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AIM OF THE STUDY Negative intrathoracic pressure (ITP) during the decompression phase of cardiopulmonary resuscitation (CPR) is essential to refill the heart, increase cardiac output, maintain cerebral and coronary perfusion pressures,... more
AIM OF THE STUDY Negative intrathoracic pressure (ITP) during the decompression phase of cardiopulmonary resuscitation (CPR) is essential to refill the heart, increase cardiac output, maintain cerebral and coronary perfusion pressures, and improve survival. In order to generate negative ITP, an airway seal is necessary. We tested the hypothesis that some supraglottic airway (SGA) devices do not seal the airway as well the standard endotracheal tube (ETT). METHODS Airway pressures (AP) were measured as a surrogate for ITP in seven recently deceased human cadavers of varying body habitus. Conventional manual, automated, and active compression-decompression CPR were performed with and without an impedance threshold device (ITD) in supine and Head Up positions. Positive pressure ventilation was delivered by an ETT and 5 SGA devices tested in a randomized order in this prospective cross-over designed study. The primary outcome was comparisons of decompression AP between all groups. RESULTS An ITD was required to generate significantly lower negative ITP during the decompression phase of all methods of CPR. SGAs varied in their ability to support negative ITP. CONCLUSION In a human cadaver model, the ability to generate negative intrathoracic pressures varied with different SGAs and an ITD regardless of the body position or CPR method. Differences in SGAs devices should be strongly considered when trying to optimize cardiac arrest outcomes, as some SGAs do not consistently develop a seal or negative intrathoracic pressure with multiple different CPR methods and devices.
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Background: The likelihood of neurologically favorable survival declines with prolonged resuscitation. However, the ability of extracorporeal cardiopulmonary resuscitation (ECPR) to modulate this decline is unknown. Our aim was to examine... more
Background: The likelihood of neurologically favorable survival declines with prolonged resuscitation. However, the ability of extracorporeal cardiopulmonary resuscitation (ECPR) to modulate this decline is unknown. Our aim was to examine the effects of resuscitation duration on survival and metabolic profile in patients who undergo ECPR for refractory ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest. Methods: We retrospectively evaluated survival in 160 consecutive adults with refractory ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest treated with the University of Minnesota (UMN) ECPR protocol (transport with ongoing cardiopulmonary resuscitation [CPR] to the cardiac catheterization laboratory for ECPR) compared with 654 adults who had received standard CPR in the amiodarone arm of the ALPS trial (Amiodarone, Lidocaine, or Placebo Study). We evaluated the metabolic changes and rate of survival in relation to duration of CPR in UMN-ECPR patients. Results: Neurologically favorable survival was significantly higher in UMN-ECPR patients versus ALPS patients (33% versus 23%; P =0.01) overall. The mean duration of CPR was also significantly longer for UMN-ECPR patients versus ALPS patients (60 minutes versus 35 minutes; P <0.001). Analysis of the effect of CPR duration on neurologically favorable survival demonstrated significantly higher neurologically favorable survival for UMN-ECPR patients compared with ALPS patients at each CPR duration interval <60 minutes; however, longer CPR duration was associated with a progressive decline in neurologically favorable survival in both groups. All UMN-ECPR patients with 20 to 29 minutes of CPR (8 of 8) survived with neurologically favorable status compared with 24% (24 of 102) of ALPS patients with the same duration of CPR. There were no neurologically favorable survivors in the ALPS cohort with CPR ≥40 minutes, whereas neurologically favorable survival was 25% (9 of 36) for UMN-ECPR patients with 50 to 59 minutes of CPR and 19% with ≥60 minutes of CPR. Relative risk of mortality or poor neurological function was significantly reduced in UMN-ECPR patients with CPR duration ≥60 minutes. Significant metabolic changes included decline in pH, increased lactic acid and arterial partial pressure of carbon dioxide, and thickened left ventricular wall with prolonged professional CPR. Conclusions: ECPR was associated with improved neurologically favorable survival at all CPR durations <60 minutes despite severe progressive metabolic derangement. However, CPR duration remains a critical determinate of survival.
