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Medicine, Science, and the Law Apr 2022When is it lawful not to resuscitate and when is it unlawful? What is the meaning of mental capacity on the part of the patient and what is meant by patient autonomy?...
When is it lawful not to resuscitate and when is it unlawful? What is the meaning of mental capacity on the part of the patient and what is meant by patient autonomy? What is the extent of clinical discretion in decisions not to resuscitate? Does the presumption in favour of life still obtain? What about the risks in cardiopulmonary resuscitation? What have the judges decided about decisions not to resuscitate, and what is the contemporary role of the doctor in this area? Is there any need for change or reform?
Topics: Cardiopulmonary Resuscitation; Humans; Resuscitation Orders
PubMed: 34269630
DOI: 10.1177/00258024211032799 -
Shock (Augusta, Ga.) Sep 2016Management of non-compressible torso hemorrhage (NCTH) remains a challenge despite continued advancements in trauma resuscitation. Resuscitative thoracotomy with aortic... (Review)
Review
Management of non-compressible torso hemorrhage (NCTH) remains a challenge despite continued advancements in trauma resuscitation. Resuscitative thoracotomy with aortic cross-clamping and recent advances in endovascular aortic occlusion, including resuscitative endovascular occlusion of the aorta, have finite durations of therapy due to the inherent physiologic stressors that accompany complete occlusion. Here, we attempt to illuminate the current state of aortic occlusion for trauma resuscitation including explanation of the deleterious consequences of complete occlusion, potential methods and limitations of existing technology to overcome these consequences, and a description of innovative methods to improve the resuscitation of NCTH. By explaining the complexity and potential deleterious effects of resuscitation augmented with aortic occlusion, our goal is to provide practitioners with a real-world perspective on current endovascular technology and to encourage the continued innovation required to overcome existing obstacles.
Topics: Aorta, Thoracic; Balloon Occlusion; Hemorrhage; Humans; Resuscitation; Shock, Hemorrhagic; Treatment Outcome
PubMed: 27172156
DOI: 10.1097/SHK.0000000000000641 -
Current Opinion in Critical Care Jun 2018To review the epidemiology, peri-arrest management, and research priorities related to in-hospital cardiac arrest (IHCA) and explore key distinctions between IHCA and... (Comparative Study)
Comparative Study Review
PURPOSE OF REVIEW
To review the epidemiology, peri-arrest management, and research priorities related to in-hospital cardiac arrest (IHCA) and explore key distinctions between IHCA and out-of-hospital cardiac arrest (OHCA) as they pertain to the clinician and resuscitation scientist.
RECENT FINDINGS
IHCA is a common and highly morbid event amongst hospitalized patients in the United States. As compared with patients who experience an OHCA, patients who experience an IHCA tend to have more medical comorbidities, have a witnessed arrest, and be attended to by professional first responders. Further, providers resuscitating patients from IHCA commonly have access to tools and information not readily available to the OHCA responders. Despite these differences, society guidelines for the peri-arrest management of patients with IHCA are often based on data extrapolated from the OHCA population. To advance the care of patients with IHCA, clinicians and investigators should recognize the many important distinctions between OHCA and IHCA.
SUMMARY
IHCA is a unique disease entity with an epidemiology and natural history that are distinct from OHCA. In both research and clinical practice, physicians should recognize these distinctions so as to advance the care of IHCA victims.
Topics: Adult; Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Emergency Medical Services; Female; Heart Arrest; Humans; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Practice Guidelines as Topic; Survival Rate; Treatment Outcome; United States
PubMed: 29688939
DOI: 10.1097/MCC.0000000000000505 -
Journal of Pain and Symptom Management Apr 2021One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status.
CONTEXT
One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status.
OBJECTIVES
This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors.
METHODS
The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score).
RESULTS
A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year.
CONCLUSION
At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.
Topics: APACHE; Adult; Cardiopulmonary Resuscitation; Hospitalization; Humans; Intensive Care Units; Resuscitation Orders; Terminal Care
PubMed: 32949762
DOI: 10.1016/j.jpainsymman.2020.09.015 -
American Journal of Surgery Sep 2020Resuscitation of the critically ill patient with fluid and blood products is one of the most widespread interventions in medicine. This is especially relevant for trauma... (Review)
Review
Resuscitation of the critically ill patient with fluid and blood products is one of the most widespread interventions in medicine. This is especially relevant for trauma patients, as hemorrhagic shock remains the most common cause of preventable death after injury. Consequently, the study of the ideal resuscitative product for patients in shock has become an area of great scientific interest and investigation. Recently, the pendulum has swung towards increased utilization of blood products for resuscitation. However, pathogens, immune reactions and the limited availability of this resource remain a challenge for clinicians. Technologic advances in pathogen reduction and innovations in blood product processing will allow us to increase the safety profile and efficacy of blood products, ultimately to the benefit of patients. The purpose of this article is to review the current state of blood product based resuscitative strategies as well as technologic advancements that may lead to safer resuscitation.
