U n i v e r s i t yH o s p i t a l , P i t t s b u r g h , P e n n s y l v a n t a Study hypothesis: A miniature, infrared, solid.-state CO" detector {vrinicap III) can be used to accurately confirm endotracheal tube placement. Population: 68 consecutive adult patients requiring emergency intubation in the emergency department, ICU, or ward settings' Methods: This prospective clinical trial consisted of 75 cases Di{{iculty of intu'bation and confirmation of endotracheal tube placement were recorded using a linear scale of zero ileast) to l0 exact test (o = imost). Comparisons between groups use Fisher's
.05) R.rrllts'Casesincluded60 (80%)ICU,ninell2"l')ED,andsix
(8%) ward patients.The indication was consideredurgent.in 62 Route of intubation i}z.i"/"1 ^.rd .-.rg..rt (arrest)in 13 117.3%1. nasalin Iive 16J%) and tracheostomyin was oral in 68 1.90.7%1, The mean number of intubation attempts *?t.!:ll two 12.7%). was 6'41,and diffilimg!,'oio". to four); difficulty o{ intubation confirmation was 7.47. Capnometric dctermination of t"f,i endotrachealtube position revealedintratrachealintubation in 72 196%land esophagealintubation in three (47u! cases Thcse were all confirmedby radiographyor direct visualization Scnsitivity and specificity ior endotrachealtubc localization was 1007u lP < .00011. EndotrachealTirbe Position I raencal
Esophageal
Minicap III
Tracheal 72 True-postttve ( loo'2,) 0 F a l s c - p otsi vi e
{0'x, )
Esophageal U Falsc-negative (0'x,l 3 T r u c - n c g avt ic (I ( X ) ' U ),
Conclusion:Corrcct position was dctcrminedin all 75 cascs cardiacor traumaticarrt-st,by usc (100%),including 13(17..i'X,Jin in{raredCO" detector of the miniaturc, s<-rlid-statc,
70
Key Role of Prehospital Resuscitation in Survival From Out'of'HosPital Cardiac Arrest
M J B o n n i n ,P E P e p e , P S C l a r k J r / D e p a r t m e n t o f M e d t c i n e , Baylor College of Medicine; City of Houston Emergency Medical Services, Houston.Texas In view of the inherent hazards of cmcrgency transport/ wc examined the valuc of continued cmergency dcpartment resuscltapative efforts for nontraumatic out-of-hospital cardiac arrest tients (OHCAPS) when prehospital advanccd life support {ALSJ {ailed io achieve restoration of spontaneous circulation' For 16 months, all OHCAPS were pr,rspeitively studied.in terms of multiple {actors including thc timing of ALS procedures, restoratron u{' ronn,^.tao,rs circul-ation, in-patient admission, and successful hospital discharge. Results: Of th; 1,283 OHCAPS studied, 909 did not attain pr'ehospital restoration of spontaneous circulation' Despite further efft-,lts at the ED, only 18 of these {2%) achievedin-patient admission and only two (ri.z%1 werc even-tuallv discharged' Both sur vivors had presented and remained in ventricular fibrillation throughout ihe prehospital phase, and both were left with residual nJurologlcal'deficits. Duiing the study period, the overall discases was abott 20Y", charge rate" for ventricular fibrillation wheieas mean ALS scene and transport times were 27 '8 and 7 I minutes, respectively. Conclusion: With the sole possible exception of refractory ventricular fibrillation cases, the;e data support the validity-of terminatinq resuscitative efforts at the scene when patients do not regain pulses after standard ALS interventions'
71
Gorrelation of Central Arterial Blood Gas Values With Perfusion During Gardiac Arest in a Ganine lilodel
