Emergency medicine journal : EMJ
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Timely defibrillation and high-quality cardiopulmonary resuscitation (CPR) are the only pre-hospital interventions which have been demonstrated to save lives after OHCA (out-of-hospital cardiac arrest). Standard resuscitation using the advanced life support (ALS) algorithm specifies a period of two minutes of CPR after delivering a shock before re-assessing the rhythm and delivering a further shock if indicated. Recent work has focused on improving quality of CPR, but few studies have examined how effectively defibrillation is carried out in pre-hospital practice. This study aims to assess the timing of shocks during resuscitation after OHCA. ⋯ There were 189 cardiac arrests in the study period, with 70 cases eligible for inclusion. Mean time between shocks was 3:06 min (0:15 min-18:23 min, SD 1:54 min). 53% of inter-shock intervals were >2:30 min and 21% were <2:00 min. Only 26% of intervals were compliant with ALS guidelines. Figure 1 shows a scatter plot of the inter-shock intervals for each OHCA resuscitation episode. The red bar indicates the 'compliant' zone of 2:00-2:30 min. emermed;31/9/781-b/EMERMED2014204221F7F1EMERMED2014204221F7 CONCLUSION: The majority of intervals between shocks delivered in out-of-hospital cardiac arrest were non-compliant with current ALS guidelines. Whilst the underlying reasons for this finding remain unclear, the extreme outliers appeared to be related to transporting the patient from the scene of the arrest. It was still the case, however, that the majority of defibrillation attempts were delivered either earlier than 2 min or later than 2:30 min, which may reflect a loss of situational awareness in the distracting environment of an OHCA resuscitation. Further work needs to be done to establish the cause of this deviation from recommended shock timing in order to develop strategies to optimise practice.
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Transfusion thresholds for upper gastrointestinal bleeding (UGIB) are controversial. Observational studies suggest associations between liberal red blood cell (RBC) transfusion and adverse outcome. A recent trial reported increased mortality following liberal transfusion. We delivered a cluster randomised trial to evaluate the feasibility and safety of implementing a restrictive (transfusion when haemoglobin (Hb) <8 g dL) vs liberal (transfusion when Hb <10 g/dL) RBC transfusion policy for UGIB. ⋯ Adherence to both policies was high, resulting in a reduction in RBC transfusion and separation in the degree of anaemia and RBC exposure. There was a trend towards improved safety in the restrictive policy. We have demonstrated that a large-scale cluster randomised trial is feasible and is now warranted to determine the effectiveness of implementing restrictive RBC transfusion for all patients with AUGIB.
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The continuing shortfall of organs for transplantation has led to interest in Maastricht Category II (uncontrolled) Donation after Circulatory Death (DCD) organ donation. As preparation for a proposed pilot, this study aimed to explore the potential of uncontrolled DCD organ donation from patients presenting in cardiac arrest to the emergency department (ED) who are unsuccessfully resuscitated. ⋯ Identifying potential organ donors in the ED who are unsuccessfully resuscitated from cardiac arrest may contribute to reducing the shortfall of organs for transplantation, although numbers are likely to be small. If such a programme was to be introduced during weekday working hours, there may be around four donors a year. However, even one additional donor per year from hospitals across the UK with an ED and a transplantation service would add considerably to the overall organ donation rate.
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ANPs are autonomous practitioners and form a core part of many Emergency Departments (EDs). However, there is little data on their role in major trauma and deployment within MTTs. The project aimed to explore clinicians' views on the role of ANPs within MTTs in Major Trauma Centres (MTCs). ⋯ The project data shows that, although ANPs are now part of many ED teams and are increasingly taking on extended autonomous ED roles, there is still a level of uncertainty and lack of clarity on their role as part of an MTT. There needs to be a national policy outlining and standardising ANP training, qualification and utilisation within the ED as well as a robust programme to promote their education, training and skills, to optimise their deployment.
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Pulmonary Embolism (PE) in pregnancy remains one of the leading causes of maternal morbidity and mortality in the developed world. However, there is a paucity of high quality evidence resulting in a lack of consensus in managing this group of patients. The aim of the study was to address the diagnostic utility of D dimer for suspected PE in pregnant and postpartum patients, and to identify any clinical presentation variables that are predictors of PE in this group of patients. ⋯ According to our study, there is supportive evidence that a negative D-dimer result is useful as a means of ruling out PE in pregnant and post-partum patients. However, we need a larger prospective observational study to collaborate the findings.