這是急診醫師的必備技能之一！
http://www.youtube.com/watch?v=fntJ7GLjCSU
PS: 可以用 youtube downloader 下載影片喔！
2009年6月29日 星期一
2009年6月24日 星期三
Alcoholic Hepatitis - 預後
What determines the prognosis of alcoholic hepatitis?
A: Abstinence from alcohol is the cornerstone of recovery. A promising clinical course in alcoholic hepatitis is largely dictated by abstinence from alcohol, a mild clinical syndrome, and the implementation of appropriate treatment. Within several weeks after discontinuation of alcohol intake, jaundice and fever may resolve, but ascites and hepatic encephalopathy may persist for months to years. Either continued jaundice or the onset of renal failure signifies a poor prognosis. Unfortunately, even when patients adhere to all aspects of medical management, recovery from alcoholic hepatitis is not guaranteed. Up to 40% of patients with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome.
What is the risk of liver cirrhosis in patients with chronic excessive alcohol consumption?
A: The association between alcohol intake and alcoholic liver disease has been well documented, although cirrhosis of the liver develops in only a small proportion of heavy drinkers. The risk of cirrhosis increases proportionally with daily consumption of more than 30 g of alcohol per day; the highest risk is associated with daily consumption of more than 120 g per day. The point prevalence of cirrhosis is 1% in persons drinking 30 to 60 g of alcohol a day and up to 5.7% in those consuming 120 g per day. It is presumed that other factors, such as sex, genetic characteristics, and environmental influences (including chronic viral infection such as hepatitis C), play a role in the genesis of alcoholic liver disease.
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New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
A: Abstinence from alcohol is the cornerstone of recovery. A promising clinical course in alcoholic hepatitis is largely dictated by abstinence from alcohol, a mild clinical syndrome, and the implementation of appropriate treatment. Within several weeks after discontinuation of alcohol intake, jaundice and fever may resolve, but ascites and hepatic encephalopathy may persist for months to years. Either continued jaundice or the onset of renal failure signifies a poor prognosis. Unfortunately, even when patients adhere to all aspects of medical management, recovery from alcoholic hepatitis is not guaranteed. Up to 40% of patients with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome.
What is the risk of liver cirrhosis in patients with chronic excessive alcohol consumption?
A: The association between alcohol intake and alcoholic liver disease has been well documented, although cirrhosis of the liver develops in only a small proportion of heavy drinkers. The risk of cirrhosis increases proportionally with daily consumption of more than 30 g of alcohol per day; the highest risk is associated with daily consumption of more than 120 g per day. The point prevalence of cirrhosis is 1% in persons drinking 30 to 60 g of alcohol a day and up to 5.7% in those consuming 120 g per day. It is presumed that other factors, such as sex, genetic characteristics, and environmental influences (including chronic viral infection such as hepatitis C), play a role in the genesis of alcoholic liver disease.
---
New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
Alcoholic Hepatitis - 臨床表現
Clinical Presentation of Alcoholic Hepatitis
Alcoholic hepatitis is a clinical syndrome of jaundice and liver failure that generally occurs after decades of heavy alcohol use. The cardinal sign of alcoholic hepatitis is the rapid onset of jaundice. Other common signs and symptoms include fever, ascites, and proximal muscle loss. Patients with severe alcoholic hepatitis may have encephalopathy. Typically, the liver is enlarged and tender.
Treatment of Alcoholic Hepatitis
General approaches for patients with decompensated liver disease include treatment of ascites (salt restriction and diuretics) and of hepatic encephalopathy (lactulose and gut-cleansing antibiotics). Infections should be treated with appropriate antibiotics, chosen according to the sensitivity of the organisms isolated. Enteral feeding may be required, as patients are often anorectic. A daily protein intake of 1.5 g per kilogram of body weight is recommended, even among patients with hepatic encephalopathy. Thiamine and other vitamins should be administered.
