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To determine the safety and possible efficacy of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of patients in Class II–IV hemorrhagic, hypovolemic shock.
Design:
Multicenter, randomized, normal saline-controlled, dose-escalation study.
Setting:
Eleven hospitals in the U.S. and Belgium.
Subjects:
One hundred and thirty-nine (139) hospitalized patients with Class II–IV hemorrhagic, hypovolemic shock within the previous 4 hours who still were requiring therapy for shock.
Interventions:
Beginning with the lowest dose, patients were randomized to receive 50,100, or 200 mL of either 10% DCLHb or normal saline infused intravenously over 15 minutes. Following infusion of either treatment, further fluid resuscitation could be given, as necessary, to maintain perfusion. Vital signs, laboratory assessments, blood and fluid administration, complications, and adverse events were recorded at various times from the end of infusion through 72 hours after infusion.
Results:
A total of 29 (13 DCLHb- and 16 saline-treated) patients died during the study period. Adverse events were experienced by 61% of patients in the DCLHb group and 53% of patients in the saline group; serious adverse events occurred in 28% of DCLHb-treated patients and 30% of saline-treated patients. The incidence of prospectively defined, clinical complications, including renal insufficiency and renal failure, was similar between the treatment groups except for the occurrence of dysrhythmias/conduction disorders, which occurred significantly more frequently in the saline-treated patients than the DCLHb-treated patients (p = 0.041). At the highest dose level (200 mL), statistically significant between-group differences were observed with greater increases in serum amylase, LDH, the isoenzymes LD1,2,4 and 5, and CK-MB in the DCLHb group compared to the control group; none were of clinical significance. The volume of blood administered did not differ between the groups. Overall 24- and 72-hour survival rates were similar between treatment groups, although the hospital discharge rate was slightly higher in the DCLHb-treated patients (80%) compared with the saline-treated patients (74%).
Conclusion:
Administration of 50 to 200 mL of DCLHb to patients in hemorrhagic, hypovolemic shock was not associated with evidence of end organ toxuity or significant adverse events. Further studies involving larger doses and, perhaps, earlier administration of DCLHb are warranted.
The tasks required for the preservation of the health of rescuers can be accomplished with the creation of a system for medical examinations and rehabilitation that functions with commonly used methodological and organizational principles. Absence of such a common methodological platform often results in the disqualification of members of the special contingent and a mistake in the evaluation process that gives birth to serious medical and social problems. The specific character of the rescuers' activities during conditions associated with extraordinary situations necessitates the development of criteria-based evaluation systems for determining the prognosis, and the clinical, diagnostic, normative, and legal, medical, and social criteria that include methodological approaches that define the criteria to be used in the examinations. We propose that the concept of the professional health examinations becomes the methodological basis used for the medical examinations and rehabilitation of the rescuers.
The most recent tragedy in Manitoba illustrates that disasters can strike any community. Within Canada, a tiered disaster response system exists. Even though physicians often play an integral role in the disaster plan, few participate in the planning process or even appreciate their potential role in the event a disaster should occur. Physician involvement would guarantee health matters be appropriately addressed resulting in reduced mortality and decreased morbidity. There are ample opportunities to become involved in disaster planning and response at all levels government. The objective of this paper to inform physicians about the disaste planning infrastructure that exists in Canada, show them where they may get involved, and urge them to do so.
“Ganbaro ya!” was a phrase of encouragement that could be heard, seen, and felt all over Kobe, Japan following the devastating 1995 Great Hanshin Earthquake. Having the collective meaning of “It's hard, but keep trying! Together we'll succeed! Go! Go! Go!” Ganbaro ya became the mantra of the citizens of Kobe as they struggled to rebuild their lives and community.
The objective of this review is to establish a framework about the educational activities of the Cardiopulmonary Resuscitation (CPR) National Committee of the Saudi Heart Association (SHA) and determine if it has had any effect on the survival rate in daily hospital work. Further, the review puts forward recommendations regarding the key to success for future implementations and improvement in the outcome of heart attacks in the Kingdom of Saudi Arabia (KSA).
