Fernando L. Benitez

Mechanical devices for cardiopulmonary resuscitation

Purpose of the reviewFor over 40 years, manual chest compressions have been the foundation of cardiopulmonary resuscitation and recent studies have clearly reconfirmed the hemodynamic significance of delivering consistent, high-quality, infrequently-interrupted chest compressions. However, there remain multiple inadequacies in the actual delivery of manual chest compressions during cardiopulmonary resuscitation. One potential solution is use of adjunct mechanical devices. Recent findingsTwo different methods of accessory chest compression techniques recently have demonstrated enhanced short-term survival. The active compression-decompression device is a hand-held, manually operated suction device applied to the center of the chest wall. In tandem with an impedance threshold (airway) device, active compression-decompression has shown a 65% improvement in 24-hour survival rates (compared with standard cardiopulmonary resuscitation) in a randomized out-of-hospital clinical trial (n = 210). The second device, called Auto-Pulse CPR is an automated machine that uses a load-distributing, broad compression band that is applied across the entire anterior chest. A recent out-of-hospital retrospective case-control study (n = 162) also revealed improved short-term survival. SummaryHigh quality chest compressions during cardiopulmonary resuscitation are critical elements in effecting successful resuscitation following a cardiac arrest. Recent studies utilizing adjunct mechanical devices have not only revealed significant increases in the effectiveness of chest compressions, including improved hemodynamics in both animal models and human studies, but also improvements in short-term human survival in the clinical setting. It is hoped that these promising findings will eventually be corroborated in terms of improved neurologically intact, long-term patient survival. Clinical trials are currently underway to validate such efficacy.

Role of the physician in prehospital management of trauma: North American perspective.

To some extent or another, physicians have been involved in emergency medical services (EMS) systems in North America for decades. Over the years, physicians from different specialties have been involved with EMS, occasionally as full-time or part-time employees of the EMS system but more often on a voluntary or small contractual basis. Regardless of the employment relationship, most states and provinces now require by statute that each EMS system, particularly those providing advanced life support (ALS) services, have a designated EMS medical director. However, in the United States and most of Canada, such physicians typically oversee EMS systems by acting as administrative medical supervisors, educators, mentors, and, in some cases, even as system managers. Throughout many European countries, the physician is the primary care provider for a large percentage of the serious prehospital medical emergencies. In contrast, throughout North America, basic emergency medical technicians (EMTs) and paramedics (specially trained ALS providers) serve as the EMS system medical directors surrogates. In this system of care, such physician surrogates provide almost all of the prehospital medical care interventions without any on-scene physician presence. Nevertheless, because of their medical supervisory requirements, by statute, North American medical directors generally are still accountable for patient care. Therefore, in many areas of the United States and Canada, the responsible physicians also respond to EMS scenes on a routine basis. They do so, both announced and unannounced, independently or with EMS personnel. In this capacity, they can serve as a direct patient care resource for the EMTs, paramedics, and the patients themselves. However, by becoming an intermittent participating member of the EMS team in the unique out-of-hospital setting, these on-scene physicians can help to better scrutinize the care rendered and thus more effectively modify applicable protocols and training as needed. Historically, such practices have helped many EMS systems—not only in terms of reforming traditional protocols but also by helping to establish improved medical care priorities and even system management changes that affect patient care. In addition, active participation helps the accountable EMS physician not only to identify weaknesses in personnel skills and system approaches, but it also provides an opportunity for role modeling, both medically and managerially.

Recurrent life-threatening ventricular dysrhythmias associated with acute hydrofluoric acid ingestion: Observations in one case and implications for mechanism of toxicity

Introduction. Hydrofluoric acid (HF) is a weak inorganic acid used for etching and as rust remover. Systemic toxicity is manifested as ventricular dysrhythmias. The mechanisms for these dysrhythmias are not well elucidated. Case report. An 82-year-old woman ingested 8 ounces of 7% HF. Shortly after emergency department (ED) arrival, she became pulseless, developing recurrent ventricular dysrhythmias. She was defibrillated 17 times and received several doses of calcium, magnesium, and lidocaine. After three hours, she returned to sustained NSR. She was discharged home after four days. Discussion. The electrocardiographic findings in this patient demonstrate hypocalcemia, which has been implicated as the culprit in HF-induced arrhythmias. However, despite correction of the hypocalcemia, the ventricular arrhythmias persisted. The proposed mechanisms of systemic HF toxicity and the relevant literature are discussed. Conclusion. Ventricular dysrhythmias due to HF toxicity seem to be independent of either hypocalcemia or hyperkalemia. Systemic toxicity after ingestions may be delayed and precipitous.