Topics: Blood Component Transfusion; Fluid Therapy; Forecasting; Humans; Resuscitation; Shock, Hemorrhagic
PubMed: 32409009
DOI: 10.1016/j.amjsurg.2020.05.008 -
European Journal of Trauma and... Jun 2022Resuscitation quality and pace depend on effective team coordination, which can be facilitated by adequate leadership. Our primary aim was to assess the influence of...
PURPOSE
Resuscitation quality and pace depend on effective team coordination, which can be facilitated by adequate leadership. Our primary aim was to assess the influence of trauma team leader experience on resuscitation pace. Second, we investigated the influence of injury severity on resuscitation pace.
METHODS
The trauma team leaders were identified (Staff trauma surgeon vs Fellow trauma surgeon) and classified from video analysis during a 1-week period. Resuscitations were assessed for time to the treatment plan, total resuscitation time, and procedure time. Furthermore, patient and resuscitation characteristics were assessed and compared: age, gender, Injury Severity Score, Glasgow Coma Scale < 9, and the number (and duration) of surgical procedures during initial resuscitation. Correlations between total resuscitation time, Injury Severity Score, and time to treatment plan were calculated.
RESULTS
After adjustment for the time needed for procedures, the time to treatment plan and total resuscitation time was significantly shorter in resuscitations led by a Staff trauma surgeon compared to a Fellow trauma surgeon (median 648 s (IQR 472-813) vs 852 s (IQR 694-1256); p 0.01 resp. median 1280 s (IQR 979-1494) vs 1535 s (IQR 1247-1864), p 0.04). Surgical procedures were only performed during resuscitations led by Staff trauma surgeons (4 thorax drains, 1 endotracheal intubation, 1 closed fracture reduction). Moreover, a significant negative correlation (r: - 0.698, p < 0.01) between Injury Severity Score and resuscitation time was found.
CONCLUSION
Experienced trauma team leaders may positively influence the pace of the resuscitation. Moreover, we found that the resuscitation pace increases when the patient is more severely injured.
Topics: Glasgow Coma Scale; Humans; Injury Severity Score; Leadership; Patient Care Team; Resuscitation; Trauma Centers; Wounds and Injuries
PubMed: 35141771
DOI: 10.1007/s00068-021-01838-2 -
The Western Journal of Emergency... Feb 2022Effective leadership improves patient care during medical and trauma resuscitations. While dedicated training programs can improve leadership in trauma resuscitation, we...
INTRODUCTION
Effective leadership improves patient care during medical and trauma resuscitations. While dedicated training programs can improve leadership in trauma resuscitation, we have a limited understanding of the optimal training methods. Our objective was to explore learners' and teachers' perceptions of effective methods of leadership training for trauma resuscitation.
METHODS
We performed a qualitative exploration of learner and teacher perceptions of leadership training methods using a modified grounded theory approach. We interviewed 28 participants, including attending physicians, residents, fellows, and nurses who regularly participated in trauma team activations. We then analyzed transcripts in an iterative manner to form codes, identify themes, and explore relationships between themes.
RESULTS
Based on interviewees' perceptions, we identified seven methods used to train leadership in trauma resuscitation: reflection; feedback; hands-on learning; role modeling; simulation; group reflection; and didactic. We also identified three major themes in perceived best practices in training leaders in trauma resuscitation: formal vs informal curriculum; training techniques for novice vs more senior learner; and interprofessional training. Participants felt that informal training methods were the most important part of training, and that a significant part of a training program for leaders in trauma resuscitation should use informal methods. Learners who were earlier in their training preferred more supervision and guidance, while learners who were more advanced in their training preferred a greater degree of autonomy. Finally, participants believed leadership training for trauma resuscitation should be multidisciplinary and interprofessional.
CONCLUSION
We identified several important themes for training leaders in trauma resuscitation, including using a variety of different training methods, adapting the methods used based on the learner's level of training, and incorporating opportunities for multidisciplinary and interprofessional training. More research is needed to determine the optimal balance of informal and formal training, how to standardize and increase consistency in informal training, and the optimal way to incorporate multidisciplinary and interprofessional learning into a leadership in trauma resuscitation training program.