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Introduction: Multiple clinical trials have failed to show significant differences in survival between use of endotracheal intubation (ETI) and supraglottic airway devices (SGA) in patients with out-of-hospital cardiac arrest (OHCA).... more
Introduction: Multiple clinical trials have failed to show significant differences in survival between use of endotracheal intubation (ETI) and supraglottic airway devices (SGA) in patients with out-of-hospital cardiac arrest (OHCA). However, treatment in these trials was limited to standard ACLS, which favors short duration of CPR. We sought to compare the physiological effect of ETI versus SGA use in patients treated with prolonged CPR and extracorporeal pulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia (VT/VF) by the Minnesota Mobile Resuscitation Consortium (MMRC). Methods: Consecutive refractory VT/VF OHCA patients transported by the MMRC to the University of Minnesota for ECPR between 2015 and 2021 were included in this retrospective analysis. Patients were considered ineligible for ECPR if they failed specific arterial blood gas metabolic criteria (lactic acid >18 mmol/L, PaO2 <50 mmHg, and ETCO2 <10 mmHg). Metabolic param...
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Introduction: Gasping has been found to be common after cardiac arrest and associated with increased survival to discharge for out-of-hospital cardiac arrests (OHCA). Active compression decompression (ACD) plus an impedance threshold... more
Introduction: Gasping has been found to be common after cardiac arrest and associated with increased survival to discharge for out-of-hospital cardiac arrests (OHCA). Active compression decompression (ACD) plus an impedance threshold device (ITD) improves brain blood flow and survival to hospital discharge with favorable neurologic function after OHCA compared with standard CPR (S-CPR). Hypothesis: We assessed the association of gasping during CPR on 1-year survival. Methods: The ResQTrial data, which compared ACD+ITD versus S-CPR, was used for these analyses. Nearly all one-year survivors had normal brain function. We included all evaluable subjects in the run-in and pivotal phases of the trial. Beginning in January 2007, the original case report forms were modified to include whether or not spontaneous gasping or breathing was observed at anytime during CPR. A logistic regression analysis was performed. Odds ratios (OR) were adjusted for ResQTrial study intervention arm, pre-speci...
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Invasively monitoring blood pressure through the IO device has not been thoroughly demonstrated. This study attempted to establish baseline values of IO pressure in a healthy human population. This was a prospective, healthy volunteer,... more
Invasively monitoring blood pressure through the IO device has not been thoroughly demonstrated. This study attempted to establish baseline values of IO pressure in a healthy human population. This was a prospective, healthy volunteer, observational study. Participants had two IO devices placed (humerus and tibia), and participant IO pressures, vital signs, and pain scores were monitored for up to 60 minutes. Participants were contacted at 24-hours and 7 days post-testing to assess for adverse events. Summary statistics were calculated for systolic, diastolic, and mean humeral and tibial IO pressure. The ratio of IO to non-invasive blood pressure was calculated, and Bland Altman plots were created. The slope (linear) of the mean humeral and the tibial IO pressures were also calculated. Fifteen subjects were enrolled between April and July 2015. Fourteen of 15 humeral IOs were placed successfully (93.3%) and all 15 of the tibial IOs were placed successfully. Mean tibial systolic, dia...
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Research Interests: Medicine, Electrocardiography, Emergency Medical Services, Humans, Internal Medicine, and 15 moreGlucose, Insulin, Female, Male, Aged, Middle Aged, Acute Coronary Syndrome, Myocardial Infarction, Hospital Mortality, JAMA, Decision Support Techniques, Allied Health Personnel, Heart arrest, Medical and Health Sciences, and hazard ratio
Objectives: To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest. Design, Setting, and Patients: Population-based outcomes... more
Objectives: To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest. Design, Setting, and Patients: Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the wel...