Delirium tremens and the acute alcohol withdrawal syndrome should be treated with short-acting benzodiazepines. The use of corticosteroids to treat alcoholic hepatitis has been controversial. Pentoxifylline, a nonselective phosphodiesterase inhibitor, decreases the transcription of tumor necrosis factor. Since TNF is elevated in alcoholic hepatitis, the agent is considered for use in some patients. Selected patients with severe alcoholic hepatitis who fail to respond to medical management should be evaluated for liver transplantation.
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New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
Alcoholic hepatitis is a clinical syndrome of jaundice and liver failure that generally occurs after decades of heavy alcohol use. The cardinal sign of alcoholic hepatitis is the rapid onset of jaundice. Other common signs and symptoms include fever, ascites, and proximal muscle loss. Patients with severe alcoholic hepatitis may have encephalopathy. Typically, the liver is enlarged and tender.
Treatment of Alcoholic Hepatitis
General approaches for patients with decompensated liver disease include treatment of ascites (salt restriction and diuretics) and of hepatic encephalopathy (lactulose and gut-cleansing antibiotics). Infections should be treated with appropriate antibiotics, chosen according to the sensitivity of the organisms isolated. Enteral feeding may be required, as patients are often anorectic. A daily protein intake of 1.5 g per kilogram of body weight is recommended, even among patients with hepatic encephalopathy. Thiamine and other vitamins should be administered.
Delirium tremens and the acute alcohol withdrawal syndrome should be treated with short-acting benzodiazepines. The use of corticosteroids to treat alcoholic hepatitis has been controversial. Pentoxifylline, a nonselective phosphodiesterase inhibitor, decreases the transcription of tumor necrosis factor. Since TNF is elevated in alcoholic hepatitis, the agent is considered for use in some patients. Selected patients with severe alcoholic hepatitis who fail to respond to medical management should be evaluated for liver transplantation.
---
New England Journal of Medicine - Vol. 360, No. 26, June 25, 2009
PCI after tPA, when?
What is the optimal time window to perform early percutaneous coronary intervention after fibrinolysis for acute myocardial infarction?
A: The time to percutaneous coronary intervention (PCI) was well under 24 hours after fibrinolysis in previous studies, and there was no difference among the trials in efficacy relative to the time to PCI. The intervals ranged from 2 to 17 hours. A two-hour interval after fibrinolysis should be considered to be the lowest acceptable interval, since PCI immediately after fibrinolysis has proven to be ineffective. An interval of 17 hours seems to be as good as PCI at 2 hours. Waiting longer than 24 hours can be disadvantageous, given the increasing risk of reocclusion of the infarct-related artery. Thus, the optimal window for early PCI after fibrinolysis is somewhere between 2 and 24 hours.
A: The time to percutaneous coronary intervention (PCI) was well under 24 hours after fibrinolysis in previous studies, and there was no difference among the trials in efficacy relative to the time to PCI. The intervals ranged from 2 to 17 hours. A two-hour interval after fibrinolysis should be considered to be the lowest acceptable interval, since PCI immediately after fibrinolysis has proven to be ineffective. An interval of 17 hours seems to be as good as PCI at 2 hours. Waiting longer than 24 hours can be disadvantageous, given the increasing risk of reocclusion of the infarct-related artery. Thus, the optimal window for early PCI after fibrinolysis is somewhere between 2 and 24 hours.
打通血管，誰較強？
What are the reperfusion rates after fibrinolysis compared to primary percutaneous coronary intervention in myocardial infarction with ST-segment elevation?
A: The goal of reperfusion therapy is early and complete recanalization of the infarct-related artery to salvage myocardium and improve both early and late clinical outcomes. Complete reperfusion can be achieved with either fibrinolysis or primary percutaneous coronary intervention (PCI). The success rate of primary PCI is higher than 90%, whereas current fibrinolytic therapy leads to full reperfusion in only 50 to 55% of recipients. Primary PCI, therefore, appears to be the most appropriate reperfusion tool, but there are substantial logistic restrictions associated with its use.
