Annals of emergency medicine
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Adrenergic therapy is indicated during CPR to increase the coronary and cerebral perfusion pressure. Epinephrine hydrochloride at a dosage of 1.0 mg has been the most commonly used adrenergic agonist for resuscitation of adults, but there has been considerable controversy over whether higher doses should be given. ⋯ There were no consistent adverse effects associated with the use of higher-than-standard doses of epinephrine. The consensus of the Adrenergic Agonist Panel was that: 1) epinephrine by i.v. bolus should remain the drug of choice for use during resuscitation in adults; 2) data presented from the clinical trials in adults do not support an increase in the recommended dose of epinephrine; 3) because there was no evidence of significant harm from the use of high-dose epinephrine, it was felt that use of such dosages should receive a II-b recommendation pending the results of further ongoing clinical trials; 4) the standard i.v. bolus dosage of epinephrine should be simplified to 1.0 mg every three to five minutes; and 5) the endotracheal dosage of epinephrine should be at least 2 to 2.5 times larger than the peripheral i.v. dosage.
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Although endotracheal intubation is still the most definitive technique for airway management in patients with cardiac or respiratory arrest, in some emergency care systems, use of endotracheal intubation by prehospital care personnel has been restricted by policy or statute. Therefore, alternative airway devices have been developed. These alternative airway devices include the Esophageal Obturator Airway (EOA) and Esophageal Gastric Tube Airway (EGTA), the Pharyngeotracheal Lumen Airway (PTL), and the Esophageal-Tracheal Combitube (ETC). ⋯ Therefore, proper training and expert medical supervision probably have more influence on the successful use and impact of these devices than any other factors related to the devices themselves. Future training efforts would be most useful if directed at proper endotracheal intubation training and development of improved basic ventilatory skills. Nevertheless, additional controlled, direct-comparison studies of the PTL and ETC devices are recommended and should be conducted in properly supervised emergency medical services systems.
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Submersion injury is so often lethal because it inflicts severe hypoxia. To prevent hypoxic end-organ damage to the heart and brain, the goals of resuscitation are immediate ventilation and oxygenation. Issue 1: Should submersion victims receive the Heimlich maneuver? The pathophysiologic assumptions for this intervention are that water in the airway is obstructive, thus precluding ventilation, and that aspiration of water is the major injury. ⋯ With inadequate data to support benefit from the Heimlich maneuver and concern that the Heimlich maneuver would delay initiation of ventilation, basic life support procedures are recommended in managing the airway of the submersion victim. Issue 2: What is the role of prehospital care? Outcomes of submersion victims treated with rapid, aggressive prehospital care show that the window for medical intervention for the submersion victim is in the prehospital setting, not in the emergency department or intensive care unit. The submersion victim should be provided advanced cardiac life support, including intubation as needed, as soon as possible.
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CPR has been incorporated into emergency cardiac care with the evolution of both basic and advanced life support components. To date, however, the psychological issues associated with these skills have not been addressed. ⋯ This paper describes ongoing research on the impact of CPR on the rescuer, discusses a method of talking to families after a loved one has suddenly died, and provides insights into the psychological dysfunctions that emergency personnel may be exposed to. The technique and importance of critical incident debriefing following an unsuccessful CPR attempt is discussed.