Paul E. Pepe

Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries

Background Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso. Methods We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure ≤ 90 mm Hg. The study setting was a city with a single centralized system of prehospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room. Results Among the 289 patients who received...

Clinical predictors of the adult respiratory distress syndrome

One hundred thirty-six patients meeting our criteria for one or more of eight clinical conditions were prospectively observed for the development of the adult respiratory distress syndrome. A high risk population was identified, including those with sepsis syndrome (38 percent), documented aspiration of gastric contents (30 percent), multiple emergency transfusions (24 percent), and pulmonary contusion (17 percent). The risk from multiple major fractures appeared low but contributed to the risk from other factors. The risk associated with just one factor (25 percent) was compounded by the presence of two (42 percent) and three (85 percent) simultaneous factors, and this finding was more predictive of ARDS than the injury severity score or initial arterial oxygenation. Of the ARDS cases, 76 percent occurred in the initial 24 hours after meeting the criteria. ARDS did not occur after 72 hours unless there was late development of sepsis (3 of 136 patients).

A Comparison of Standard-Dose and High-Dose Epinephrine in Cardiac Arrest outside the Hospital

BACKGROUND Experimental and uncontrolled clinical evidence suggests that intravenous epinephrine in doses higher than currently recommended may improve outcome after cardiac arrest. We conducted a prospective, multicenter study comparing standard-dose epinephrine with high-dose epinephrine in the management of cardiac arrest outside the hospital. METHODS Adult patients were enrolled in the study if they remained in ventricular fibrillation, or if they had asystole or electromechanical dissociation, at the time the first drug was to be administered to treat the cardiac arrest. Patients were randomly assigned to receive either 0.02 mg of epinephrine per kilogram of body weight (standard-dose group, 632 patients) or 0.2 mg per kilogram (high-dose group, 648 patients), both given intravenously. RESULTS In the standard-dose group 190 patients (30 percent) had a return of spontaneous circulation, as compared with 217 patients (33 percent) in the high-dose group; 136 patients (22 percent) in the standard-dose group and 145 patients (22 percent) in the high-dose group survived to be admitted to the hospital. Twenty-six patients (4 percent) in the standard-dose group and 31 (5 percent) in the high-dose group survived to discharge from the hospital. Ninety-two percent of the patients discharged in the standard-dose group and 94 percent in the high-dose group were conscious at the time of hospital discharge. None of the differences in outcome between the groups were statistically significant. CONCLUSIONS In this study, we were unable to demonstrate any difference in the overall rate of return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, or neurologic outcome between patients treated with a standard dose of epinephrine and those treated with a high dose.

Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial.

The safety and efficacy of 7.5% sodium chloride in 6% dextran 70 (HSD) in posttraumatic hypotension was evaluated in Houston, Denver, and Milwaukee. Multicentered, blinded, prospective randomized studies were developed comparing 250 mL of HSD versus 250 mL of normal crystalloid solution administered before routine prehospital and emergency center resuscitation. During a 13-month period, 422 patients were enrolled, 211 of whom subsequently underwent operative procedures. Three hundred fifty-nine patients met criteria for efficacy analysis, 51% of whom were in the HSD group. Seventy-two per cent of all patients were victims of penetrating trauma. The mean injury severity score (19), Trauma Score plus Injury Severity Score (TRISS) probability of survival, revised trauma scores (5.9), age, ambulance times, preinfusion blood pressure, and etiology distribution were identical between groups. The total amount of fluid administered, white blood cell count, arterial blood gases, potassium, or bicarbonate also were identical between groups. The HSD group had an improved blood pressure (p = 0.024). Hematocrit, sodium chloride, and osmolality levels were significantly elevated in the Emergency Center. Although no difference in overall survival was demonstrated, the HSD group requiring surgery did have a better survival (p = 0.02), with some variance among centers. The HSD group had fewer complications that the standard treatment group (7 versus 24). A greater incidence of adult respiratory distress syndrome, renal failure, and coagulopathy occurred in the standard treatment group. No anaphylactoid nor Dextran-related coagulopathies occurred in the HSD group. Although this trial demonstrated trends supportive of HSD in hypotensive hemorrhagic shock patients requiring surgery, a larger sample size will be required to establish which subgroups of trauma patients might maximally benefit from the prehospital use of a small volume of hyperosmolar solution. This study demonstrates the safety of administering 250 mL 7.5% HDS to this group of patients.

