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Biomedical subjects

Paul E Pepe

Publications and source records attributed to Paul E Pepe.

At least 19 recordsLinked to original sources
PubMed2006

ED ultrasound in hepatobiliary disease.

To evaluate the diagnostic accuracy of gallbladder ultrasound performed by emergency physicians (EPUS) in patients with right upper quadrant (RUQ) and epigastric (EPI) pain, adults>18 years of age with RUQ or EPI pain were prospectively evaluated by physical examination, laboratory data, and EPUS followed by a blinded radiology department ultrasound (RADUS). Diagnostic categories included: "normal gallbladder"; "uncomplicated symptomatic cholelithiasis" (uncomplicated SCL; stones present but symptoms and signs relieved and no abnormal blood-work); or "complicated symptomatic cholelithiasis" (CSCL; stones and positive symptoms and signs including abnormal blood-work). Final Emergency Department patient assessments based on the RADUS were compared to the EPUS. Over 2-years, 127 patients were enrolled. The sensitivity of the EPUS for detecting stones was 94% (positive predictive value 99%; specificity 96%; negative predictive value 73%). In conclusion, the EPUS is a highly sensitive and reliable indicator of the presence of gallstones.

Abdominal Pain↗
PubMed2006

Key advances in critical care in the out-of-hospital setting: the evolving role of laypersons and technology.

During the past decade, critical care in the out-of-hospital setting has transcended the original emphasis on on-scene advanced life support interventions by doctors, paramedics, and nurses. Many of the life-saving efforts and advances in critical care situations have now begun to focus more and more on how, through evolving technology, the average person can save lives and perhaps even spare precious intensive care unit (ICU) resources. A striking example was the recent study conducted at the Chicago airports at which automated external defibrillators (AEDs) were deployed throughout the airline terminals for use by the public at large. Not only did random bystanders on the concourses save an extremely high percentage of cardiac arrest patients with the AEDs, most patients rapidly awakened, even before the arrival of professional rescuers. Thus, this technology-assisted intervention, performed by an average person, pre-empted the need for many other critical care interventions and prolonged care in the ICU. Equipped with automated prompts to improve performance, new technology also exists to help to monitor the inadequacies and too-frequent interruption of life-saving chest compressions during basic cardiopulmonary resuscitation. As a result of these technological advances, survival rates for cardiac arrest are now expected to improve significantly.

Ambulatory Care↗
PubMed2006

Intensive care and emergency medicine: progress over the past 25 years.

Over the last quarter of a century, intensive care medicine has developed into an established hospital specialty with its own unique identity and characteristics. Significant advances have occurred, mostly in a succession of small steps rather than any dramatic leap, with many being linked to advances in health care across other disciplines. In addition, many changes have resulted from the scientific identification of the detrimental effects of certain traditional practices once thought to be therapeutic. Here, in an attempt to learn from the past and offer guidance for future progress, we detail some of the key changes in various aspects of intensive care medicine including respiratory, cardiovascular, metabolic, and nutritional care, as well as sepsis, polytrauma, organization, and management.

Cardiovascular Diseases↗
PubMed2005

Modified cardiopulmonary resuscitation (CPR) instruction protocols for emergency medical dispatchers: rationale and recommendations.

BACKGROUND: International consensus guidelines now support the use of "chest compressions-only" cardiopulmonary resuscitation (CPR) instructions (CCOIs) by emergency medical dispatch (EMD) personnel providing telephone assistance to untrained bystanders at a cardiac arrest scene. These guidelines are based largely on evolving experimental data and a clinical trial conducted in one venue with distinct emergency medical services (EMS) system features. Accordingly, the Council of Standards for the National Academies of Emergency Dispatch was asked to adapt a modified telephone CPR protocol, and specifically one that could be applied more broadly to the spectrum of EMS systems. METHODS: A group of international EMD specialists, researchers and professional association representatives analyzed available scientific data and considered variations in EMS systems, particularly those in Europe and North America. RESULTS AND CONCLUSIONS: Several recommendations were established: (1) to avoid confusion, bystanders already providing CPR should continue those previously learned methods; (2) following a sudden collapse unlikely to be of respiratory etiology, CCOIs should be provided when the bystander is not CPR-trained, declining to perform mouth-to-mouth ventilation or unsure of actions to take; (3) following 4 min of CCOIs, ventilations can be provided, but, for now, only at a compression-ventilation ratio of 100:2 until EMS arrives; (4) until more data become available, dispatchers should follow existing compression-ventilation protocols for children and adult cases involving probable respiratory/trauma etiologies; (5) EMD CPR protocols should account for EMS system features and receive quality oversight and expert medical direction.

Adult↗
PubMed2005

The detrimental effects of ventilation during low-blood-flow states.