A: The goal of reperfusion therapy is early and complete recanalization of the infarct-related artery to salvage myocardium and improve both early and late clinical outcomes. Complete reperfusion can be achieved with either fibrinolysis or primary percutaneous coronary intervention (PCI). The success rate of primary PCI is higher than 90%, whereas current fibrinolytic therapy leads to full reperfusion in only 50 to 55% of recipients. Primary PCI, therefore, appears to be the most appropriate reperfusion tool, but there are substantial logistic restrictions associated with its use.
2009年6月23日 星期二
Diabetes Drugs news
New NICE guidelines in the UK on newer drugs for use in diabetes are summarised in the BMJ. Some key points are:
- Add sitagliptin (a DPP-4 inhibitor) as second line treatment with metformin instead of a sulphonylurea when blood glucose control is inadequate if sulphonylureas are contraindicated or if the patient is at risk of hypoglycaemia
- Add sitagliptin or a thiazolidinedione (pioglitazone or rosiglitazone) as a third line treatment if metformin and a sulphonylurea are not adequately controlling blood glucose and insulin is unsuitable
- Don't use thiazolidinediones in patients with heart failure or at high risk of fracture
- Add pioglitazone to insulin therapy if a thiazolidinedione has lowered blood glucose in the past or if high dose insulin is not adequately controlling blood glucose.
Source: BMJ 2009;338:b1668
2009年6月18日 星期四
毛地黃花開 勿觸摸以免中毒
記者黃玿琮／中縣報導
大雪山森林遊樂區是夏日避暑的好去處，目前區內正值毛地黃花朵綻放季節，吸引民眾上山避暑與賞花。由於毛地黃全株具有毒性，東勢林管處呼籲遊客勿採摘花朵，以免發生中毒意外。
林管處育樂課指出，花姿奇特的毛地黃因它的外觀有著茸毛密佈的莖葉及酷似地黃的葉片，故而命名為毛地黃；又名洋地黃和毒藥草、指頭花等別名，花期通常在5月至7月的時刻。是多年生而耐寒性草本植物，株高1至4尺，莖葉有毛。宛如倒掛銅鈴的花穗成串，呈現婀娜多姿，把原本翠綠的山區點綴得更嬌美，也更吸引民眾上山。
毛地黃係1910年由日本藥廠引進試種於阿里山、八仙山、大雪山、太平山、清境農場等地，海拔約二千公尺的高山，由於條件適合，目前已成為野生植物。這種「毒藥草 」全株有毒，但因性喜冷涼，栽培地區僅限於高冷地，平地栽培不易成活。
毛地黃原為藥用植物，為強心利尿藥，常用於治療充血性心衰竭和心律不整（如心房纖維顫動、心房撲動、陣發性上心室搏動過速），此兩種疾病常見於老年族群中，所以毛地黃成為老年心臟病患普遍使用的藥物之一。不過，處長陳奕煌強調，毛地黃全株具毒性，雖然是全球著名的心臟強心劑，惟需經過萃取提煉及醫師處方；遊客看到毛地黃時不宜採摘，以防中毒。
此外，遊客若有需要住宿服務，請先行電洽大雪山森林遊樂區訂妥房間，除可電話預訂外，尚有網路訂房服務，訂房網址：http://tsfs.forest.gov.tw/，大雪山國家森林遊樂區服務中心 04-25877901或04-25877902，相關旅遊資訊可上東勢林區管理處網站查詢：http://dongshih.forest.gov.tw/
2009年6月13日 星期六
正常ECG無法排除ACS
Normal ECG During Chest Pain Does Not Rule Out ACS
Among chest pain patients with normal initial ECGs, a similar percentage had acute coronary syndrome whether the ECG was performed when chest pain was present or absent.
A normal electrocardiogram does not exclude acute coronary syndrome (ACS) in patients who present with chest pain, but many clinicians believe that ACS is unlikely to be the cause of the chest pain if the normal ECG was obtained during a pain episode. To clarify this issue, these authors conducted a prospective, observational study of 387 patients who presented to an emergency department with chest pain, had normal initial ECGs, and were admitted for evaluation for ACS.