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<jats:p> <jats:bold>Background:</jats:bold> Cardiac arrest patients that have been successfully resuscitated from shockable rhythms have a high prevalence of thrombotic and/or flow limiting coronary occlusion regardless... more
<jats:p> <jats:bold>Background:</jats:bold> Cardiac arrest patients that have been successfully resuscitated from shockable rhythms have a high prevalence of thrombotic and/or flow limiting coronary occlusion regardless of the presence of STEMI on the ECG. In 2012, the Minnesota Resuscitation Consortium (MRC) developed an organized approach for all those patients to gain early access to the cardiac catheterization laboratory (CCL). We report the two-year outcomes. </jats:p> <jats:p> <jats:bold>Methods:</jats:bold> Eleven metropolitan hospitals with 24/7 PCI capabilities agreed to provide early (within 2 hours of arrival to the emergency department) access to the CCL for all patients that were successfully resuscitated from VF/VT arrest regardless of the presence or absence of STEMI on the surface ECG. Inclusion criteria were: witnessed or un-witnessed, age &gt;18 and &lt;70, cardiac arrest of presumed cardiac etiology, comatose or conscious patients. Patients with PEA or asystole, known DNR/DNI, non-cardiac etiology, significant bleeding of any cause, terminal disease were excluded. Patient outcomes were recorded in the state database Cardiac Arrest Registry to Enhance Survival. </jats:p> <jats:p> <jats:bold>Results:</jats:bold> A total of 370 patients were resuscitated and met the inclusion criteria. Of those, 313 (85%) patients were taken to the CCL per protocol. The mean age was 55.5 years, 77% were men and 79% had witnessed arrest. Only 57 patients (15%) did not gain access to the CCL. Of the 313 patients that had early coronary angiography a total of 47% received primary angioplasty and had at least one vessel disease and 5% received coronary artery bypass. All comatose patients received therapeutic hypothermia and 35% received and implantable cardiac defibrillator. A total of 235/313 (75%) were discharged alive and of those 222/235 (94.5%) were discharged neurologically intact with a CPC of 1. Of the patients that did not gain access to the CCL, 46% (26/57) were discharged alive and of those 73% (19/26) had CPC of 1 [OR: 3.63; 2.03-6.5, p&lt; 0.001]. </jats:p> <jats:p> <jats:bold>Conclusions:</jats:bold> Over the first two years of implementation, the MRC protocol for early access to the CCL in resuscitated patients from shockable rhythm was associated with 75% survival to hospital discharge and excellent neurological outcomes in a large metropolitan area and real-life clinical practice. </jats:p>
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The objectives were: 1) replicate key elements of Head Up (HUP) cardiopulmonary resuscitation (CPR) physiology in a traditional swine model of ventricular fibrillation (VF), 2) compare HUP CPR physiology in pig cadavers (PC) to the VF... more
The objectives were: 1) replicate key elements of Head Up (HUP) cardiopulmonary resuscitation (CPR) physiology in a traditional swine model of ventricular fibrillation (VF), 2) compare HUP CPR physiology in pig cadavers (PC) to the VF model 3) develop a new human cadaver (HC) CPR model, and 4) assess HUP CPR in HC. Nine female pigs were intubated, and anesthetized. Venous, arterial, and intracranial access were obtained. After 6 min of VF, CPR was performed for 2 min epochs as follows: Standard (S)-CPR supine (SUP), Active compression decompression (ACD) CPR + impedance threshold device (ITD-16) CPR SUP, then ACD + ITD HUP CPR. The same sequence was performed in PC 3 h later. In 9 HC, similar vascular and intracranial access were obtained and CPR performed for 1 min epochs using the same sequence as above. The mean cerebral perfusion pressure (CerPP, mmHg) was 14.5 ± 6 for ACD + ITD SUP and 28.7 ± 10 for ACD + ITD HUP (p = .007) in VF, -3.6 ± 5 for ACD + ITD SUP and 7.8 ± 9 for ACD ...