PURPOSE OF REVIEW: In recent years, it has become increasingly apparent that resuscitative ventilatory procedures, classically thought to be life saving, may have profound detrimental effects. RECENT FINDINGS: Most assisted breathing techniques during resuscitation involve the provision of intermittent positive pressure ventilation to inflate lung zones for erythrocyte oxygenation and clearance of carbon dioxide. A growing number of studies involving low-flow states, however, have demonstrated that provision of overzealous (or even 'normal') ventilatory rates with intermittent positive pressure ventilation can significantly diminish both systemic and coronary circulation, most likely through inhibition of venous return. Recent laboratory studies of hemorrhage have shown not only a direct detrimental impact of each positive pressure ventilation breath on coronary perfusion, but also how dramatic improvements in blood flow can be achieved, without loss of oxygenation, by delivering breaths infrequently during such low-flow states. Likewise, in cardiac arrest models, studies have shown that interrupting chest compressions, even to provide breaths, can be extremely deleterious by abruptly (and continually) lowering the aortic pressure head to the coronary arteries, thus impairing restoration of spontaneous circulation. Even with endotracheal intubation and uninterrupted chest compressions, frequent positive pressure ventilation still inhibits circulation during cardiopulmonary resuscitation. Despite directed training, paramedics (and other rescuers) have been shown to still excessively ventilate during cardiac arrest resuscitations. SUMMARY: Ventilation can have profound detrimental hemodynamic effects in low-flow states, exacerbating the circulatory compromise. This underappreciated confounding variable may be one of the reasons many clinical trials of resuscitative interventions have failed despite dramatic successes in the laboratory.

Blood Flow Velocity↗
PubMed2005

Mechanical devices for cardiopulmonary resuscitation.

PURPOSE OF THE REVIEW: For over 40 years, manual chest compressions have been the foundation of cardiopulmonary resuscitation and recent studies have clearly reconfirmed the hemodynamic significance of delivering consistent, high-quality, infrequently-interrupted chest compressions. However, there remain multiple inadequacies in the actual delivery of manual chest compressions during cardiopulmonary resuscitation. One potential solution is use of adjunct mechanical devices. RECENT FINDINGS: Two different methods of accessory chest compression techniques recently have demonstrated enhanced short-term survival. The active compression-decompression device is a hand-held, manually operated suction device applied to the center of the chest wall. In tandem with an impedance threshold (airway) device, active compression-decompression has shown a 65% improvement in 24-hour survival rates (compared with standard cardiopulmonary resuscitation) in a randomized out-of-hospital clinical trial (n = 210). The second device, called Auto-Pulse CPR is an automated machine that uses a load-distributing, broad compression band that is applied across the entire anterior chest. A recent out-of-hospital retrospective case-control study (n = 162) also revealed improved short-term survival. SUMMARY: High quality chest compressions during cardiopulmonary resuscitation are critical elements in effecting successful resuscitation following a cardiac arrest. Recent studies utilizing adjunct mechanical devices have not only revealed significant increases in the effectiveness of chest compressions, including improved hemodynamics in both animal models and human studies, but also improvements in short-term human survival in the clinical setting. It is hoped that these promising findings will eventually be corroborated in terms of improved neurologically intact, long-term patient survival. Clinical trials are currently underway to validate such efficacy.

Animals↗
PubMed2004

The perspective of paramedics about on-scene termination of resuscitation efforts for pediatric patients.

OBJECTIVES: The purpose of this study was to assess the attitude of paramedics to on-scene termination of cardiopulmonary resuscitation (T-CPR) efforts in children prior to developing a pediatric T-CPR policy. METHODS: A 26-item anonymous survey was conducted of all of the active paramedics in a large urban EMS system where T-CPR had been practiced routinely for adults. Questions addressed paramedic demographics, training level, experience with adult and pediatric advanced cardiac life support (ACLS), experience with T-CPR in adults, T-CPR case scenarios, and T-CPR in children. RESULTS: All 201 paramedics in the system (mean age=34.2 years; mean years as paramedic = 8.5 ) completed all relevant items of the survey (100% compliance). Two-thirds had provided ACLS for cardiac arrest to >50 adults (93% >10 adults) and more than one-third had performed ACLS on >20 children (72% >5 children). In addition, 90% had participated in T-CPR for adults. The majority of paramedics reported at least occasional (pre-defined) difficulty with adult T-CPR including family confrontation, 43%; personal discomfort, 13%; disagreement with physician decision to continue efforts, 11%; and fear of liability, 10%. Paramedic self ratings of comfort with terminating CPR on a scale from 1 to 10 (1: very comfortable; 10: uncomfortable) for adults and children were 1 and 9, respectively (P<0.001). In addition, the clear majority (72%) responded that children deserve more aggressive resuscitative efforts than adults. CONCLUSIONS: Paramedics feel relatively uncomfortable with the concept of terminating resuscitation efforts in children in the pre-hospital setting.