Patients were divided into two groups, based on whether they had active chest pain during acquisition of the normal initial ECG: 126 had chest pain and 261 did not. ACS was defined as non–ST-segment-elevation myocardial infarction, >70% stenosis on coronary angiography, or positive noninvasive cardiac stress test. The prevalence of ACS did not differ significantly between the groups that did and did not have chest pain when the normal initial ECG was obtained (16% and 20%).
Comment:
Lack of changes on an ECG performed during chest pain often is thought to reduce the likelihood of ACS. Findings from this and a previous study (JW Emerg Med Dec 22 2006) show that this assumption is erroneous and that, in fact, the likelihood of serious cardiac disease in patients who present with chest pain and an initial normal ECG is the same whether or not chest pain was present when the ECG was obtained.
— Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine June 12, 2009
Citation(s): Turnipseed SD et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009 Jun; 16:495.
Among chest pain patients with normal initial ECGs, a similar percentage had acute coronary syndrome whether the ECG was performed when chest pain was present or absent.
A normal electrocardiogram does not exclude acute coronary syndrome (ACS) in patients who present with chest pain, but many clinicians believe that ACS is unlikely to be the cause of the chest pain if the normal ECG was obtained during a pain episode. To clarify this issue, these authors conducted a prospective, observational study of 387 patients who presented to an emergency department with chest pain, had normal initial ECGs, and were admitted for evaluation for ACS.
Patients were divided into two groups, based on whether they had active chest pain during acquisition of the normal initial ECG: 126 had chest pain and 261 did not. ACS was defined as non–ST-segment-elevation myocardial infarction, >70% stenosis on coronary angiography, or positive noninvasive cardiac stress test. The prevalence of ACS did not differ significantly between the groups that did and did not have chest pain when the normal initial ECG was obtained (16% and 20%).
Comment:
Lack of changes on an ECG performed during chest pain often is thought to reduce the likelihood of ACS. Findings from this and a previous study (JW Emerg Med Dec 22 2006) show that this assumption is erroneous and that, in fact, the likelihood of serious cardiac disease in patients who present with chest pain and an initial normal ECG is the same whether or not chest pain was present when the ECG was obtained.
— Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine June 12, 2009
Citation(s): Turnipseed SD et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009 Jun; 16:495.
2009年6月10日 星期三
懷孕前期使用primperan安全嗎？
The Safety of Metoclopramide Use in the First Trimester of Pregnancy
Background
In various countries, metoclopramide is the antiemetic drug of choice in pregnant women, but insufficient information exists regarding its safety in pregnancy.
Methods
We investigated the safety of metoclopramide use during the first trimester of pregnancy by linking a computerized database of medications dispensed between January 1, 1998, and March 31, 2007, to all women registered in the Clalit Health Services, southern district of Israel, with computerized databases containing maternal and infant hospital records from the district hospital during the same period. We assessed associations between the use of metoclopramide in pregnancy and adverse outcomes for the fetus, adjusting for parity, maternal age, ethnic group, presence or absence of maternal diabetes, smoking status, and presence or absence of peripartum fever.
Results
There were 113,612 singleton births during the study period. A total of 81,703 of the infants (71.9%) were born to women registered in Clalit Health Services; 3458 of them (4.2%) were exposed to metoclopramide during the first trimester of pregnancy. Exposure to metoclopramide, as compared with no exposure to the drug, was not associated with significantly increased risks of major congenital malformations (5.3% and 4.9%, respectively; odds ratio, 1.04; 95% confidence interval [CI], 0.89 to 1.21), low birth weight (8.5% and 8.3%; odds ratio, 1.01; 95% CI, 0.89 to 1.14), preterm delivery (6.3% and 5.9%; odds ratio, 1.15; 95% CI, 0.99 to 1.34), or perinatal death (1.5% and 2.2%; odds ratio, 0.87; 95% CI, 0.55 to 1.38). The results were materially unchanged when therapeutic abortions of exposed and unexposed fetuses were included in the analysis.
