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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Month: September 2010 (Page 1 of 4)

Critical (Intensive) Care Medicine and CPR – A Personal History By Max Harry Weil

Abstract

I perceive that the most consitent pursuits of successful innovators and leaders in medicine, as in all endeavors, come from aspirations generated by dreams rather than hope or by fate alone; from the excitement with which the dreamer atracts collaborators who have prepared minds and skillful hands; they join talents and destinities to convert the dream to expert plans.Contigent on the vigor, the persistence and on the attention to detail with which they commit to the execution of their plans, the secure the advances that contribute to the social goods and bring ultimate success to all who have jioned destinies to seriously pursue those dreams.

Key words: cardiopulmonary resuscitation, critical care medicine, intensive care medicine, history, progress, future

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From Science to Guidelines: The Future for Resuscitation

Abstract

The periodic development and publication of treatment guidelines is integral to the field of cardiopulmonary resuscitation and emergency cardiovascular care. The methods for guideline development have evolved over the past few decades, and the process itself has become the subject of increasing scientific investigation. An internationally validated tool for assessing the quality of clinical practice guidelines is The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Applying this tool to the ILCOR 2010 International Consensus on CPR (cardiopulmonary resuscitation) and ECC (emergency cardiac care) Science with Treatment Recommendations (CoSTR) and the resulting member council guidelines will be a valuable initial step in evaluating both the process and the product. By doing so, important strengths can be recognized as well as opportunities for improvement moving forward. Beyond validated tools to assess and improve the quality of the traditional guidelines process, a critical reassessment of the overall strategy for improving cardiac arrest outcomes is indicated. From the lay-provider perspective, innovative approaches to facilitate performance of bystander CPR are needed. This is likely to entail more individualized instructional methods that are titrated to the provider’s capabilities for learning and performance. What the future might hold for professional providers is a more individualized treatment strategy titrated to real-time physiologic monitoring with mechanized delivery of therapies guided by real-time computer-aided medical decision-making. These individualized instructional and treatment strategies could revolutionize our approach to cardiac arrest resuscitation, and dramatically change how guidelines are developed, implemented and evaluated.

Keywords: cardiac arrest, cardiopulmonary resuscitation, CPR, guidelines

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Hypothermia during percutaneous coronary intervention in comatose survivors of cardiac arrest

Abstract

Urgent invasive coronary strategy including coronary angiography and percutaneous coronary intervention (PCI) is feasible and safe in combination with mild induced hypothermia and may significantly improve survival with good neurological outcome in comatose patients after reestablishment of spontaneous circulation (ROSC). The starting hypothermia already in the prehospital setting or immediately after arrival to the catheterization laboratory to complement urgent coronary angiography and PCI seems to be a logical strategy.

Keywords: cardiac arrest, urgent coronary angiography, percutaneous coronary intervention PCI , mild induced hypothermia, outcome

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Targeting the Endothelium

Abstract

The endothelium is an active organ with paracrine-endocrine capabilities that directs a multitude of physiological actions both locally and remotely. Cardiac arrest and resuscitation is a model of whole body ischemia reperfusion injury, interventions that have their basis in cytoprotection, reduction of the inflammatory cascade, fibrinolysis and improvement of microvasculature blood flow target the endothelium. This presentation will review pharmacologic, cell targeted therapies and periodic acceleration (pGz) interventions that have the endothelium in part as the target organ. The clinical potential of such interventions as preconditioning, conditioning and postconditioning strategies associated with cardiac arrest will be defined.

Keywords: endothelium, periodic acceleration (pGz), cardiac arrest, cardiopulmonary resuscitation, ischemia reperfusion, nitric oxide, shear stress

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The Role of Oxygen in Cardiac Arrest Resuscitation

Abstract

The heart is incapable of storing significant oxygen or substrates and thus is entirely dependent on a continuous delivery of flow in order to support its high metabolic state. Following cardiac arrest, myocardial tissue oxygen tension falls rapidly and aerobic production of ATP ceases. Without re-oxygenation of the ischemic myocardium, return of spontaneous circulation (ROSC) cannot be achieved. The oxygen paradox which has been described regarding other ischemia-reperfusion conditions seems to have application in cardiac arrest. It is clear that some level of oxygenation is necessary to achieve ROSC, however post ROSC there appears to be increased toxicity associated with hyperoxia. The optimal conditions for re-oxygenation in the setting of cardiac arrest remain ill defined at present.

Keywords: cardiac arrest, oxygen, myocard, oxygen delivery, Adenosine-5′-triphosphate (ATP), mitochondria, measurement of tissue oxygen, oxygen paradox

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