Cardiopulmonary resuscitation (CPR) was introduced into the Kingdom of Saudi Arabia in the 1980s. The birth of CPR in the Kingdom was conducted by the American Heart Association (AHA) provision of the first instructor course in Basic Cardiac Life Support (BCLS) and Advanced Cardiac Life Support (ACLS) in the spring of 1984. This educational activity was initiated by the Postgraduate Center of the College of Medicine and currently is a function of the Saudi Heart Association (SHA). The National Heart Center (NHC) continually expands its activities. The number of courses organized, conducted, and reported herein totaled 459 for providers and instructors in BCLS and advanced cardiac life support. This resulted in certification of 916 and 204 instructors in basic and advanced CPR respectively. There were 80 centers established in the Kingdom over the span of 15 years. They all provide BCLS courses; only 13 provide advanced cardiac life support courses. The SHA issued a total of 84,659 certificates.
A comprehensive state wide emergency medical services and helicopter transport system has been developed in the State of Maryland on the principle that early definitive care improves patient out comes. The purpose of this study was to determine if empirical data exist to support the theory that air medical transportation services provided by the Maryland State Police (Maryland State Police) Aviation Division contribute to an improved trauma patient survival rate in Maryland.
Methods:
A retrospective study was conducted on the records of all patients transported by helicopter or ground ambulance and admitted to the R Adams Cowley Shock Trauma Center (R Adams Cowley Shock Trauma Center of the University of Maryland Medical System) of the University of Maryland Medical System. Data were obtained from the Maryland Institute of Emergency Medical Services Systems (Maryland Institute for Emergency Medical Services Systems) Shock Trauma Clinical Registry for the period January 1988 through July 1995, covering 23,002 patients. Patients included those transported directly from the scene of injury to the Maryland Institute for Emergency Medical Services Systems as well as those from interfacility transfers. All patients were stratified by injury severity and compared by outcome (mortality) using Mantel-Haenszel statistics.
Results:
During the study period, 11,379 patients were transported by ground and 11,623 were transported by Maryland State Police helicopter. The mean Injury Severity Score (Maryland State Police) for patients transported by ground was 12.7 (standard deviation = 12.52) and the mean Injury Severity Score for patients transported by air was 14.6 (Injury Severity Score = 13.42), p <0.001. Among patients classified as having a high index of injury severity, the mortality rate was lower among those transported by Maryland State Police helicopter than among those transported by ambulance. The mortality rate was significantly lower for air transported patient with an Injury Severity Score higher than 31.
Conclusion:
The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.
Determining the predictors of demand for emergency prehospital care can assist ambulance services in undertaking policy and planning activities.
Hypothesis:
Demand for prehospital care can be explained by demographic, health status, and economic determinants.
Methods:
The study used a cross-sectional design to investigate the association of demographic, health status, and insurance factors with the use of prehospital, ambulance care. Core data items including age, gender, marital status, country of origin, triage score, diagnosis, time of presentation, method of arrival, and patient disposition were collected for every patient who pre-sented at the Emergency Department of the study hospital over a four-month period. Ambulance usage was analysed using Poisson regression.
Results:
For the 10,229 patients surveyed, only a small number were triaged as having the highest level of urgent medical need (0.8%), but the majority of these used prehospital emergency medical care (90.2%). Predictors of ambulance use included age >65years (Prevalence Ratio [Prevalence Ratio] = 2.92; 95% confidence interval [ Confidence Interval]: 2.35–3.63), being married or in a defacto relationship (Prevalence Ratio = 0.69; 95% Confidence Interval: 0.60–0.79) or divorced, separated, or widowed (Prevalence Ratio = 0.83; 95% Confidence Interval: 0.70–0.98), triage score level 1 or 2 (Prevalence Ratio = 1.95; 95% Confidence Interval: 1.68–2.28), or triage score level 3 (Prevalence Ratio = 1.54; 95% Confidence Interval: 1.38–1.72), diagnosis involving either mental (Prevalence Ratio = 4.29; 95% Confidence Interval: 1.84–10.01), nervous (Prevalence Ratio = 2.74; 95% Confidence Interval: 1.19–6.31) or trauma (Prevalence Ratio = 2.33; 95% Confidence Interval: 1.03–5.27) conditions, and insurance status (Prevalence Ratio =1.54; 95% Confidence Interval: 1.40–1.71). Ethnicity, gender, and time of day were not associated with usage.