Conclusions
In this large cohort of infants, exposure to metoclopramide in the first trimester was not associated with significantly increased risks of any of several adverse outcomes. These findings provide reassurance regarding the safety of metoclopramide for the fetus when the drug is given to women to relieve nausea and vomiting during pregnancy.
From NEJM Volume 360:2528-2535 June 11, 2009 Number 24
------------------------
In the U.S., treatment of nausea and vomiting during early pregnancy usually involves pyridoxine (vitamin B6) and antihistamines, such as doxylamine succinate, promethazine, or meclizine. If these agents are not effective, clinicians might turn to more-potent antiemetics, such as the dopamine antagonist metoclopramide. To assess the association between metoclopramide use during early pregnancy and risk for congenital malformations, investigators linked administrative records from an Israeli HMO with medical records from the hospital at which the insured women delivered. From 1998 to 2007, 81,703 singleton live births and 998 induced abortions occurred among participants (mean age, 28; two thirds Bedouin Muslim, one third Jewish).
Among women who had singleton births and induced abortions, 4.2% and 3.8%, respectively, received first-trimester metoclopramide. Among women who had singleton births and who were exposed to metoclopramide, the rate of major congenital malformations was 5.3%; among those who were not exposed, the rate was 4.9% (adjusted odds ratio, 1.04; 95% confidence interval, 0.89–1.21). Analyses that included pregnancy terminations yielded similar findings. Early exposure to metoclopramide also was not associated with significantly altered risk for minor or multiple congenital malformations; moreover, metoclopramide showed no dose-response effect.
Comment:
Background
In various countries, metoclopramide is the antiemetic drug of choice in pregnant women, but insufficient information exists regarding its safety in pregnancy.
Methods
We investigated the safety of metoclopramide use during the first trimester of pregnancy by linking a computerized database of medications dispensed between January 1, 1998, and March 31, 2007, to all women registered in the Clalit Health Services, southern district of Israel, with computerized databases containing maternal and infant hospital records from the district hospital during the same period. We assessed associations between the use of metoclopramide in pregnancy and adverse outcomes for the fetus, adjusting for parity, maternal age, ethnic group, presence or absence of maternal diabetes, smoking status, and presence or absence of peripartum fever.
Results
There were 113,612 singleton births during the study period. A total of 81,703 of the infants (71.9%) were born to women registered in Clalit Health Services; 3458 of them (4.2%) were exposed to metoclopramide during the first trimester of pregnancy. Exposure to metoclopramide, as compared with no exposure to the drug, was not associated with significantly increased risks of major congenital malformations (5.3% and 4.9%, respectively; odds ratio, 1.04; 95% confidence interval [CI], 0.89 to 1.21), low birth weight (8.5% and 8.3%; odds ratio, 1.01; 95% CI, 0.89 to 1.14), preterm delivery (6.3% and 5.9%; odds ratio, 1.15; 95% CI, 0.99 to 1.34), or perinatal death (1.5% and 2.2%; odds ratio, 0.87; 95% CI, 0.55 to 1.38). The results were materially unchanged when therapeutic abortions of exposed and unexposed fetuses were included in the analysis.
Conclusions
In this large cohort of infants, exposure to metoclopramide in the first trimester was not associated with significantly increased risks of any of several adverse outcomes. These findings provide reassurance regarding the safety of metoclopramide for the fetus when the drug is given to women to relieve nausea and vomiting during pregnancy.
From NEJM Volume 360:2528-2535 June 11, 2009 Number 24
------------------------
In the U.S., treatment of nausea and vomiting during early pregnancy usually involves pyridoxine (vitamin B6) and antihistamines, such as doxylamine succinate, promethazine, or meclizine. If these agents are not effective, clinicians might turn to more-potent antiemetics, such as the dopamine antagonist metoclopramide. To assess the association between metoclopramide use during early pregnancy and risk for congenital malformations, investigators linked administrative records from an Israeli HMO with medical records from the hospital at which the insured women delivered. From 1998 to 2007, 81,703 singleton live births and 998 induced abortions occurred among participants (mean age, 28; two thirds Bedouin Muslim, one third Jewish).
