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Biomedical subjects

J R Hedges

Publications and source records attributed to J R Hedges.

At least 91 records · Page 5Linked to original sources
PubMed1990

Prospective evaluation of gastric emptying in the self-poisoned patient.

The authors prospectively studied the effect of gastric emptying (GE) and activated charcoal (AC) upon clinical outcome in acutely self-poisoned patients. Presumed overdose patients (n = 808) were treated using an alternate day protocol based on a 10-question cognitive function examination and presenting vital sign parameters. Asymptomatic patients (n = 451) did not receive GE. AC was administered to asymptomatic patients only on even days. GE in the remaining symptomatic patients (n = 357) was performed only on even days. On emptying days, alert patients had ipecac-induced emesis while obtunded patients received gastric lavage. AC therapy followed gastric emptying. On nonemptying days, symptomatic patients were treated only with AC. No clinical deterioration occurred in the asymptomatic patients treated without GE. AC use did not alter outcome measures in asymptomatic patients. GE procedures in symptomatic patients did not significantly alter the length of stay in the emergency department, mean length of time intubated, or mean length of stay in the intensive care unit. Gastric lavage was associated with a higher prevalence of medical intensive care unit admissions (P = .0001) and aspiration pneumonia (P = .0001). The data support the management of selected acute overdose patients without GE and fail to show a benefit from AC in asymptomatic overdose patients.

Adolescent↗
PubMed1990

Patients who initially refuse prehospital evaluation and/or therapy.

The authors performed a retrospective descriptive and analytical cohort study of prehospital patient initial refusal of care (PIRC) cases to characterize the types of patients encountered and to assess factors associated with their dispositions. During a 6-month period, 169 of 1715 (9.9%) base station calls in an urban emergency medical service (EMS) system were for physician involvement in a PIRC. Patients' dispositions were as follows: left at scene against medical advice (53%); taken by ambulance to the hospital (28%); left with friend (13%); other disposition (5%). While police were called to the scene 41 times, they placed a "legal hold" on only 10 patients. Leaving the patient at the scene against medical advice was associated (logistic regression analysis; P less than .05) with the absence of the following factors: family on the scene and a police hold, and with the presence of the following factors: treated hypoglycemia, alcohol use, orientation, and normal speech. The development of statutes that allow police hold placement under the guidance of the base station physician may be necessary. Such statutes would aid transportation of a patient considered by EMS personnel to have impaired mental capacity that may limit the patient's ability to understand medical care decisions.

Cohort Studies↗
PubMed1989

Intravenous fluid therapy in the prehospital management of hemorrhagic shock: improved outcome with hypertonic saline/6% Dextran 70 in a swine model.

The small quantities of 7.5% hypertonic saline (HTS) in 6% Dextran 70 (DEX 70; Travenol Laboratories, Deerfield, IL) required to produce marked improvement in tissue perfusion may make it an ideal solution for the prehospital management of hypotensive trauma patients. This study shows that the initial treatment of porcine hemorrhagic shock with 7.5% HTS/6% DEX 70 results in significantly improved hemodynamics and higher survival rates than those seen in animals treated with normal saline. These results are very encouraging and dictate the need for evaluation in human trials.

Animals↗
PubMed1989

Stroke patient evaluation in the emergency department before pharmacologic therapy.

The standard of care for acute thromboembolic stroke is changing rapidly with the advent of new pharmacologic therapies. The deterioration of focal cerebral ischemia to infarction can be lessened with timely restoration of cerebral blood flow. As pharmacologic therapy of acute stroke evolves, emergency physicians will increasingly facilitate its implementation. The purpose of this study was to elucidate those factors significantly affecting the acute stroke patient's emergency department (ED) evaluation time. The pretreatment ED evaluations of 20 patients entered in an ongoing trial of a fibrinolytic agent (ancrod) for acute ischemic stroke were reviewed. Pretreatment screening factors included the assessment of hematologic status, concurrent illness, and potential neoplastic disease or cerebral hemorrhage as the etiology for the neurological deficit. The following factors had a statistically significant effect on pretreatment evaluation time (range, 2.6 to 11.4 hours) by multiple linear regression analysis: time from arrival until bleeding time completed (P less than .005), time from arrangement of computed head tomography until its completion (P less than .05), chosen site of treatment (ED v neurological step-down unit; P less than .005), order of patient entry (P less than .01), and time from arrival until completion of fibrinogen level assay (P less than .05). These results emphasize the need to coordinate and streamline the clinical evaluation process. The use of the ED as the site of treatment, abbreviating the time until pharmacologic therapy, has not been previously documented. Expedient completion of an evaluation compatible with safe pharmacologic therapy of acute ischemic stroke will dictate the time of definitive therapy. These results should assist other institutions considering rapid pharmacologic therapy for acute ischemic stroke.

Ancrod↗
PubMed1989

Early versus late fluid resuscitation: lack of effect in porcine hemorrhagic shock.