Conclusion:
Demand for ambulance services can be predicted by a number of demographic, medical status, and insurance variables. Age and triage levels are key influences on demand for ambulance services. Ambulance insurance status provides an economic incentive to use ambulance services regardless of the urgency of the medical condition.
To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.
Methods:
A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.
Results:
A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, emergency medical services providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The emergency medical services providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath / respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).
Conclusion:
Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.
The development of Disaster Medicine as a science is dependent on clear definitions of its language. This article proposes a set of definitions to supplement those currently accepted.
The document is published in collaboration with the following organisations: the European Society of Emergency Medicine (Leuven); the European Resuscitation Council (Antwerpen); the Air Medical Physician Association (Salt Lake City, US); the German Interdisciplinary Association of Critical Care Medicine; and the German Society of Anaesthesiology and Intensive Care. The document is to be published jointly in the following journals: 1) Trauma Care (ITACCS); 2) Resuscitation; 3) Prehospital and Disaster Medicine; 4) European Journal of Emergency Medicine; 5) Trauma and Emergency Medicine Journal (SA); 6) Emergency Medicine(Norway); 7) JEUR; and 8) Notfall und Rettungsmedizin (Germany).
From 25 January 1994 to 02 February 1994, staff aboard four Veterans Affairs Mobile Clinics treated Northridge Earthquake victims. This study examined the types of conditions treated by Clinic staff during the disaster.
Methods:
A descriptive case series using 1,123 ambulatory encounter forms was undertaken. Case-mix was assessed by classifying diagnoses into 120 possible diagnostic clusters.
Results:
Forty-five percent of patients were infants or children and 60% were female. The primary diagnoses were characterize by acute conditions: 1) upper respiratory infection (34.6%); 2) stress reactions (11.9%); 3) otitis media (10.1%); and injuries (8%). Two-thirds of the infants and children either had an upper respiratory infection (46.4%) or otitis media (20.1%). Increasing age indicated an increased likelihood of stress and anxiety reactions.
Conclusion:
The results provide additional information for agencies involved in planning for and responding to disasters. Based on the types of conditions diagnosed at the United States Veterans' Administration mobile clinics (i.e., a high prevalence of acute conditions, including stress and anxiety reactions, and the large numbers of children), staff trained in primary care, mental health, and pediatrics should be considered for relief missions that begin several days after an event resulting in a disaster.
Despite the increases in the aged population in Japan, there are little data on geriatric patients with traumatic injuries. A prospective clinical study was carried out to evaluate the use of the emergency medical services (emergency medical services) system, mechanisms of injury, and prehospital assessment and triage of elderly victims of trauma.
Patients and Methods:
From July 1996 through June 1997, a group of geriatric trauma (Group G, n = 22) and a control group of younger trauma patients (n = 173) were compared with respect to transfer method to an Emergency Center (direct or indirect), Revised Trauma Scores on the scene of the accident (revised trauma score-l) and on admission to the Emergency Center (revised trauma score-2), and outcome (survival).
Results:
The mean values for revised trauma score-l in the Control Group (Group C) were not different from those in Group G, but revised trauma score-2 of the indirect-transfer patients (indirectly transported patients) in Group G were significantly lower than were those for Group C. Group G mortality rates were significantly higher than were the control rates (p = 0.0001). The mortality rate of the indirectly transported patients subgroup was significantly lower than that of the direct transfer subgroup (directly transported patients) (30/68 vs. 5/70, p<0.0001) in the Group C, but mortality rate of the indirectly transported patients subgroup exceeded that of the directly transported patients subgroup of Group G (8/14 vs. 5/8).
Conclusion:
The data suggest that in geriatric-age patients, direct transfer patients have a lower mortality rate than do indirect transfer patients when controlled for injury severity score. Therefore, it seems that a different set of triage criteria should be developed and implemented for geriatric-age victims with trauma-induced injuries and that those who meet these more stringent criteria should be transferred directly to a Trauma Center.