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The prevalence of coronary artery disease (CAD) among patients with refractory out-of-hospital (OH) ventricular fibrillation (VF)/ventricular tachycardia (VT) cardiac arrest is unknown. The goal of this study was to describe the... more
The prevalence of coronary artery disease (CAD) among patients with refractory out-of-hospital (OH) ventricular fibrillation (VF)/ventricular tachycardia (VT) cardiac arrest is unknown. The goal of this study was to describe the prevalence and complexity of CAD and report survival to hospital discharge in patients experiencing refractory VF/VT cardiac arrest treated with a novel protocol of early transport to a cardiac catheterization laboratory (CCL) for extracorporeal life support (ECLS) and revascularization. Between December 1, 2015, and December 1, 2016, consecutive adult patients with refractory OH VF/VT cardiac arrest requiring ongoing cardiopulmonary resuscitation were transported by emergency medical services to the CCL. ECLS, coronary angiography, and percutaneous coronary intervention were performed, as appropriate. Functionally favorable survival to hospital discharge (Cerebral Performance Category 1 or 2) was determined. Outcomes in a historical comparison group were al...
Research Interests: Cardiology, Emergency Medicine, Adolescent, Medicine, Humans, and 15 moreInternal Medicine, United States, Female, Male, Cardiopulmonary Resuscitation, Aged, Middle Aged, Percutaneous Coronary Intervention, Adult, Public health systems and services research, Survival Rate, Retrospective Studies, Coronary Artery Disease, Hospital Mortality, and Cardiovascular medicine and haematology
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Objective: Supraglottic airway devices (SGDs) can be inserted ‘blindly’ without stopping compressions during cardiopulmonary resuscitation (CPR) and are therefore often used instead of endotracheal...
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Background: A randomized multicenter clinical trial compared standard CPR (S-CPR) with active compression decompression CPR plus an inspiratory impedance threshold device (ACD+ITD) in patients with...
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Introduction: Pulmonary edema (PE) is a sign of heart failure. In a recent out-of-hospital cardiac arrest (OHCA) trial, the presence of PE was associated with increased survival with favorable neurological outcome (SFNO) [PE present... more
Introduction: Pulmonary edema (PE) is a sign of heart failure. In a recent out-of-hospital cardiac arrest (OHCA) trial, the presence of PE was associated with increased survival with favorable neurological outcome (SFNO) [PE present (28/200 (14%) vs. no PE 119/1912 (6.2%), p<0.001). In subjects treated with standard (S) cardiopulmonary resuscitation (CPR), the presence of PE was associated with SFNO [PE 11/75 (14.7%) vs no PE 50/948 (5.3%), p=0.003]. PE was also associated with active compression decompression CPR plus an impedance threshold device (ACD+ITD) and SFNO rates [PE 17/125 (13.6%) vs no PE 69/964 (7.1%), p=0.020]. To help explain this paradox, we examined the relationship between PE in subjects reported to gasp or manifest agonal breathing during CPR. We hypothesized that gasping decreased intrathoracic pressure, enhanced venous return, lowered intracranial pressure, and in some cases induced PE.Methods: Data related to the frequency of gasping and SFNO was available f...