The benefit of IV fluid therapy in the prehospital management of hemorrhagic shock is unproven. We used a reproducible, lightly anesthetized model of porcine continuous hemorrhage to evaluate the usefulness of pre-hospital IV fluid therapy. Incorporated into the model were time delays associated with ambulance request and dispatch, patient evaluation and treatment, and transport to the hospital in the average urban prehospital care system. Treatment occurred concurrently with hemorrhage. Twenty-eight immature swine (15 to 20 kg) were bled at a rate of 1.25 mL/kg/min. Animals in the prehospital IV group (n = 14) received fluid resuscitation at 1 mL/kg/min beginning 20 minutes after initiation of hemorrhage; those in the in-hospital IV group (n = 14) received fluid at a rate of 3 mL/kg/min beginning 35 minutes after hemorrhage. Both groups received blood and saline at 3 mL/kg/min 45 minutes after hemorrhage began, and both groups had hemorrhage controlled 25 minutes after simulated hospital arrival. Survival was 57% in both groups, and there were no statistically significant differences seen in measured hemodynamic or biochemical parameters. We conclude that early administration of IV normal saline has no effect on hemodynamics or survival in this porcine hemorrhagic shock model simulating an urban prehospital care system.

Animals↗
PubMed1989

Decision rules and clinical prediction of pneumonia: evaluation of low-yield criteria.

Prediction rules have been recommended for guiding the ordering of diagnostic tests. Such rules can be used to define low-yield criteria (LYC) for the purpose of identifying patients with an extremely low probability of disease and hence discouraging test ordering by the physician on patients meeting LYC. In this study, community hospital emergency department populations of adults (n = 255) and children (n = 78) were evaluated prospectively for the presence of predictive clinical parameters and the physician's estimate of pneumonia prior to obtaining a chest film. We developed LYC and analyzed published LYC for obtaining chest films on patients considered at risk for pneumonia by means of logistic regression, receiver operating characteristics curve, and negative predictive value analyses. We were unable to derive or validate clinically useful LYC to improve on the seasoned clinician's probability estimate of pneumonia. We discuss the inherent limitations in the development and application of LYC that must be understood by those who seek to limit the ordering of chest films by the application of guidelines developed from decision rules.

Adult↗
PubMed1989

Hypothermia outcome score: development and implications.

Multiple rewarming methods have been recommended for the treatment of hypothermia in the ED. Because the hypothermic patient population is heterogenous, a method for stratifying mortality risk when comparing therapies is desired. We used univariable and multivariable statistical analyses to identify variables which discriminated between patient death or survival in the 24 h after arrival in the ED. Prehospital cardiac arrest, a low or absent presenting BP, elevated BUN, and the need for either tracheal intubation or NG tube placement in the ED were found to be significant predictors of patient demise in a large database (n = 428). The likelihood ratio was used to develop and validate an empiric hypothermia outcome score that can be used in future hypothermia treatment studies to account for differences of patient presentation.

Adult↗
PubMed1988

Evaluation of venous distension device: phase II: cannulation of nonemergent patients.

A device designed to augment venous filling by applying a vacuum to the arm during tourniquet application was evaluated in adult patients considered to have difficult peripheral venous access and in need of nonemergent venipuncture or intravenous cannulation. Patients taking medications that affected platelet activity or who had venipuncture attempts within 1 week in the same extremity were excluded. A total of 21 patients (age, 38.8 +/- 15 years; weight, 77.3 +/- 22.5 kg) were studied. The majority were obese (62%) and/or did not have prominent veins even when a standard tourniquet cuff was placed (71%). Use of the device was successful in 19 patients (90%), with a mean time to venipuncture after vacuum removal of 38 +/- 30 seconds. In the 2 patients in whom the device was unsuccessful, both patients were intravenous drug users and subsequently required either external jugular or central venous line placement. Seven patients had unsuccessful attempts at venipuncture or intravenous cannulation on the opposite extremity immediately before use of the device. In these 7 patients, subsequent use of the device was 100% successful (p = 0.0003, Fisher's exact test, assuming all attempts using standard techniques would have been unsuccessful). When conventional tourniquets are unsuccessful for venipuncture, the use of the venous distension device may obviate the need for more invasive forms of venous access.

Adolescent↗
PubMed1988

Factors contributing to paramedic onscene time during evaluation and management of blunt trauma.

