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Aufderheide T.P.,Medical College of Wisconsin | Frascone R.J.,Regions Hospital | Wayne M.A.,St Joseph Medical Center | Mahoney B.D.,Hennepin County Medical Center | And 8 more authors.
The Lancet

Active compression-decompression cardiopulmonary resuscitation (CPR) with decreased intrathoracic pressure in the decompression phase can lead to improved haemodynamics compared with standard CPR. We aimed to assess effectiveness and safety of this intervention on survival with favourable neurological function after out-of-hospital cardiac arrest. In our randomised trial of 46 emergency medical service agencies (serving 2·3 million people) in urban, suburban, and rural areas of the USA, we assessed outcomes for patients with out-of-hospital cardiac arrest according to Utstein guidelines. We provisionally enrolled patients to receive standard CPR or active compression-decompression CPR with augmented negative intrathoracic pressure (via an impedance-threshold device) with a computer-generated block randomisation weekly schedule in a one-to-one ratio. Adults (presumed age or age ≥18 years) who had a non-traumatic arrest of presumed cardiac cause and met initial and final selection criteria received designated CPR and were included in the final analyses. The primary endpoint was survival to hospital discharge with favourable neurological function (modified Rankin scale score of ≤3). All investigators apart from initial rescuers were masked to treatment group assignment. This trial is registered with ClinicalTrials.gov, number NCT00189423. 2470 provisionally enrolled patients were randomly allocated to treatment groups. 813 (68) of 1201 patients assigned to the standard CPR group (controls) and 840 (66) of 1269 assigned to intervention CPR received designated CPR and were included in the final analyses. 47 (6) of 813 controls survived to hospital discharge with favourable neurological function compared with 75 (9) of 840 patients in the intervention group (odds ratio 1·58, 95 CI 1·07-2·36; p=0·019]. 74 (9) of 840 patients survived to 1 year in the intervention group compared with 48 (6) of 813 controls (p=0·03), with equivalent cognitive skills, disability ratings, and emotional-psychological statuses in both groups. The overall major adverse event rate did not differ between groups, but more patients had pulmonary oedema in the intervention group (94 [11] of 840) than did controls (62 [7] of 813; p=0·015). On the basis of our findings showing increased effectiveness and generalisability of the study intervention, active compression-decompression CPR with augmentation of negative intrathoracic pressure should be considered as an alternative to standard CPR to increase long-term survival after cardiac arrest. US National Institutes of Health grant R44-HL065851-03, Advanced Circulatory Systems. © 2011 Elsevier Ltd. Source

Dries D.J.,Regions Hospital | Dries D.J.,University of Minnesota
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Introduction: There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation.Methods: An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area.Results: Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy.Conclusion: In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism. © 2010 Dries; licensee BioMed Central Ltd. Source

Wangensteen K.J.,University of Minnesota | Kalliainen L.K.,Regions Hospital | Kalliainen L.K.,University of Minnesota

A chart review was conducted of all patients receiving NeuraGen® conduits from 2002 to 2007 at Regions Hospital, a level I trauma center. Ninety-six patients underwent 126 repairs using NeuraGen® conduits, and 64 patients were seen in follow-up. Repairs were largely of upper extremity sensory nerves but six were repairs of nerves elsewhere in the body. There were no intra-operative complications, but there were two minor postoperative complications and one postoperative pulmonary embolus. Forty of 126 repairs were lost to follow-up. Twenty-six of 126 repairs had follow-up with quantitative testing of nerve recovery (2-point discrimination, Semmes-Weinstein, or EMG testing), with 35% reporting improvement and 31% going on to a revision operation. Sixty of 126 repairs had qualitative testing performed (subjective or objective reporting of sensation or motor function), with 45% reporting improvement and 5% going on to a revision operation. Patients who went on to revision surgery were more likely to have undergone quantitative evaluation of sensation. Overall, sensory recovery was in the 35-45% range in our experience. Our results indicate that NeuraGen® collagen conduits can be used safely throughout the body. © 2009 American Association for Hand Surgery. Source

Harris C.R.,Regions Hospital | Brown A.,Clinical Toxicology Section
Journal of Emergency Medicine

Background: Synthetic cannabinoid receptor agonists are becoming increasingly popular with adolescents as an abused substance. Chronic use of these drugs can lead to addiction syndrome and withdrawal symptoms similar to cannabis abuse. Due to their potential health risk, several countries have banned these substances. Objectives: To report the clinical presentation and legislation status of synthetic cannabinoids in "Spice" products and alert the health care community about the identification and risk assessment problems of these compounds. Case Reports: We retrospectively reviewed cases presenting to our Emergency Department (ED) during a 3-month period with chief complaints of Spice drug use before arrival. Six cases presented to our ED after using Spice drugs. Two patients were admitted after reporting seizures. All but one presented with tachycardia. Two patients had hallucinations. The average length of ED observation was 2.8 h. No patient with seizures had recurrent episodes. Conclusion: Spice drugs can cause potentially serious health care conditions that necessitate ED evaluation. Most cases can be discharged from the ED after a period of observation. Legal issues surrounding these drugs are yet to be finalized in the United States. Copyright © 2013 Elsevier Inc. Printed in the USA. All rights reserved. Source

Endorf F.W.,The burn Center | Dries D.J.,Regions Hospital
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost. Under resuscitation may lead to organ failure and death. With adoption of weight and injury size-based formulas for resuscitation, multiple organ dysfunction and inadequate resuscitation have become uncommon. Instead, administration of fluid volumes well in excess of historic guidelines has been reported. A number of strategies including greater use of colloids and vasoactive drugs are now under investigation to optimize preservation of end organ function while avoiding complications which can include respiratory failure and compartment syndromes. Adjuncts to resuscitation, such as antioxidants, are also being investigated along with parameters beyond urine output and vital signs to identify endpoints of therapy. Here we briefly review the state-of-the-art and provide a sample of protocols now under investigation in North American burn centers. © 2011 Endorf and Dries; licensee BioMed Central Ltd. Source

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