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Major political conventions are classified as National Special Security Events (NSSEs) as established in 1998 by Presidential Directive 62. Under the directive, the United States Secret Service (USSS) is designated as the lead agency for... more
Major political conventions are classified as National Special Security Events (NSSEs) as established in 1998 by Presidential Directive 62. Under the directive, the United States Secret Service (USSS) is designated as the lead agency for design and implementation of the operational security plan, the Federal Bureau of Investigation (FBI) is designated as the lead agency or crisis response, and the Federal Emergency Management Agency is designated as the lead agency for crisis or consequence management. For all practical purposes, the USSS is the lead agency unless, and until, a federal crime is committed or a situation has to be mitigated where the FBI or Federal Emergency Management Agency would take the lead, respectively. Other examples of NSSEs include the Olympics, presidential inaugurations, and special large multinational meetings. NSSEs require different approaches from planning for usual mass gathering events as they require planning for individuals protected by the USSS, a higher probability of protest-related violence and terrorist attacks, and the potential for medical care delivery in a venue that is isolated from other medical resources due to security concerns. Planners must include preparation for low-probability, high-impact incidents such as nuclear, biologic, and chemical attacks and/or large explosions with or without structural collapse. Owing to the scale of NSSEs, they are typically held in large urban centers across the United States. St. Paul, a city of approximately 270,000 people, was considered by many to be an unlikely site for a major political convention. Fifteen to twenty thousand media alone were anticipated for the 2008 Republican National Convention (RNC), along with 5,000 delegates and their alternates, and 20,000 to 50,000 protesters including up to 3,000 individuals from various anarchist groups. A massive Labor Day protest march was planned. Because of the size of this event relative to available accommodations in St. Paul, attendees and support personnel for the convention were spread throughout the Twin Cities and communities to the immediate north and south of the metropolitan area, thus adding complexity to the planning. With the large influx of individuals into Minnesota during the weeks leading up to and during the convention, we anticipated an increase in the frequency of medical emergencies and need for general medical care in both Minneapolis and St. Paul. Many of the preparations described in this article were implemented to meet these needs. We discovered during the planning process that there was scant literature to guide us. We believe that the documentation of our planning may be of value to other communities hosting future NSSEs, although we realize that each NSSE will have specific challenges to face, thus requiring different resource commitments. As the focus is on NSSE planning, we will emphasize the unique aspects of these events rather than review general mass gathering preparedness.
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EMS crews encounter implantable cardioverter defibrillators (ICDs) daily, but these encounters rarely involve ICDs firing repeatedly on an awake, alert and understandably frightened individual. But... more
EMS crews encounter implantable cardioverter defibrillators (ICDs) daily, but these encounters rarely involve ICDs firing repeatedly on an awake, alert and understandably frightened individual. But that&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s exactly what happened when an EMS crew from Cottage Grove, Minn., responded to a man with a known heart condition who reported that his implantable defibrillator was firing inappropriately.
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Intramuscular ketamine has become increasingly popular for prehospital chemical restraint of severely agitated or violent patients because of its favorable adverse effect profile, rapid onset, and wide therapeutic window. However, there... more
Intramuscular ketamine has become increasingly popular for prehospital chemical restraint of severely agitated or violent patients because of its favorable adverse effect profile, rapid onset, and wide therapeutic window. However, there is currently no literature quantifying the need for intubation or hospital admission for these patients once they reach the emergency department. Medical records for patients receiving prehospital ketamine who were transported to a single level 1 trauma center were abstracted. Ketamine dose, patient weight, final disposition, and presence of intubation were recorded. Exclusion criteria were missing dose or weight and ketamine given for an indication other than chemical restraint. Statistical analysis was preformed with unadjusted Student t test. Statistical significance was defined as P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05. A convenience sample of 51 consecutive patients was identified with 2 excluded because of missing data, leaving 49 for analysis. Ketamine dosing ranged from 2.25 to 9.42 mg/kg (mean, 5.26 ± 1.65 mg/kg). Significant differences were noted between those who required intubation (n = 14) and those who did not (n = 35) (6.16 ± 1.62 mg/kg vs 4.90 ± 1.54 mg/kg, P = .02). No patients were intubated prehospital. There was an increased dose in patients admitted to a medical ward (57%, 28/49) that approached statistical significance (5.62 ± 1.80 vs 4.78 ± 1.31, P = .06). Intubation was observed in our emergency department in 29% of patients administered intramuscular ketamine for prehospital chemical restraint. There was a positive association between higher ketamine doses and both endotracheal intubation and hospital admission. Future research should aim to define the minimum effective ketamine dose for successful chemical restraint.