A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest

STUDY OBJECTIVES To perform a population-based study addressing the demography, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest (PCPA). METHODS Prospective, population-based study of all children (17 years of age or younger) in a large urban municipality who were treated by EMS personnel for apneic, pulseless conditions. Data were collected prospectively for 3(1/2) years using a comprehensive data collection tool and on-line computerized database. Each child received standard pediatric advanced cardiac life support. RESULTS During the 3(1/2)-year period, 300 children presented with PCPA (annual incidence of 19. 7/100,000 at risk). Of these, 60% (n=181) were male (P =.0003), and 54% (n=161) were patients 12 months of age or younger (152,500 at risk). Compared with the population at risk (32% black patients, 36% Hispanic patients, 26% white patients), a disproportionate number of arrests occurred in black children (51.6% versus 26.6% in Hispanics, and 17% in white children; P <.0001). Over 60% of all cases (n=181) occurred in the home with family members present, and yet those family members initiated basic CPR in only 31 (17%) of such cases. Only 33 (11%) of the total 300 PCPA cases had a return of spontaneous circulation, and 5 of the 6 discharged survivors had significant neurologic sequelae. Only 1 factor, endotracheal intubation, was correlated positively with return of spontaneous circulation (P =.032). CONCLUSION This population-based study underscores the need to investigate new therapeutic interventions for PCPA, as well as innovative strategies for improving the frequency of basic CPR for children.

Recommended guidelines for uniform reporting of data from drowning: the “Utstein style”

This document presents the consensus of a group of international investigators who met to establish guidelines for the uniform reporting of data from studies of drowning incidents. The consensus process consisted of formal discussions at 3 international meetings as well as expert review, endorsements from multiple organizations, and invited recommendations from other interested parties. The concept of using consensus workshops to formulate guidelines is not new. Similar consensus guidelines for reporting surveillance and resuscitation research have been developed for both adult and pediatric cardiac arrest.1–3 The principal purpose of the recommendations in this advisory is to establish consistency in the reporting of drowning-related studies, both in terms of nomenclature and guidelines for reporting data. These recommendations are intended to improve the clarity of scientific communication and the comparability of scientific investigations. Improved clarity and comparability of future scientific reports will advance the clinical and epidemiological knowledge base. In turn, such studies can help identify appropriate prevention strategies as well as the best treatment for victims of drowning and can ultimately save lives. Laboratory and clinical investigators from many different specialties contribute to the multidisciplinary knowledge base of injury prevention and resuscitation science. Although diversity can be a strength, it can also be an obstacle because of the lack of a common language and communication between investigators from different backgrounds. In response to these problems, in June 1990 an international group of scientists concerned with research involving out-of-hospital cardiac arrest met at the Utstein Abbey in Stavanger, Norway. Participants discussed the lack of standardized nomenclature and definitions as a key problem in research reports. A second meeting, the Utstein Consensus Conference, was held in December 1990 in Brighton, England. Recommendations from this follow-up conference were published simultaneously in American and European journals.4,5 The report included uniform definitions, terminology, and …

A Reappraisal of Mouth-to-Mouth Ventilation During Bystander-Initiated Cardiopulmonary Resuscitation A Statement for Healthcare Professionals From the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association

