple restoration of hemodynamic and chemical abnormalities to the normal range, as has been the endpoint of the traditional approach.     

Successful resuscitation using external cardiac pacing

The resuscitation of a patient with failure of a permanent artificial pacemaker is described. A mechanically inactive heart showed a variety of ineffective rhythms, and dissociation could not be overcome by drug therapy. The urgent need for artificial pacing presented problems that eventually were overcome. The time required to establish effective transvenous pacing would have prevented a favorable outcome if external cardiac pacing had not been available. External pacing maintained effective cardiac action for two hours and 55 minutes. The need for external cardiac pacing capability in EDs is considered.     

Interpretation of pediatric x-ray films by emergency department pediatricians

This study compared the interpretation of pediatric roentgenograms by emergency department pediatricians and radiologists. Data were available from 532 of 600 children who had 564 radiographic studies during a six-week period: 217 examinations of the chest, 200 of the extremities, 74 of the skull, 35 of the abdomen, and 38 of miscellaneous structures. The emergency department pediatricians and the radiologists were in agreement in 91.1% of the cases. Among the 50 of 564 (8.9%) discordant studies, only seven (1.2%) required changes in therapy. The results attest to the accuracy of emergency department pediatricians in interpreting the usual types of films ordered in their department. However, this group specifically erred in the identification of subtle fractures and the detection of abnormalities incidental to the primary purpose for which the film was obtained. Future educational programs should address these areas of deficiency.     

Resuscitation time in ventricular fibrillation — a prognostic indicator

Length of resuscitation in prehospital ventricular fibrillation patients was studied to define its relationship to survival. Five hundred sixty-five patients presenting with the initial rhythm of ventricular fibrillation to the Milwaukee County Paramedic System between January 1978 and April 1982 were resuscitated successfully. Pediatric patients and patients with trauma, poisoning, and drowning were excluded. Of the 565 resuscitated patients, 262 (46%) were discharged alive and 303 (54%) died during hospitalization. For all 565 patients the resuscitation time and times from arrival of paramedics until the first sustained pulse were plotted against survival to define a curve. The curve demonstrated rapidly declining survival rates for resuscitation time up to 20 minutes; thereafter, survival declined more gradually with respect to resuscitation time. The mean resuscitation time for those eventually discharged alive was 12.6 minutes, which was statistically shorter (P less than .0001) than the mean resuscitation time of 23.9 minutes for those who eventually died. The overall survival curve of witnessed arrest patients was not statistically different from that of unwitnessed patients. The survival curve of those patients receiving bystander cardiopulmonary resuscitation (CPR) was similar to the curve of those who received no CPR. We conclude that resuscitation time is a heretofore undefined significant predictor of survival of resuscitated prehospital ventricular fibrillation patients.     

Oxygen delivery and resuscitation

Modern concepts of oxygen delivery date from the work of Joseph Barcroft, who in 1920 classified deficits of oxygen delivery as "anoxic" when the blood is not filled with oxygen, "anemic" when hemoglobin concentration is low, or "stagnant" when blood flow is inadequate. These three pathologic states may occur singly or in combination, and may be quantitated by the expression: Oxygen delivery = cardiac output X arterial oxygen content Oxygen delivery is an extremely important physiologic concept for resuscitating critically ill patients because tissue availability of oxygen is totally dependent on oxygen delivery. However, other physiologic alterations also can alter tissue use of oxygen, even in the presence of adequate oxygen delivery. These include alterations of oxyhemoglobin dissociation, alterations in microcirculatory blood flow, the presence of carbon monoxide, and mitochondrial dysfunction. The major goal of resuscitation of seriously ill and injured patients is to provide them with sufficient oxygen to meet their metabolic requirements. These needs are significantly increased following shock, injury, and illness. Only by meeting these increased cellular oxygen demands can adequate cellular function be maintained and organ failure avoided.