Adult↗
PubMed2004

Detrimental hemodynamic effects of assisted ventilation in hemorrhagic states.

OBJECTIVE: Our goal was to demonstrate explicitly that lower-frequency positive-pressure ventilation not only preserves adequate oxygenation and acid-base status in hemorrhagic states, but also that "normal" or higher respiratory rates significantly compromise hemodynamics, even with moderate degrees of hemorrhage. DESIGN AND SUBJECTS: Eight intubated pigs (ventilated with 12 mL/kg tidal volume, 28% FIO2, respiratory rate = 12 breaths/min) were hemorrhaged to <65 mm Hg of systolic blood pressure. Respiratory rates were then sequentially changed every 10 mins to 6, 20, 30, and 6 breaths/min. MEASUREMENTS AND MAIN RESULTS: With respiratory rates at 6 breaths/min, all subjects maintained pH of >7.25 and SaO2 of >99% while increasing systolic blood pressure (mean, 65-84 mm Hg; p < .05), time-averaged coronary perfusion pressure (50 +/- 2 to 60 +/- 4 mm Hg; p < .05), and cardiac output (2.4 to 2.8 L/min; p < .05). With respiratory rates of 20 and 30 breaths/min, systolic blood pressure (73 +/- 4 and 66 +/- 5 mm Hg, respectively), coronary perfusion pressure (47 +/- 3 and 42 +/- 4 mm Hg), and cardiac output (2.5 and 2.4 L/min) diminished. When returned to 6 breaths/min, systolic blood pressure (95 mm Hg), coronary perfusion pressure (71 + 6 mm Hg), and cardiac output (3.0 L/min) improved significantly (p < .05 for all comparisons). CONCLUSIONS: After moderate hemorrhage, animals maintain adequate oxygenation and acid-base status with lower-frequency respiratory rates, whereas increasingly higher respiratory rates progressively and significantly impair hemodynamics. Current ventilatory protocols for trauma resuscitation should be re-examined and considered a possible cause of worsened clinical outcomes and unrecognized confounded study results.

Animals↗
PubMed2003

Clinical review: Reappraising the concept of immediate defibrillatory attempts for out-of-hospital ventricular fibrillation.

Despite well developed emergency medical services with rapid response advanced life support capabilities, survival rates following out-of-hospital ventricular fibrillation (VF) have remained bleak in many venues. Generally, these poor resuscitation rates are attributed to delays in the performance of basic cardiopulmonary resuscitation by bystanders or delays in defibrillation, but recent laboratory data suggest that the current standard of immediately providing a countershock as the first therapeutic intervention may be detrimental when VF is prolonged beyond several minutes. Several studies now suggest that when myocardial energy supplies begin to dwindle following more prolonged periods of VF, improvements in coronary artery perfusion must first be achieved in order to prime the heart for successful return of spontaneous circulation after defibrillation. Therefore, before countershocks, certain pharmacologic and/or mechanical interventions might take precedence during resuscitative efforts. This evolving concept has been substantiated recently by clinical studies, including a controlled clinical trial, demonstrating a significant improvement in survival when basic cardiopulmonary resuscitation is provided for several minutes before the initial countershock. Although this evolving concept differs from current standards and may pose a potential problem for automated defibrillator initiatives (e.g. public access defibrillation), successful defibrillation and return of spontaneous circulation have been rendered more predictable by evolving technologies that can score the VF waveform signal and differentiate between those who can be shocked immediately and those who should receive other interventions first.

Advanced Cardiac Life Support↗
PubMed2003

Emergency ventilatory management in hemorrhagic states: elemental or detrimental?

BACKGROUND: A study was performed to demonstrate that slower respiratory rates (RRs) of positive-pressure ventilation can preserve adequate oxygenation and acid-base status in hemorrhagic states, whereas "normal" or higher RRs worsen hemodynamics. METHODS: Eight swine (ventilated with 12 mL/kg tidal volume, 0.28 Fio(2); RR of 12 breaths/min) were hemorrhaged to < 65 mm Hg systolic arterial blood pressure (SABP). RRs were then sequentially changed every 10 minutes to 6, 20, 30, and 6 breaths/min. RESULTS: With RRs at 6 breaths/min, the animals maintained pH > 7.25/Sao(2) > 99%, but increased mean SABP (from 65 to 84 mm Hg; p < 0.05), time-averaged coronary perfusion pressure (CPP) (from 50 +/- 2 to 60 +/- 4 mm Hg; p < 0.05), and cardiac output (Qt) (from 2.4 to 2.8 L/min; p < 0.05). With RRs of 20 and 30 breaths/min, SABP (73 and 66 mm Hg), CPP (47 +/- 3 and 42 +/- 4 mm Hg), and Qt (2.5 and 2.4 L/min) decreased, as did Pao(2) and Paco(2) (< 30 mm Hg), with p < 0.05 for each comparison, respectively. When RR returned to 6 breaths/min, SABP (95 mm Hg), CPP (71 +/- 6 mm Hg), and Qt (3.0 L/min) improved significantly (p < 0.05). CONCLUSION: After even moderate levels of hemorrhage in animals, positive-pressure ventilation with "normal" or higher RRs can impair hemodynamics. Hemodynamics can be improved with lower RRs while still maintaining adequate oxygenation and ventilation.