Cardiopulmonary resuscitation (CPR) performed by bystanders clearly improves survival and victims of out-of-hospital cardiac arrest and other life-threatening conditions such as drowning and respiratory arrest.1 2 However, despite three decades of promulgation, CPR is not performed for the majority of victims who require lifesaving care.3 4 5 6 Studies have identified reticence to perform mouth-to-mouth ventilation as a significant barrier to more frequent performance of bystander CPR.1 7 8 9 10 11 12 13 In addition to acting as a barrier to initiation of CPR, the mouth-to-mouth ventilation component of CPR may have other adverse effects, such as promoting gastric insufflation14 15 16 17 or decreasing the percentage of time allocated to effective chest compression.18 19 20 Because early CPR plays a central role in saving lives, the Ventilation Working Group of the Basic Life Support (BLS) and Pediatric Life Support Subcommittees of the AHA Emergency Cardiovascular Care (ECC) Committee reviewed the scientific evidence on mouth-to-mouth ventilation. The ECC Committee and its subcommittees prepare guidelines and recommendations for providing emergency cardiovascular care and cardiopulmonary resuscitation in the United States and will formally review and publish updated guidelines in the year 2000. Although this report represents a focused analysis and serves as a consensus statement regarding the role of mouth-to-mouth ventilation during CPR, it is not intended to change any current AHA recommendations or guidelines for performance of CPR. The specific purpose of this report is to review the historical rationale for providing mouth-to-mouth ventilation during CPR and to critically analyze, using the available scientific literature, the following questions: (1) Does assisted ventilation during CPR result in improved physiological status or survival? (2) Are there adverse effects that result from inclusion of mouth-to-mouth ventilation in basic CPR techniques? (3) Could mouth-to-mouth ventilation be deferred or delayed …

Emergency center thoracotomy: impact of prehospital resuscitation.

Emergency center thoracotomy was performed at our facility on 389 patients from 1984 through 1989. There were no patients excluded from the study, and survival for all patients was 8.3% with survival rates of 15.2% and 7.3% for stab and gunshot wounds, respectively. Emergency center thoracotomy was performed on 42 patients suffering from isolated extrathoracic injuries with 7% survival. There were no survivors of blunt trauma in this study. Fifty-three percent of the patients arrived with cardiopulmonary resuscitation (CPR) in progress. The average time of prehospital CPR for survivors was 5.1 minutes compared with 9.1 minutes for nonsurvivors. Of the survivors, prehospital endotracheal intubation prolonged successful toleration of CPR to 9.4 minutes compared with 4.2 minutes for nonintubated surviving patients (p less than 0.001). Emergency center thoracotomy is useful in the resuscitation of victims dying of penetrating truncal trauma. Prehospital endotracheal intubation significantly lengthened the time of successful CPR.

Prehospital Endotracheal Intubation: Rationale for Training Emergency Medical Personnel

Endotracheal intubation by emergency medical services (EMS) personnel in the prehospital setting decreases morbidity and helps to improve the outcome of critically ill patients, especially those with cardiac or respiratory arrest, multiple injuries, or severe head trauma. The endotracheal tube facilitates better oxygenation and ventilation because it enhances lung inflation and protects the lungs from aspiration. No other alternative modality is as efficacious. Compared to physicians in general, properly instructed, well-supervised paramedics can be trained to perform this procedure safely and more efficiently in the emergency setting. The use of the endotracheal tube in the prehospital setting should be strongly encouraged and the training of EMS personnel in this skill should be given high priority.

Prospective MAST study in 911 patients

Nine hundred eleven patients with systolic blood pressures less than or equal to 90 mm Hg were randomized to MAST and No-MAST groups, and all taken to a single Level I Trauma Center. Epidemiologic analysis of etiology, age, race, sex, Trauma Scores, and Injury Severity Scores revealed the two groups to be statistically identical. Seven hundred eighty-four patients were analyzed in detail. The principal injury location was thorax in 41%, abdomen in 32%, extremity in 16%, head in 7%, and neck in 4%. In patients with head and extremity wounds, the mortality rate was clearly not a function of MAST use. In the chest, abdomen, and neck, MAST did not improve survival. Although the total prehospital time was 35.8 + 10.4 minutes for MAST patients and 32.5 +/- 10.7 minutes for No-MAST patients, 70% of patients with MAST had prehospital times greater than 30 minutes compared to 55% of the No-MAST patients. When the prehospital time was greater than 30 minutes, 31% of the MAST patients died, compared to 21% of the No-MAST patients. MAST application adversely affected the outcome most significantly for patients with cardiac and thoracic vascular injury. The overall mortality of 31% in the MAST group, compared to 25% in the No-MAST group was statistically significant (p = 0.05).