Among women who had singleton births and induced abortions, 4.2% and 3.8%, respectively, received first-trimester metoclopramide. Among women who had singleton births and who were exposed to metoclopramide, the rate of major congenital malformations was 5.3%; among those who were not exposed, the rate was 4.9% (adjusted odds ratio, 1.04; 95% confidence interval, 0.89–1.21). Analyses that included pregnancy terminations yielded similar findings. Early exposure to metoclopramide also was not associated with significantly altered risk for minor or multiple congenital malformations; moreover, metoclopramide showed no dose-response effect.
Comment:
Although metoclopramide is used more widely for treating women with nausea and vomiting during early pregnancy in Israel and some European countries than in the U.S., its use for this indication in the U.S. is not uncommon. Results of previous small studies have suggested that use during pregnancy is not linked to incidence of congenital anomalies. This large, retrospective cohort study provides substantial reassurance that metoclopramide does not cause congenital malformations. However, clinicians should be aware that use of this dopamine antagonist can cause maternal extrapyramidal symptoms (i.e., acute dystonic reactions and tardive dyskinesia).
—
Andrew M. Kaunitz, MD
Published in Journal Watch Women's Health June 10, 2009
—
Andrew M. Kaunitz, MD
Published in Journal Watch Women's Health June 10, 2009
2009年6月5日 星期五
快快壓繼續壓....很重要！
A Resuscitation Protocol That Minimizes Hands-Off Time Improves Survival
A prehospital protocol emphasizing minimal interruption of chest compressions was associated with improved survival to hospital discharge.
Recent research suggests that minimizing interruptions during cardiopulmonary resuscitation improves coronary perfusion pressure and increases the likelihood of return of spontaneous circulation (ROSC). The Kansas City, Missouri, emergency medical services system changed its cardiac arrest protocol to emphasize early chest compressions and de-emphasize airway management for resuscitation of adult patients with primary cardiac arrest (ventricular fibrillation [VF] or pulseless ventricular tachycardia). Changes included increasing the compression-to-ventilation ratio from 5:1 to 50:2 (with 200 mandatory compressions without interruption), managing the airway initially with only a nonrebreather mask followed by bag-mask ventilation, and not attempting intubation until after the third round of chest compressions or ROSC; a maximum of 10 seconds was allowed for intubation attempts.
In a retrospective study, researchers compared ROSC, survival to discharge, and cognitive function in 1097 patients with primary cardiac arrest during the 36 months before the change and 339 patients during the 12 months after. Overall, survival to discharge increased significantly from 7% before the change to 14% after (odds ratio, 1.8). In the subset of adult patients with witnessed arrest and an initial rhythm of VF (143 before the change and 57 after), survival to discharge increased significantly from 22% to 44% (OR, 2.7), and rates of ROSC increased significantly from 38% to 60% (OR, 2.4). In this subset, cerebral performance category scores at discharge (assessed only in the after group) were favorable (scores of 1 or 2) in 88% of 25 survivors.
Comment: The concept of minimally interrupted cardiac resuscitation is important for revising how we think about CPR. Our focus should be to provide sufficient and sustained perfusion to the ailing myocardium. Prolonged or repeated interruptions (e.g., frequent pulse checks or attempts to intubate) significantly undermine the process. The American Heart Association guidelines likely will be revised to incorporate this concept. In the meantime, push hard, push fast, and minimize "hands-off" time.
—
Aaron E. Bair, MD, MSc, FAAEM, FACEPPublished in Journal Watch Emergency Medicine June 5, 2009
Citation(s):
Garza AG et al. Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation 2009 May 19; 119:2597.
A prehospital protocol emphasizing minimal interruption of chest compressions was associated with improved survival to hospital discharge.
