Effect of prehospital induction of mild hypothermia on 3-month neurological status and 1-year survival among adults with cardiac arrest: long-term follow-up of a randomized, clinical trial.

Background: Randomized trials of prehospital cooling after cardiac arrest have shown that neither prehospital cooling nor targeted temperature management differentially affected short-term survival or neurological function. In this follow-up study, we assess the association of prehospital hypothermia with neurological function at least 3 months after cardiac arrest and survival 1 year after cardiac arrest.

Methods And Results: There were 508 individuals who were discharged alive from hospitals in King County, Washington; 373 (73%) were interviewed by telephone 123±43 days after the initial event.

Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial.

Importance: Hospital cooling improves outcome after cardiac arrest, but prehospital cooling immediately after return of spontaneous circulation may result in better outcomes.

Objective: To determine whether prehospital cooling improves outcomes after resuscitation from cardiac arrest in patients with ventricular fibrillation (VF) and without VF.

Design, Setting, And Participants: A randomized clinical trial that assigned adults with prehospital cardiac arrest to standard care with or without prehospital cooling, accomplished by infusing up to 2 L of 4°C normal saline as soon as possible following return of spontaneous circulation.

Prehospital systolic blood pressure thresholds: a community-based outcomes study.

Objectives: Emergency medical services (EMS) personnel commonly use systolic blood pressure (sBP) to triage and treat acutely ill patients. The definition of prehospital hypotension and its associated outcomes are poorly defined. The authors sought to determine the discrimination of prehospital sBP thresholds for 30-day mortality and to compare patient classification by best-performing thresholds to traditional cutoffs.

Comparison of role of early (less than six hours) to later (more than six hours) or no cardiac catheterization after resuscitation from out-of-hospital cardiac arrest.

Despite reports of patients with resuscitated sudden cardiac arrest (rSCA) receiving acute cardiac catheterization, the efficacy of this strategy is largely unknown. We hypothesized that acute cardiac catheterization of patients with rSCA would improve survival to hospital discharge. A retrospective cohort of 240 patients with out-of-hospital rSCA caused by ventricular tachycardia or fibrillation was identified from 11 institutions in Seattle, Washington from 1999 through 2002.

Understanding of sepsis among emergency medical services: a survey study.

Background: Emergency medical services (EMS) personnel commonly encounter sepsis, yet little is known about their understanding of sepsis.

Study Objectives: To determine the awareness, knowledge, current practice, and attitudes about sepsis among EMS personnel.

Methods: We performed an anonymous, multi-agency, online survey of emergency medical technicians (EMTs), firefighter-emergency medical technicians (FF-EMTs), and paramedics in a metropolitan, 2-tier EMS system.

The association between obesity and difficult prehospital tracheal intubation.

Background: Nonphysician advanced life support (ALS) providers often perform tracheal intubation (TI) for cardiac arrest or other life-threatening indications in the prehospital setting, where airway assessment and airway management tools are limited. However, the frequency of difficult TI in obese patients in this setting is unclear. In this study we determined factors associated with TI success, and determined TI difficulty as a function of body mass index (BMI) in a system of ALS providers experienced in TI, to guide future prehospital education efforts.

Endogenous red blood cell membrane fatty acids and sudden cardiac arrest.

Little is known of the associations of endogenous fatty acids with sudden cardiac arrest (SCA). We investigated the associations of SCA with red blood cell membrane fatty acids that are end products of de novo fatty acid synthesis: myristic acid (14:0), palmitic acid (16:0), palmitoleic acid (16:1 n7), vaccenic acid (18:1 n7), stearic acid (18:0), oleic acid (18:1 n9), and a related fatty acid, cis-7 hexadecenoic acid (16:1 n9). We used data from a population-based case-control study where cases, aged 25 to 74 years, were out-of-hospital SCA patients attended by paramedics in Seattle, WA (n = 265).

Paramedic training for proficient prehospital endotracheal intubation.

Background: Emergency airway management is an important component of resuscitation of critically ill patients. Multiple studies demonstrate variable endotracheal intubation (ETI) success by prehospital providers. Data describing how many ETI training experiences are required to achieve high success rates are sparse.

Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest: a retrospective before-and-after comparison in a single hospital.

Objective: To evaluate whether implementation of a therapeutic hypothermia protocol on arrival in a community hospital improved survival and neurologic outcomes in patients initially found to have ventricular fibrillation, pulseless electrical activity, or asystole, and then successfully resuscitated from out-of-hospital cardiac arrest.

Design: A retrospective study of patients who presented after implementation of a therapeutic hypothermia protocol compared with those who presented before the protocol was implemented.

Setting: Harborview Medical Center, Seattle, WA.

Red blood cell membrane alpha-linolenic acid and the risk of sudden cardiac arrest.

Higher levels of long-chain n-3 polyunsaturated fatty acids in red blood cell membranes are associated with lower risk of sudden cardiac arrest. Whether membrane levels of alpha-linolenic acid, a medium-chain n-3 polyunsaturated fatty acid, show a similar association is unclear. We investigated the association of red blood cell membrane alpha-linolenic acid with sudden cardiac arrest risk in a population-based case-control study.

The utility of early end-tidal capnography in monitoring ventilation status after severe injury.