Serotonin Syndrome with Elevated Paroxetine Concentrations

OBJECTIVE To describe a case of serotonin syndrome due to paroxetine and ethanol. CASE SUMMARY A 57-year-old white man was brought to the emergency department one day after ingesting paroxetine 3600 mg and a pint of hard liquor. He denied the use of any other drug or herbal products and regular use of alcohol. Upon arrival to the hospital, vital signs were blood pressure 188/103 mm Hg, heart rate 114 beats/min, respiratory rate 28 breaths/min, temperature 36.8 °C, and O2 saturation 96% on room air. Findings on physical examination included dilated pupils, facial flushing, diaphoresis, shivering, myoclonic jerks, tremors, and hyperreflexia. A tentative diagnosis of serotonin syndrome was made. Initially, cyproheptadine 8 mg was administered orally with no observable effect. An additional 12 mg was given in 3 doses over 24 hours. Symptoms abated slowly over the next 6 days, during which a thorough evaluation failed to reveal any other potential causes for the patients condition. Serum paroxetine concentrations at 27.5 and 40 hours after ingestion were 1800 and 1600 ng/mL, respectively (normal 20–200 ng/mL). DISCUSSION Serotonin syndrome is rarely reported in patients taking only one serotonergic medication. Although serum paroxetine concentrations have not been shown to correlate with efficacy or toxicity, our patients serum paroxetine concentration was 9 times the upper end of the therapeutic range. Cyproheptadine, which has been suggested as a therapy, did not appear beneficial in this patient. Use of the Naranjo probability scale indicated a probable relationship between the serotonin syndrome and the overdose of paroxetine taken by this patient. CONCLUSIONS More studies are needed to better assess the role of cyproheptadine and other serotonin antagonists in the management of the serotonin syndrome. Regardless of the use of cyproheptadine or other agents, attention should be paid to fluid status, decontamination, and management of hyperthermia, agitation, and seizures.

The Lifesaving Potential of Specialized On-Scene Medical Support for Urban Tactical Operations

Since the 1980s, the specialized field of tactical medicine has evolved with growing support from numerous law-enforcement and medical organizations. On-scene backup from tactical emergency medical support (TEMS) providers has not only permitted more immediate advanced medical aid to injured officers, victims, bystanders, and suspects, but also allows for rapid after-incident medical screening or minor treatments that can obviate an unnecessary transport to an emergency department. The purpose of this report is to document one very explicit benefit of TEMS deployment, namely, a situation in which a police officers life was saved by the routine on-scene presence of specialized TEMS physicians. In this specific case, a police officer was shot in the anterior neck during a law-enforcement operation and became moribund with massive hemorrhage and compromised airway. Two TEMS physicians, who had been integrated into the tactical law-enforcement team, were on scene, controlled the hemorrhage, and provided a surgical airway. By the time of arrival at the hospital, the patient had begun purposeful movements and, within 12 hours, was alert and oriented. Considering the rapid decline in the patients condition, it was later deemed by quality assurance reviewers that the on-scene presence of these TEMS providers was lifesaving.

Man With a Rash

A 48-year-old man with a history of hypertension and medication noncompliance presented to the emergency department, complaining of a generalized pruritic rash for 2 weeks that began at both ankles and spread to his knees, back, and arms. He observed polydipsia but denied other medical problem or rashes, allergens, travel, infectious agents, medications, fever, or dysuria. On physical examination, he had a symmetric erythematous papular rash with firm centers that were creamy white but not pustular. No scaling or crust was present and there was sparing of the face, palms, and soles. The greatest concentration of lesions was on the extensor surfaces of the knees (Figures 1 and 2). A point-of-care glucose level was greater than 500 mg/dL. A laboratory test provided the diagnosis. Figure 1. The patient’s right knee. Figure 2. A close-up image of the patient’s left knee.