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The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. This study was a multi-agency, prospective, non-randomized, cross over clinical... more
The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC™ video laryngoscopes and six King Vision™ (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience. Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices. The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.
Research Interests: Nursing, Airway Management, Medicine, Prehospital Emergency Care, Emergency Medical Services, and 14 moreProspective studies, Humans, Female, Male, Clinical Sciences, Aged, Middle Aged, Adult, Public health systems and services research, Emergency Medical Technicians, Clinical Competence, Cross-Over Studies, Video Recording, and Laryngoscopy
Establishing traditional intravenous (IV) access in adult trauma and medical patients can be difficult. We evaluated provider performance for obtaining intraosseous access with two FDA-approved intraosseous devices (F.A.S.T.1 and EZ-IO)... more
Establishing traditional intravenous (IV) access in adult trauma and medical patients can be difficult. We evaluated provider performance for obtaining intraosseous access with two FDA-approved intraosseous devices (F.A.S.T.1 and EZ-IO) in two sequential field trials. One hundred twenty-four providers consented to participate in the first field trial evaluating the use of the F.A.S.T.1 system. Three hundred eighty-nine providers consented to participate in the second field trial, evaluating the use of the EZ-IO. Following each insertion attempt, a telephone data collection process with a member of the research team was completed. Insertion success rate and measures of provider comfort and satisfaction with each device were collected and analyzed. One hundred seventy-eight insertions (89 F.A.S.T.1; 89 EZ-IO) were completed between February 2000 and December 2005. Sixty-four of the 89 insertions of the F.A.S.T.1 were successful, and 78 of the 89 insertions of the EZ-IO were successful (72% vs. 87%; chi2 = 6.8; p = 0.009). Providers using the F.A.S.T.1 attempted more IV insertions prior to using the IO device than the providers using the EZ-IO (2.6 vs. 2.0, p = 0.005). There were no differences in provider comfort or provider assessed device performance between the two devices (p = 0.52; p = 0.13, respectively). In our comparison of two field trials of prehospital provider use of the F.A.S.T.1 and EZ-IO systems, more successful insertions with the EZ-IO were achieved than with the F.A.S.T.1 device. Limitations of our comparison include nonrandomization, the sequential field trial design, the potential for a learning effect, and self-reporting of data points by providers. A prospective, randomized evaluation of these devices is warranted to draw definitive conclusions about provider insertion success rate with these devices.
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An advanced life support emergency medical services (EMS) unit was dispatched with law enforcement to a report of a male patient with a possible overdose and psychiatric emergency. Police restrained the patient and cleared EMS into the... more
An advanced life support emergency medical services (EMS) unit was dispatched with law enforcement to a report of a male patient with a possible overdose and psychiatric emergency. Police restrained the patient and cleared EMS into the scene. The patient was identified as having excited delirium, and ketamine was administered intramuscularly. Sedation was achieved and the patient was transported to the closest hospital. While in the emergency department, the patient developed laryngospasm and hypoxia. The airway obstruction was overcome with bag-valve-mask ventilation. Several minutes later, a second episode of laryngospasm occurred, which again responded to positive-pressure ventilation. At this point the airway was secured with an endotracheal tube. The patient was uneventfully extubated several hours later. This is the first report of laryngospam and hypoxia associated with prehospital administration of intramuscular ketamine to a patient with excited delirium.
