Emergency medicine journal : EMJ
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Advanced cardiovascular life support (ACLS) for cardiac arrest is a cornerstone of emergency care and yet remains poorly studied in low- and middle-income countries. We characterised the clinical epidemiology and outcomes of cardiac arrest and ACLS in an ED in central Haiti, a lower middle-income country with a nascent emergency care system. ⋯ In this lower middle-income setting, cardiac arrest in the ED was associated with poor survival despite ACLS. Survival may be impacted by limited resources for prearrest monitoring as well as for ongoing critical care.
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A short cut review of the literature was carried out to examine whether a decision rule in conjunction with a D-dimer can be used to rule out aortic dissection. 117 unique papers were found of which three systematic reviews included data on patients relevant to the clinical question; these are discussed in the paper. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. The clinical bottom line is that in low-risk patients (aortic dissection detection risk score 0 or 1) who present to the Emergency Department with chest pain, a negative D-dimer level makes aortic dissection unlikely. However, further prospective validation studies are needed to optimally define the patient group that warrants investigation, the threshold for investigation and the clinical effectiveness of such a diagnostic strategy before it can be widely adopted.
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Thoracostomies, and subsequent placements of chest tubes (CTs), are a standard procedure in several domains of medicine. In emergency medicine, thoracostomies are indicated to release a relevant hemothorax or pneumothorax, particularly a life-threatening tension pneumothorax. In many cases, an initial finger-assisted thoracostomy is followed by placement of a CT to ensure continuous decompression of blood and air. ⋯ Although certainly not advocated as standard, the use of endotracheal tubes as CTs may be a suitable alternative or back-up solution in settings where commercial CTs are not readily available. We assume that this technique will be particularly of interest in settings with a high risk for thoracic injuries and limited availability of commercial CTs, for example, in military conflicts. Given the virtual absence of scientific data, more research on risks, benefits and patient outcome is required.