Jeffrey D. Ferguson

Part 1: Executive Summary 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

Part 1: Executive Summary

Mary Fran Hazinski, Co-Chair*; Jerry P. Nolan, Co-Chair*; John E. Billi; Bernd W. Böttiger; Leo Bossaert; Allan R. de Caen; Charles D. Deakin; Saul Drajer; Brian Eigel; Robert W. Hickey; Ian Jacobs; Monica E. Kleinman; Walter Kloeck; Rudolph W. Koster; Swee Han Lim; Mary E. Mancini; William H. Montgomery; Peter T. Morley; Laurie J. Morrison; Vinay M. Nadkarni; Robert E. O’Connor; Kazuo Okada; Jeffrey M. Perlman; Michael R. Sayre; Michael Shuster; Jasmeet Soar; Kjetil Sunde; Andrew H. Travers; Jonathan Wyllie; David Zideman

Part 15: First Aid 2015 American Heart Association and American Red Cross Guidelines Update for First Aid

The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force was formed in 2013 to review and evaluate the scientific literature on first aid in preparation for development of international first aid guidelines, including the 2015 American Heart Association (AHA) and American Red Cross Guidelines Update for First Aid . The 14 members of the task force represent 6 of the international member organizations of ILCOR. Before 2015, evidence evaluation for first aid was conducted by the International First Aid Science Advisory Board and the National First Aid Advisory Board. Although the group responsible for evidence evaluation has changed, the goals remain the same: to reduce morbidity and mortality due to emergency events by making recommendations based on an analysis of the scientific evidence. A critical review of the scientific literature by appointed ILCOR First Aid Task Force members and evidence evaluators resulted in consensus on science statements with treatment recommendations for 22 selected questions addressing first aid interventions. These findings are presented in “Part 9: First Aid” of the 2015 ILCOR International Consensus on First Aid Science With Treatment Recommendations ,1,2 and they include a list of identified knowledge gaps that may be filled through future research. The ILCOR treatment recommendations are intended for the international first aid community, with the understanding that local, state, or provincial regulatory requirements may limit the ability to implement recommended first aid interventions. The current AHA/American Red Cross First Aid guidelines are derived from this work. New topics found in the 2015 First Aid Guidelines Update include first aid education, recognition of stroke, recognition of concussion, treatment of mild symptomatic hypoglycemia, and management of open chest wounds. Other topics have been updated based on findings from the corresponding ILCOR reviews. The roots of first aid have been recorded throughout …

Part 17: First Aid

The American Heart Association (AHA) and the American Red Cross (Red Cross) cofounded the National First Aid Science Advisory Board to review and evaluate the scientific literature on first aid in preparation for the 2005 American Heart Association (AHA) and American Red Cross Guidelines for First Aid. 1 In preparation for the 2010 evidence evaluation process, the National First Aid Advisory Board was expanded to become the International First Aid Science Advisory Board with the addition of representatives from a number of international first aid organizations (see Table). The goal of the board is to reduce morbidity and mortality due to emergency events by making treatment recommendations based on an analysis of the scientific evidence that answers the following questions: View this table: Table. International First Aid Science Advisory Board Member Organizations A critical review of the scientific literature by members of the International First Aid Science Advisory Board is summarized in the 2010 International Consensus on First Aid Science With Treatment Recommendations ( ILCOR 2010 CPR Consensus ), from which these guidelines are derived.2 That critical review evaluates the literature and identifies knowledge gaps that might be filled through future scientific research. The history of first aid can be traced to the dawn of organized human societies. For example, Native American Sioux medicine men of the Bear Society were noted for treating battle injuries, fixing fractures, controlling bleeding, removing arrows, and using a sharp flint to cut around wounds and inflammation.3 Modern, organized first aid evolved from military experiences when surgeons taught soldiers how to splint and bandage battlefield wounds. Two British officers, Peter Shepherd and …

Part 13: First Aid 2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment Recommendations

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Dilution with Milk or Water”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets, co-copyrighted by the American Heart Association and American Red Cross, are available in PDF format and are open access.

Part 9: First Aid 2015 International Consensus on First Aid Science With Treatment Recommendations

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Part 9: First aid

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Analysis of Moonshine for Contaminants

Objectives: In the past, some moonshine products contained potentially toxic contaminants. Although moonshine production continues in the United States, no studies have analyzed the content of moonshine since the early 1960s. We hypothesize that moonshine continues to contain potentially toxic concentrations of contaminants. Methods: Forty‐eight samples of illicitly distilled moonshine were obtained from law enforcement agencies. An independent laboratory, blinded to both the moonshine source and a control sample of ethanol, conducted the analysis. Lead content was determined using atomic absorption spectrophotometry with a graphite tube atomizer. Alcohol content, including ethanol, acetone, isopropanol, methanol, and ethylene glycol, was determined using gas liquid chromatography with flame ionization detection. Results: Ethanol content ranged from 10.5% to 66.0% with a mean value of 41.2%. Lead was found in measurable quantities in 43 of 48 samples with values ranging from 5 to 599 parts per billion (ppb) with a mean value of 80.7 ppb. A total of 29 of 48 (60%) of samples contained lead concentrations above or equal to the EPA water guideline of 15 ppb. Methanol was found in only one sample at a concentration of 0.11%. No samples contained detectable concentrations of acetone, isopropanol, or ethylene glycol. Conclusions: Many moonshine samples contain detectable concentrations of lead. Extrapolations based on the described moonshine lead content suggest that chronic consumers of moonshine may develop elevated lead concentrations. Physicians should consider lead toxicity in the differential diagnosis when evaluating patients consuming moonshine.