DJ DeBehnke,JE Leasure/ WrightStateUniversity MG Angelos, -of School Medicine,Departmentof EmergencyMedicine,Dayton' Ohio Previousstudieshave shown end-tidal CO, to reflect coronary perfusion pressure{CorPP},which is a key prognostic outcome variable during ventricular fibrillation' Study hypotlesis: Arterial Paco, and pH correlatewith CorPP durins'veniricularfibrillation, therebyprovidingan indirect ass.ss-l.tt of myocardial perfusion. corPopulation: i4 rno.tgt.1dogs with left anterior.descending o.rrry ,r,..y occlusionfollowcd by ventricular.fibrillationwere resuscitatedalter 12 minutes of ventricular fibrillation i""i6-f' *ith ttr.td".,t external CPR and epinephrine(CR I, eight),cardiopulmonary bypass {GR Il, eight), or open-chestCPR (GR III' eightJ. "Methods: Central arterial blood gas and hemodynamicdata *.r" rn""rt:tad at predeterminedtimes during ventricular fibrillation. Group comparisonswere done with I tests and analysis of variancewith a Tukey post-hoctest Correlationwasdctermined using a Pcatsoncorrelationwith a Bonferroniadiustment' R.tultt, Suring Thumper'ECPR and beforeinstitution of technique, there *ete-.to significant differencesin CorPP,Pacor, pH, o,'brr. excess.Two ,n iht." minutes alter technique,Pacot and in CR II pH were significantly higher and lowcr, resp-ec-tively, * 0.12)and GR III (Paco2,34 ! Izi iPr.,,tr., 'ptl,Li'l:t46\ lst pH,7.04 17 t ll; pH, 0.02)when comparedwith GR I {Pat:cr-r, 7.q1 ). o.tz), (P < .05).Survivors(la) had significantlyhigher and lower pH (P = 0llJ tha-n CorPP(P = .03),P"<.,,,,(P = .01.5), = '002) nn.,struiunrt (eight).pif showcd a strong correlation (P a *.iket iorrelation (P = '055)with CorPP' Pac;c>, and Cnrr.lrrt'in.t'Central arterial pH and Paco, may reflect the adequacy of perfusionand predict resuscitationoutcome during ventricular f ibrillation.
The Effect of High- and Low'Dose Perfusion, on Myocardial Epinephrine Gardiac Output, and End'Tidal Garbon Dioxide During Prolonged GPR PB Chase,KB Kern,AB Sanders,CW Otto,GA Ewy / Universtty of Arizona,Collegeof Medicine,Tucson Study hypothesis: There will be no difference in myocardial perfusionpressureimyocardialblood flow, cardiacoutput, or endiiJri cO, partial pressure(P.1co"J after infusion of no-, low;;;, ;;d'tiign aoi. epitteph.Ine during prolonged cPR in the porcine model of cardiac arrest. ' Poprrlation,l0 swine (weight, 20 to 35 kg) were studied Each animal _ t u t o l " served ' o d ' . A fas t e its r t hown r e e mcontrol. inutesofuntreatedventricularfibrilla.
lqa ' I
3
tion, each animal receivedfive minutes of standardCPR without epinephrine,five minutes of CPR after low-doseepinephrine epif 0 . 0 2 ' m g l k g ) ,a n d f i v e m i n u t e s o f C P R a f t e r h i g h - d o s . e ;;hil; {0."i'mglkg), for a total of 15 minutes of closed-chest CpR. Rnimal, i..i ittttr,rmented to obtain aortic and right pr.tt.ttes and for infusion of microspheresfor cardiacout*iu* P"rco, levelswere continuouslymonitored' out detirminations. 'Cardiac outputs and iegional myocardialblood flow were measured with nonradioactive,colored microspheres'Repeated-measures analysis of variance was used to determine statisticalsig.. nificance. n.t"i,t, Myocardial perfusionpressure,was significantly-in+ I creasedover baselinewiih high-doseepinephrine(15 5 vs 32 t 9 mm Hg; P < .01)but not low-doseepinephrine(15 t- 5.vs2l frll Epinephrine's effect on myocardial blood flow was O -+ 12 mLl similar - increasing after high-dose(13 :: 3 vs 60 epinephrine low-dose i13-t 3 vs .tot a{tir < 5rlt -itrltOO g; P .05) 25 + 12 ml/min/100 g). Cardiac output d;cre;sed significantly < after high-doseepinephrine{213 L 30 vs ll4-t 22mLlmini P + .tjii1"f "", lo*idote epinephrine (213 't .30.vs 173 37 mL/ min). Epinephrine'seffect on Putco, paralleledcardiacoutput'
36