Topics: Clinical Competence; Curriculum; Humans; Leadership; Patient Care Team; Resuscitation
PubMed: 35302453
DOI: 10.5811/westjem.2021.5.51428 -
Scandinavian Journal of Trauma,... Sep 2018The hybrid emergency room (hybrid ER) system was first established in 2011 in Japan. It is defined as an integrated system including an ER, emergency computed tomography... (Review)
Review
The hybrid emergency room (hybrid ER) system was first established in 2011 in Japan. It is defined as an integrated system including an ER, emergency computed tomography (CT) and interventional radiology (IVR) rooms, and operating rooms. Severe trauma patients can undergo emergency CT examinations and therapies (surgeries) without being transferred. The hybrid ER system is attracting attention because trauma resuscitation using this system has been reported to potentially improve the mortality rate in severe trauma patients. In August 2017, we established a new table-rotated-type hybrid ER to facilitate surgical functions. Herein, we introduce a new table-rotated-type hybrid ER consisting of an IVR-CT-operating room system and discuss its efficiency and feasibility for trauma resuscitation, including surgery and IVR. This system includes four new concepts: (1) to secure a wide working space during trauma resuscitation by reconsidering the arrangement of the C-arm, (2) ensure an air-conditioned operating room in the hybrid ER, (3) adopt an operating table but not interventional radiology table, and (4) prepare a trauma bay with three additional beds for multiple victims. This hybrid ER system also adopted the rotated-type table to secure a wide working space during the resuscitation phase. The C-arm was located away from the patients and placed on the wall opposite to the CT gantry, in contrast to that in previous systems. If patients needed an emergency IVR, the table was just rotated, and the IVR could be conducted immediately. This improvement can secure a wide working space in the hybrid ER. Moreover, the patient table was also a surgical operating table, and the hybrid ER system had an air-conditioned operating room (class 10,000). In the anticipation of many trauma patients being transported to the ER, a new trauma bay with three additional beds next to the hybrid ER was established, which also had an air-conditioned operating room. This new rotated-type hybrid ER system facilitates efficient surgical functions during trauma resuscitation and can secure a wide working space for the medical team to immediately perform resuscitative procedures and IVRs without delay.
Topics: Emergency Service, Hospital; Equipment Design; Humans; Japan; Operating Rooms; Operating Tables; Resuscitation
PubMed: 30223859
DOI: 10.1186/s13049-018-0532-z -
Journal of Medical Ethics Aug 2015'Calling' a code can be an ambiguous undertaking. Despite guidelines and the medical literature outlining when it is acceptable to stop resuscitation, code cessation and... (Review)
Review
'Calling' a code can be an ambiguous undertaking. Despite guidelines and the medical literature outlining when it is acceptable to stop resuscitation, code cessation and deciding what not to do during a code, in practice, is an art form. Familiarity with classic evidence suggesting most codes are unsuccessful may influence decisions about when to terminate resuscitative efforts, in effect enacting self-fulfilling prophesies. Code interventions and duration may be influenced by patient demographics, gender or a concern about the stewardship of scarce resources. Yet, recent evidence links longer code duration with improved outcomes, and advances in resuscitation techniques complicate attempts to standardise both resuscitation length and the application of advanced interventions. In this context of increasing clinical and moral uncertainty, discussions between patients, families and medical providers about resuscitation plans take on an increased degree of importance. For some patients, a 'bespoke' resuscitation plan may be in order.
Topics: Advance Directives; Attitude of Health Personnel; Cardiopulmonary Resuscitation; Emergency Medical Services; Heart Arrest; Humans; Medical Futility; Resuscitation Orders; Withholding Treatment
PubMed: 25249374
DOI: 10.1136/medethics-2013-101949 -
International Journal of Environmental... Feb 2023Cardiopulmonary resuscitation-induced consciousness is a newly recognized phenomenon with an increasing incidence. A return of consciousness during cardiopulmonary... (Review)
Review
INTRODUCTION
Cardiopulmonary resuscitation-induced consciousness is a newly recognized phenomenon with an increasing incidence. A return of consciousness during cardiopulmonary resuscitation affects up to 0.9% of cases. Patients may also experience physical pain associated with chest compressions, as most victims of cardiac arrest who are subjected to resuscitative efforts sustain ribs or sternum fractures.
METHODS
A rapid review was carried out from August 2021 to December 2022.
RESULTS
Thirty-two articles were included in the rapid review. Of these, eleven studies focused on the return of consciousness during CPR, and twenty-one on CPR-induced chest injuries.
CONCLUSION
A small number of studies that have dealt with the return of consciousness associated with cardiopulmonary resuscitation made it hard to clearly determine how often this occurs. There were more studies that dealt with chest trauma during resuscitation, but no study considered the use of analgesics. Of note, there was no standardized therapeutic approach as far as the use of analgesics and/or sedatives was considered. This is probably due to the lack of guidelines for analgesic management during cardiopulmonary resuscitation and peri-resuscitative period.
Topics: Humans; Cardiopulmonary Resuscitation; Heart Arrest; Thoracic Injuries; Thorax; Analgesics
PubMed: 36834346
DOI: 10.3390/ijerph20043654