David Crippen

Improved survival of hemorrhagic shock with oxygen and hypothermia in rats

A previously established model in awake rats of hemorrhagic shock (HS) with 25% spontaneous survival rate (without resuscitation) was used to evaluate the effects of 4 novel life-supporting first aid (LSFA) measures on survival time and rate. After shed blood volume (SBV) of 3.25 ml/100 g, withdrawn over 20 min, hemodynamic and respiratory responses were recorded to 3 h and survival to 24 h. The 5 groups of 20 rats each (total n = 100) were as follows: group I, controls without treatment; II, oxygen 100% inhalation; III, external cooling to rectal temperature 30 degrees C; IV, Ringers solution 5 ml/100 g rectally; and V, acoustic and surface stimuli for arousal. Survival rates were: control group I, 35% at 3 h and 15% at 24 h; oxygen group II, 75% (P less than 0.05 compared with group I) at 3 h and 60% (P less than 0.05 compared with group I) at 24 h; hypothermia group III, 65% at 3 h and 45% (P less than 0.05 compared with group I) at 24 h; rectal fluid group IV, 50% at 3 h and 40% at 24 h; stimulated group V, 15% at 3 h and 15% at 24 h. Compared with group I, median survival times during HS 0-3 h were longer in groups II and III; and self-resuscitation attempts were longer in groups II, III and IV. We conclude that in untreated severe hemorrhagic shock, chances of survival to delayed arrival of advanced life support with i.v. fluid resuscitation might be increased with O2 inhalation and/or moderate external cooling.

Disaster Reanimatology Potentials: A Structured Interview Study in Armenia. III. Results, Conclusions, and Recommendations

National medical responses to catastrophic disasters have failed to incorporate a resuscitation component. Purpose: This study sought to determine the lifesaving potentials of modern resuscitation medicine as applied to a catastrophic disaster situation. Previous articles reported the preliminary results (I), and methodology (II) of a structured, retrospective interview study of the 1988 earthquake in Armenia. The present article (III) reports and discusses the definitive findings, formulates conclusions, and puts forth recommendations for future responses to catastrophic disasters anywhere in the world. Results: Observations include: 1) The lack of adequate construction materials and procedures in the Armenian region contributed significantly to injury and loss of life; 2) The uninjured, lay population together with medical teams including physicians in Armenia were capable of rapid response (within two hours); 3) Due to a lack of Advanced Trauma Life Support (ATLS) training for medical teams and of basic first-aid training of the lay public, and scarcity of supplies and equipment for extrication of casualties, they were unable to do much at the scene. As a result, an undetermined number of severely injured earthquake victims in Armenia died slowly without the benefit of appropriate and feasible resuscitation attempts. Recommendations: 1) Widespread adoption of seismic-resistant building codes for regions of high seismic risk; 2) The lay public living in these regions should be trained in life-supporting first-aid (LSFA) and basic rescue techniques; 3) Community-wide emergency medical services (EMS) systems should be developed world-wide (tai-lored to the emergency needs of each region) with ATLS capability for field resuscitation; 4) Such systems be prepared to extend coverage to mass casualties; 5) National disaster medical system (NDMS) plans should provide integration of existing trauma-EMS systems into regional systems linked with advanced (heavy) rescue (public works, fire, police); and 6) New techniques and devices for victim extrication should be developed to enable rapid extrication of earthquake casualties within 24 hours.

Pro/con ethics debate: When is dead really dead?

Contemporary intensive care unit (ICU) medicine has complicated the issue of what constitutes death in a life support environment. Not only is the distinction between sapient life and prolongation of vital signs blurred but the concept of death itself has been made more complex. The demand for organs to facilitate transplantation promotes a strong incentive to define clinical death in a manner that most effectively supplies that demand. We consider the problem of defining death in the ICU as a function of viable organ availability for transplantation

Appropriate response to humanitarian crises

Pictures of the aftermath of the earthquake in Haiti have led to questions about the relief effort. Charles Krin and colleagues offer some advice for prospective volunteers

Ethics roundtable: 'Open-ended ICU care: Can we afford it?'

THE CASE The patient is a 27-year-old previously healthy male with a diagnosis of viral encephalitis with a lymphocytic pleocytosis on cerebrospinal fluid examination. For 3 months, he has been in status epilepticus (SE) on high doses of barbiturates, benzodiazepines, and ketamine and a ketogenic feeding-tube formula. He remains in burst suppression on continuous electroencephalography (EEG). He is trached and has a percutaneous endoscopic gastrostomy (PEG) feeding tube. He has been treated several times for pneumonia, and he is on a warming blanket and is on vasopressors to maintain his blood pressure. His vitals are stable and his lab work is within limits. The sedation is decreased under EEG guidance every 72 hours, after which he goes back into SE and heavy sedation is resumed. The latest magnetic resonance imaging (MRI) shows edema but otherwise no obvious permanent cortical damage. The family wants a realistic assessment of the likely outcome. The neurologist tells them the literature suggests the outlook is poor but not 100% fatal. As long as all of his other organs are functioning on life support, there is always a chance the seizures will stop at some time in the future, and so the neurologist recommends an open-ended intensive care unit (ICU) plan and hopes for that outcome.