Prehospital patient management decisions are complex because the traumatized patient population is heterogeneous with respect to demographics, mechanism of injury, physiological response to injury, and time from injury to medical care. One hundred and nine blunt trauma patient evaluations by paramedics in a county-wide semirural emergency medical services (EMS) system were analyzed to determine paramedic time on the scene and the factors that might influence onscene time. Onscene time linearly correlated with a prolonged transport time. Hemodynamic and respiratory dysfunction were also associated with increased onscene time. Mean onscene time was not significantly different between high (greater than 13) and low (less than or equal to 13) trauma score (TS) groups, although patients with low TS did receive more interventions (more intravenous lines, more frequent intubation, and more frequent pneumatic antishock garment use). Similar results were found when high (greater than 10) and low (less than or equal to 10) Glasgow Coma Scale (GCS) groups were compared. The correlation of emergency department TS with initial prehospital TS and onscene time demonstrated a small improvement in TS with increasing onscene time for the patient with an initial TS greater than or equal to 13. However, patient groups with either a low TS or a low GCS score showed no significant improvement in TS with increasing onscene time. Without a strict management algorithm, paramedics use a variety of cues to guide their actions during the onscene management of blunt trauma. Future studies should address the impact of strict management algorithms on onscene time and ultimate patient outcome.

Adolescent↗
PubMed1988

Use of ancrod in acute or progressing ischemic cerebral infarction.

Ancrod has been used in Europe for over 15 years for peripheral vascular disease, deep vein thrombosis, and central retinal venous thrombosis, and in patients at risk for thromboembolism. In a double-blind, randomized, placebo-controlled study at University Hospitals in Cincinnati, 20 acute cerebral infarction patients received a series of IV infusions of ancrod (ten) or placebo (ten) for seven days. Early fibrinolysis with a small decrease in fibrinogen was observed, and d-dimers were elevated at four hours, indicating early clot lysis. At three months, patients with moderate to severe strokes (less than 40 on the Scandinavian Stroke Scale) in the ancrod group showed average improvement by a factor of 3 over the placebo group. No bleeding, abnormal laboratory results, or deaths occurred, but ancrod was discontinued in one patient who had seizures. As a result of this study, a double-blind multicenter international clinical trial to further assess the safety and effectiveness of ancrod is being planned.

Ancrod↗
PubMed1988

Prehospital use of neuromuscular blocking agents in a helicopter ambulance program.

We prospectively studied the use of succinylcholine chloride and pancuronium bromide by the physician/nurse flight team of our hospital-based helicopter ambulance service. Patients who received these agents at the scene of an accident (prehospital group, n = 39) were compared with patients who were paralyzed by the flight team in the emergency department of transferring hospitals (control group, n = 35). By protocol, succinylcholine was used primarily for endotracheal intubation and pancuronium for prolonged paralysis after endotracheal intubation. Seventy-four patients received one or both agents. Overall, 61 of 74 patients had intracranial pathology as their primary diagnosis (82%). Endotracheal intubation was the primary indication for paralysis in the majority of patients (67 of 74), although intracranial pressure control, ventilation, agitation control, and seizure control were frequent secondary indications. Prior intubation attempts had failed in 40 of 74 patients (54%). After paralysis, intubation was successful in 68 of 71 patients (96%). Serious complications (ie, dysrhythmia requiring drug therapy) occurred in three patients but resolved with appropriate therapy in each case. Minor complications (ie, dysrhythmia not requiring drug therapy, histamine flush, infiltrated IV line) occurred in 18 patients. There was no significant difference in successful intubation or complication rate between the prehospital and control group. Paralysis allowed airway stabilization in a significant number of critically ill patients who could not otherwise be endotracheally intubated, with a lower incidence of complications than has been previously reported for ED patients. These results suggest that neuromuscular blocking agents can be used safely and effectively at accident scenes by a physician/nurse team.

Adolescent↗
PubMed1988

Succinylcholine-assisted intubations in prehospital care.

Although endotracheal intubation is considered the optimal technique for airway management in critically ill patients, performance of this task in the prehospital setting is at times difficult due to increased masseter muscle tone, vocal cord spasm, or patient combativeness. Use of short-acting paralyzing agents by paramedics to facilitate intubation in these situations is an uncommon practice. We report the recent experience of an emergency medical service system that has used succinylcholine (SUX) for more than ten years. We reviewed prehospital patient intubations for two years; 215 patients were intubated by paramedics without the use of SUX and 95 patients were intubated with the use of SUX. The patient group intubated with SUX was characterized by a greater percentage of women (48% vs 35%; P less than .05), a higher mean Glasgow Coma Scale score (8.6 vs 3.4), fewer intubations for cardiac arrest (3% vs 81%), and more hospital survivors (58% vs 24%; P less than .005). The groups were not different with respect to mean age or frequency of trauma. Paramedics chose to use SUX in 69% of nonarrested patients requiring intubation. SUX-assisted intubation was used most often for the indications of airway protection and respiratory distress. Review of hospital records showed no difference between the groups for frequency of either aspiration pneumonia or mechanical ventilation in patients surviving to hospital admission. No patient receiving SUX required emergency cricothyrotomy, nor was esophageal intubation noted in either group. Succinylcholine-assisted intubation was used safely and selectively by the paramedics in this EMS system to permit airway control and ventilation of patients with more difficult intubations.

Adolescent↗