Background: An arterial CO2 (Paco2) of 30 mm Hg to 39 mm Hg has been shown to be the ideal target range for early ventilation in trauma patients; however, this requires serial arterial blood gases. The use of end-tidal capnography (EtCO2) has been recommended as a surrogate measure of ventilation in the prehospital arena. This is based on the observation of close EtCO2 Pa(CO2) correlation in healthy patients, yet trauma patients frequently suffer from impaired pulmonary ventilation/perfusion.

Clinical trials in the out-of-hospital setting: rationale and strategies for successful implementation.

Cardiopulmonary arrest and trauma are two of the major epidemics of our time. In most cases, the final outcome is altered, for better or for worse, by how interventions are provided in the prehospital setting, making that venue critical for lifesaving community research efforts. In certain venues, out-of-hospital emergency medical services personnel are highly skilled at managing resuscitations and routinely operate under strict, highly scrutinized protocols, resulting in extraordinary study compliance.

The use of pre-hospital mild hypothermia after resuscitation from out-of-hospital cardiac arrest.

Hypothermia has emerged as a potent neuroprotective modality following resuscitation from cardiac arrest. Although delayed hospital cooling has been demonstrated to improve outcome after cardiac arrest, in-field cooling begun immediately following the return of spontaneous circulation may be more beneficial. Cooling in the field following resuscitation, however, presents new challenges, in that the cooling method has to be portable, safe, and effective.

Prehospital management of the difficult airway: a prospective cohort study.

The role of prehospital endotracheal intubation (ETI) remains controversial, with significant national variability in practice. The purpose of this project was to evaluate ETI management in a system of advanced life support (ALS) providers experienced in ETI and other advanced airway techniques, and describe management and outcomes of patients with a "difficult airway." Data were collected prospectively for all ETIs performed by the fire department over a 4-year period (2001-2005), and included demographics, number of laryngoscopy attempts, airway procedures, complications, and outcomes.

Sodium azide-associated laryngospasm after air bag deployment.

The advent and incorporation of the air bag into motor vehicles has resulted in the mitigation of many head and truncal injuries in motor vehicle collisions. However, air bag deployment is not risk free. We present a case of sodium azide-induced laryngospasm after air bag deployment.

Paramedic use of needle thoracostomy in the prehospital environment.

Objective: The use of prehospital needle thoracostomy (NT) is controversial as it is not without risk. Issues such as inappropriate patient selection, misplacement causing iatrogenic injury, treatment failures in obese patients, and delaying definitive tube thoracostomy in the emergency department contribute to this controversy. The purpose of this study is to evaluate a cohort of patients undergoing NT by paramedics for tension pneumothorax and review the indications for use, complications, and emergency department outcomes of NT.

Emergency department ventilation effects outcome in severe traumatic brain injury.

Background: Recently, we have demonstrated that patients with traumatic brain injury (TBI) with an arrival PaCo2 30 to 35 mm Hg have improved outcome compared with those outside this target range. We sought to determine whether achieving ventilation into a target range would translate into better outcomes in patients with TBI.

Methods: Data were retrospectively reviewed for all trauma prehospital intubations during a period of 24 months (n = 851).

Hypertonic resuscitation of hypovolemic shock after blunt trauma: a randomized controlled trial.

Background: The leading cause of late mortality after trauma is multiple organ failure syndrome, due to a dysfunctional inflammatory response early after injury. Preclinical studies demonstrate that hypertonicity alters the activation of inflammatory cells, leading to reduction in organ injury. The purpose of this study was to evaluate the effect of hypertonicity on organ injury after blunt trauma.

The impact of prehospital ventilation on outcome after severe traumatic brain injury.

Background: Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation, which is detrimental after traumatic brain injury (TBI), and impairs venous return in patients with hypovolemia. We sought to determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the impact of ventilation on outcome after severe TBI.

Methods: Data were prospectively collected for all intubated trauma patients transported directly from the field for a period of 14 months (n = 574).

Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4 degrees C normal saline.

Background: Although delayed hospital cooling has been demonstrated to improve outcome after cardiac arrest, in-field cooling started immediately after the return of spontaneous circulation may be more beneficial. The aims of the present pilot study were to assess the feasibility, safety, and effectiveness of in-field cooling.

Methods And Results: We determined the effect on esophageal temperature, before hospital arrival, of infusing up to 2 L of 4 degrees C normal saline as soon as possible after resuscitation from out-of-hospital cardiac arrest.

Transthoracic incremental monophasic versus biphasic defibrillation by emergency responders (TIMBER): a randomized comparison of monophasic with biphasic waveform ascending energy defibrillation for the resuscitation of out-of-hospital cardiac arrest due to ventricular fibrillation.

Background: Although biphasic, as compared with monophasic, waveform defibrillation for cardiac arrest is increasing in use and popularity, whether it is truly a more lifesaving waveform is unproven.

Methods And Results: Consecutive adults with nontraumatic out-of-hospital ventricular fibrillation cardiac arrest were randomly allocated to defibrillation according to the waveform from automated external defibrillators administered by prehospital medical providers. The primary event of interest was admission alive to the hospital.

Salmonella inhibit T cell proliferation by a direct, contact-dependent immunosuppressive effect.

Dendritic cells (DC) are of central importance in the initiation of T cell-mediated adaptive immunity because these professional phagocytes internalize, process, and present microbial antigens to T lymphocytes. T lymphocytes have a pivotal role in controlling and clearing infection with intracellular pathogens through cytokine production. T lymphocytes also can mediate direct lysis of infected cells or activate B and T cells.