Ondansetron as an effective antiemetic in the rural, out-of-hospital setting

with a rate of 120 beats per minute, and the percutaneous peripheral oxygen saturation was 90% on air; lower extremities appeared cool and edematous, whereas the remainder of the examination was normal. The electrocardiogram confirmed the presence of sinusal rhythm with no signs of ischemic injury. Blood tests yielded leucocytosis, renal failure, and increased D-dimer levels. A chest computed tomography scan was obtained and showed the presence of massive PE. Saline solution was rapidly administered intravenously and the patient was quickly transferred in our unit to perform thrombolytic therapy. On arrival, the patient appeared in shock, notwithstanding a large amount of fluid had been administered. A bedside US examination was performed by the emergency physician. US disclosed a normokinetic and not dilated right ventricle and an inferior vena cava with small diameter collapsing completely during inspiration; left ventricle resulted mildly dilated, hypertrophic, and hyperkinetic. In consideration of these findings, thrombolytic therapy was avoided and the patient underwent further fluid resuscitation and noradrenaline intravenous infusion after central venous catheter positioning. In the meanwhile, urine analysis showed signs of urinary tract infection and antibiotic was started. Over the following days, the patients condition gradually improved and urine culture detected the presence of Escherichia coli. Noradrenaline was stopped on the third day, and antibiotic continued for 10 days. The patient was discharged without complications. PE is a common clinical diagnosis with different clinical presentations in ED. PE with hemodynamic instability is a life-threatening event requiring thrombolytic therapy. Obstruction of pulmonary arteries induces an increase of right ventricular afterload entailing right ventricular dysfunction. The decreased right ventricular output reduces left ventricular preload and cardiac output causing hypotension and shock. US can easily detect the right ventricular dysfunction showing right ventricular enlargement, free wall hypokinesis with sparing of the apex, paradoxical septal motion, and inferior vein cava dilation without physiologic inspiratory collapse [4]. In patients with PE and normal hemodynamic parameters, US helps distinguish between subjects with intermediate and low risk. In patients with PE presenting with shock, the absence of echocardiographic signs of right ventricular dysfunction excludes PE as a cause of hemodynamic instability. In these patients, avoiding thrombolytic therapy and searching for alternative causes of shock are mandatory. US appears to be a useful tool in differential diagnosis of shock disclosing signs of cardiac tamponade, left ventricular hypokinesis, acute valvular dysfunction, and hypovolemia. In our case, the patient was diagnosed with PE but no echocardiographic signs of obstructive shock were discovered. On the contrary, US showed normal right ventricular dimensions and kinesis and normal left ventricular systolic function and signs of hypovolemia. A diagnosis of septic shock was made in consideration of history, clinical and US findings, and the patient was correctly managed with aggressive hemodynamic approach and antibiotic therapy. Determining the correct etiology and management of shock in ED patients is challenging. History and clinical findings may be scarce or misleading. Otherwise, emergency physicians are asked to take weighty decisions in a short time. Ultrasound is a goal-directed, rapid, and bedside technology widely available in ED and being able to resolve complicated clinical situations. As suggested by Hasanin and Kinsara [1], we pose the question whether US before initiating high-risk treatment (especially thrombolytic therapy) would affect the patient management and help avoiding complications.

Intubation Success after Introduction of a Quality Assurance Program Using Video Laryngoscopy

OBJECTIVE The deployment of video laryngoscopy devices that include recording capability presents a new and unique opportunity for medical directors to review prehospital patient encounters. We sought to evaluate the effect of introducing a video laryngoscope and video quality assurance program to an air medical program on measures of intubation success including overall success, first-pass success, success within 2 attempts, and the total number of attempts. METHODS This was a retrospective review of data collected on intubations by nurses and paramedics of the Virginia State Police Med-Flight 1 air medical program. RESULTS After introduction of the video laryngoscope and quality assurance program, the overall intubation success improved to 100% but did not reach statistical significance (95% confidence interval [CI], -4.40 to 12.57; P = .25). First-pass success improved from 76.19% to 92.86% (CI, 1.14-33.14; P = .02), whereas the average attempts declined from 1.31 to 1.09 per patient encounter (CI, -.41 to -.03; P = .02). Success within 2 attempts was 92.86% before the intervention and 98.21% after (CI, 4.25-17.82; P = .19). CONCLUSION Video laryngoscopy and a robust means for medical director oversight are important components of a high-performance airway management program and demonstrably improve intubation first-pass success.