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Conducting emergency research in the out-of-hospital and emergency department setting is a challenge because of the inability of patients to provide informed consent in many situations. Federal guidelines allowing research under an... more
Conducting emergency research in the out-of-hospital and emergency department setting is a challenge because of the inability of patients to provide informed consent in many situations. Federal guidelines allowing research under an exception from informed consent for emergency research have been established (21 CRF 50.24). Community consultation and public disclosure, 2 required components of obtaining this exception, are seen by many as a barrier to resuscitation research. This article will provide a brief overview of the history of the exception from informed consent for emergency research and summarize our methods recently used to successfully complete community consultation and public disclosure for a trial evaluating 2 devices used during cardiopulmonary resuscitation in a large metropolitan area.
Research Interests: Informed Consent, Medicine, Emergency Medical Services, Humans, Disclosure, and 14 moreFemale, Resuscitation, Male, Human Experimentation, Clinical Sciences, Minnesota, Cardiopulmonary Resuscitation, Medical Emergency, Consumer Participation, Public disclosure, Emergency Department, Government Regulation, Randomized Controlled Trials as Topic, and attitude to health
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Venous access is essential to providing emergency care for critically ill or injured patients. Obtaining peripheral or central access can be problematic and time consuming. Intraosseous (IO) fluid administration provides similar flow... more
Venous access is essential to providing emergency care for critically ill or injured patients. Obtaining peripheral or central access can be problematic and time consuming. Intraosseous (IO) fluid administration provides similar flow rates and central circulation times compared to central lines, but use of these devices to monitor blood pressure has not been explored. We report a case of successful IO pressure (IOP) monitoring through an IO during the resuscitation of a 31-year-old male. This is the first report of monitoring IOP in a clinical setting and comparing it to traditional measures of central pressure.
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This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls. Rotor-wing division of a single critical care... more
This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls. Rotor-wing division of a single critical care transportation company 53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO2, ETCO2 at 2 minutes after placement, and complications were also analyzed. 38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR = 0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12-46). Pre- and post-insertion SaO(1)2 values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO2 at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s airway was the most frequently reported complication (46%). Success rates with the King LTS-D were not significantly different from historical control ETI data. Time to placement was comparable to previous reports.
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Research Interests: Adolescent, Medicine, Prospective studies, Humans, Female, and 15 moreMale, Anesthesia, Clinical Sciences, Cardiopulmonary Resuscitation, Aged, Middle Aged, Adult, Inhalation, Public health systems and services research, Time Factors, Survival Rate, Odds ratio, Prognosis, Confidence Interval, and Cardiovascular medicine and haematology
International audienc
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OBJECTIVE We hypothesized that video laryngoscopy (VL) would significantly increase the first attempt and final success rates over direct laryngoscopy (DL) in helicopter emergency medical services. METHODS This was a study of an emergency... more
OBJECTIVE We hypothesized that video laryngoscopy (VL) would significantly increase the first attempt and final success rates over direct laryngoscopy (DL) in helicopter emergency medical services. METHODS This was a study of an emergency medical service in the Midwestern United States. Pediatric patients (age < 18 years) transported between January 1, 2010, and July 31, 2016, with an attempted intubation were identified. Demographics (age group and sex), first-pass success (FPS), and total attempts by intubation type were abstracted and compared with a historical control. RESULTS Fifty-five pediatric patient runs were abstracted (DL: n = 28, VL: n = 27). There were no significant differences between the DL and VL groups based on sex (DL: 54% male, VL: 70% male; P = .200) or age group (P = .239). Analyses of FPS between DL and VL showed no difference (DL: 82.1% success vs. VL: 70.4% success; P = .304). There was no difference for final success rate between DL and VL (DL: 85.7%, VL: 96.3%; P = .172). A significantly larger number of difficult airways were reported in the VL group (37.0%) compared with DL (7.1%, P = .007). CONCLUSION VL did not improve FPS over DL nor did it improve the final endotracheal intubation success rate over DL. The VL group had more airways reported as being difficult by the flight crew than the DL group.
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Introduction: Recent swine studies demonstrate the head up position (HUP) during cardiopulmonary resuscitation (CPR) improves blood flow to the brain and cerebral perfusion pressure (CePP). With HU...