Recent research suggests that minimizing interruptions during cardiopulmonary resuscitation improves coronary perfusion pressure and increases the likelihood of return of spontaneous circulation (ROSC). The Kansas City, Missouri, emergency medical services system changed its cardiac arrest protocol to emphasize early chest compressions and de-emphasize airway management for resuscitation of adult patients with primary cardiac arrest (ventricular fibrillation [VF] or pulseless ventricular tachycardia). Changes included increasing the compression-to-ventilation ratio from 5:1 to 50:2 (with 200 mandatory compressions without interruption), managing the airway initially with only a nonrebreather mask followed by bag-mask ventilation, and not attempting intubation until after the third round of chest compressions or ROSC; a maximum of 10 seconds was allowed for intubation attempts.
In a retrospective study, researchers compared ROSC, survival to discharge, and cognitive function in 1097 patients with primary cardiac arrest during the 36 months before the change and 339 patients during the 12 months after. Overall, survival to discharge increased significantly from 7% before the change to 14% after (odds ratio, 1.8). In the subset of adult patients with witnessed arrest and an initial rhythm of VF (143 before the change and 57 after), survival to discharge increased significantly from 22% to 44% (OR, 2.7), and rates of ROSC increased significantly from 38% to 60% (OR, 2.4). In this subset, cerebral performance category scores at discharge (assessed only in the after group) were favorable (scores of 1 or 2) in 88% of 25 survivors.
Comment: The concept of minimally interrupted cardiac resuscitation is important for revising how we think about CPR. Our focus should be to provide sufficient and sustained perfusion to the ailing myocardium. Prolonged or repeated interruptions (e.g., frequent pulse checks or attempts to intubate) significantly undermine the process. The American Heart Association guidelines likely will be revised to incorporate this concept. In the meantime, push hard, push fast, and minimize "hands-off" time.
—
Aaron E. Bair, MD, MSc, FAAEM, FACEPPublished in Journal Watch Emergency Medicine June 5, 2009
Citation(s):
Garza AG et al. Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation 2009 May 19; 119:2597.
2009年6月3日 星期三
TPA After Stroke
AHA/ASA Science Advisory Recommends Use of tPA Between 3 and 4.5 Hours After Stroke
May 28, 2009 — A new science advisory from the American Heart Association (AHA)/American Stroke Association (ASA) has given the green light to the use of tissue plasminogen activator (tPA) to treat acute ischemic stroke between 3 and 4.5 hours after symptom onset.
However, the advisory, published online May 28 in Stroke, still emphasizes that time is of the essence when it comes to treatment of stroke.
"Although a longer time window for treatment has been tested formally, delays in evaluation and initiation of therapy should be avoided," the authors stress. The writing group is chaired by Gregory J. del Zoppo, MD, from the University of Washington, in Seattle.
---
Susan Jeffrey
http://www.medscape.com/viewarticle/703524_print
http://stroke.ahajournals.org/cgi/reprint/40/7/2433
http://stroke.ahajournals.org/cgi/reprint/40/7/2295
http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.107.181486
http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.109.192535v1.pdf
May 28, 2009 — A new science advisory from the American Heart Association (AHA)/American Stroke Association (ASA) has given the green light to the use of tissue plasminogen activator (tPA) to treat acute ischemic stroke between 3 and 4.5 hours after symptom onset.
However, the advisory, published online May 28 in Stroke, still emphasizes that time is of the essence when it comes to treatment of stroke.
"Although a longer time window for treatment has been tested formally, delays in evaluation and initiation of therapy should be avoided," the authors stress. The writing group is chaired by Gregory J. del Zoppo, MD, from the University of Washington, in Seattle.
---
Susan Jeffrey
http://www.medscape.com/viewarticle/703524_print
http://stroke.ahajournals.org/cgi/reprint/40/7/2433
http://stroke.ahajournals.org/cgi/reprint/40/7/2295
http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.107.181486
http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.109.192535v1.pdf
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