CRITICAL CARE AND THE INTERNET: A Clinician's Perspective

The Internet holds great promise for clinicians because of its ability to access and consolidate large amounts of knowledge quickly and easily. As a result, information overload is occurring and physician users are finding it necessary to use creative and selective methods to digest this data. Physician users will have to discover new skills to determine authenticity and substance of data as they sift through mountains of coal looking for diamonds. Users will become an integral part of the evolution process, guiding the Internet towards merit and magnitude.

CRITICAL CARE TRANSPORTATION MEDICINE : NEW CONCEPTS IN PRETRANSPORT STABILIZATION OF THE CRITICALLY III PATIENT

Regionalization of health care for trauma has become commonplace, and the same concept for critically ill medical/surgical patients is developing. Recent evidence suggests that current stabilization measures used by transport teams can be inadequate for this critically ill patient population. In trauma, speed has been considered a necessity to get the patient to a facility which cannot be carried out to the field, eg, an operating room. For acute medical illnesses, critical care transport teams can bring intensive care technology to the patient. Accumulating evidence supports the premise that speed of transport is not as important as stabilization before transport, knowledge of hemodynamics during transport, and early use of critical care monitoring systems. Other reports identify the need for initial evaluation and stabilization of critically ill patients by physicians at the critical care level of expertise. Accordingly, critical care transportation teams have evolved, creating new notions of pretransport stabilization not applicable to previous transport systems.

Moral distress in medicine: Powerlessness by any other name.

In this issue of the Journal of Critical Care, Dodek et al [1] examine the subject of moral distress as it might pertain to the teammodel of health care delivery. The authors definemoral distress as “distresswhen practitioners are unable to practice according to their individual standards” and, further, as distress resulting from “conflicts between team members as to direction of care.” Moral distress ultimately stems from 3 problems: uncertainty about who is in charge, cost-cutting schemes that affect patient care, and adversarial end-of-life scenarios. These problems have existed inmedicine for years, and this article is not thefirst to describe them in detail [2-4]. They are easy to identify but much more difficult to rectify. They have been responded to with pleas for more education, counseling recommendations, advice about acceptance of circumstances unlikely to change, and the usual statement that more research is needed [5]. However, these responses are not solutions; they are merely means of accepting the state of being in moral distress and feeling better about it. Registered nurses are hospital employees who, traditionally at least, are responsible for accurately interpreting and implementing physician orders and providing comfort care to patients. Over the past decade, however, nurses have been providing more direct patient treatment, and physicians have assumed more of a supervisory role [6]. Advanced nursing practitioners (certified registered nurse anesthetists and certified registered nurse practitioners) have evenmore authority than registered nurses. These developments increase the uncertainty aboutwho is in charge. At this time, it is unclear how these changes in patient care provision will shake out. Nurses are not involved in cost containment decisions made at the congressional level; they have no say in the matter of cost cutting. If they are frustrated by the effects onpatient care, all they can do (besides grin and bear it) is move to a hopefully better job location or leave the profession. These actions affect morale and team enthusiasm on the ward but have no effect on cost-cutting policies. Physicians are more politically involved than nurses with decisions about cost containment, but they are still more observers than participants. The bureaucrats and technocratswhodesign cost-effective health care delivery (such as it is) rarely invite physicians to the table, for the simple reason that physicians advocate for individual patients, without regard to cost; they rarely advocate for the entire population [7]. As the guardians of patient comfort, many bedside nurses become frustrated by the insistence of families on prolongedmedically inappropriate care for intensive care patients in a death spiral [8]. In the United States, patients and their families have almost complete authority to

Very Elderly Patients in the ICU: Should There Be a Line in the Sand?

Critical Care Medicine www.ccmjournal.org 1527 *See also p. 1352.

Early recombinant activated factor VII for intracerebral hemorrhage reduced hematoma growth and mortality, while improving functional outcomes

Subjects: 399 adults age 18 years or older with spontaneous intracerebral hemorrhage documented by CT scanning within 3 hours of onset of symptoms. Exclusion criteria included a score of 3 to 5 on the Glasgow Coma Scale (indicating deep coma); planned surgical evacuation of hematoma within 24 hours after admission; secondary intracerebral hemorrhage related to aneurysm, arteriovenous malformation, trauma, or other causes; known use of oral anticoagulant agents; known thrombocytopenia; history of coagulopathy, acute sepsis, crush injury, or disseminated intravascular coagulation; pregnancy; preexisting disability; and symptomatic thrombotic or vasoocclusive disease within 30 days before the onset of symptoms of intracerebral hemorrhage. Midway through the trial, the last criterion was amended to exclude patients with any history of thrombotic or vaso-occlusive disease.