Acid-Base Equilibrium↗
PubMed2003

Can first responders be sent to selected 9-1-1 emergency medical services calls without an ambulance?

OBJECTIVES: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). METHODS: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. RESULTS: For ALERTs (n = 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n = 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. CONCLUSIONS: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents.

Ambulances↗
PubMed2002

Public use of automated external defibrillators.

BACKGROUND: Automated external defibrillators save lives when they are used by designated personnel in certain public settings. We performed a two-year prospective study at three Chicago airports to assess whether random bystanders witnessing out-of-hospital cardiac arrests would retrieve and successfully use automated external defibrillators. METHODS: Defibrillators were installed a brisk 60-to-90-second walk apart throughout passenger terminals at O'Hare, Midway, and Meigs Field airports, which together serve more than 100 million passengers per year. The use of defibrillators was promoted by public-service videos in waiting areas, pamphlets, and reports in the media. We assessed the time from notification of the dispatchers to defibrillation, survival rate at 72 hours and at one year among persons with cardiac arrest, their neurologic status, and the characteristics of rescuers. RESULTS: Over a two-year period, 21 persons had nontraumatic cardiac arrest, 18 of whom had ventricular fibrillation. With two exceptions, defibrillator operators were good Samaritans, acting voluntarily. In the case of four patients with ventricular fibrillation, defibrillators were neither nearby nor used within five minutes, and none of these patients survived. Three others remained in fibrillation and eventually died, despite the rapid use of a defibrillator (within five minutes). Eleven patients with ventricular fibrillation were successfully resuscitated, including eight who regained consciousness before hospital admission. No shock was delivered in four cases of suspected cardiac arrest, and the device correctly indicated that the problem was not due to ventricular fibrillation. The rescuers of 6 of the 11 successfully resuscitated patients had no training or experience in the use of automated defibrillators, although 3 had medical degrees. Ten of the 18 patients with ventricular fibrillation were alive and neurologically intact at one year. CONCLUSIONS: Automated external defibrillators deployed in readily accessible, well-marked public areas in Chicago airports were used effectively to assist patients with cardiac arrest. In the cases of survivors, most of the users had no duty to act and no prior training in the use of these devices.

Aged↗
PubMed2002

Prehospital care of the patient with major trauma.

Recent research efforts have demonstrated that many longstanding practices for the prehospital resuscitation of trauma patients may be inappropriate under certain circumstances. For example, traditional practices, such as application of anti-shock garments and i.v. fluid administration to raise blood pressure, may even be detrimental in certain patients with uncontrolled bleeding, particularly those with penetrating injuries. ETI, although potentially capable of transiently prolonging a patient's ability to tolerate circulatory arrest, may also be harmful if overzealous PPV further compromises cardiac output, particularly in those patients with severe hemodynamic instability. In addition, if these procedures delay patient transport, any benefit that they may offer could be outweighed by the delay in definitive care. Although traditionally taught to "hyperventilate" the patient with severe head injury, current recommendations are to avoid this tactic unless there is evidence of herniation. Even time-honored traditions, such as universal spinal precautions and CPR during circulatory arrest, are being scrutinized [2,134]. Further prospective randomized clinical trials are needed to better define the role of many overlapping therapies in prehospital trauma care. Such research must specifically address and stratify the different mechanisms of injury, anatomic areas involved, and the physiologic staging of the injury. Furthermore, the efficacy of a single intervention may be masked by a confounding variable [5]. For example, a trial of an effective new HBOC in moribund patients that indicates no advantage in the study results may have been confounded by overzealous PPV, which may have led to suboptimal outcomes. It is hoped that, in the future, EMS physicians will be able to not only better discriminate in their management of patients with major trauma but also improve outcomes as a result.

Craniocerebral Trauma↗
PubMed2002

Fluid resuscitation of the patient with major trauma.

Current reviews and consensus documents now recommend a more discriminating approach to the traditional practices of delivering liberal infusions of intravenous fluid to all major trauma patients with suspected or known major hemorrhage. The evolving evidence suggests that aggressive fluid resuscitation prior to hemostasis leads to additional bleeding through hydraulic acceleration of hemorrhage, soft clot dissolution, and dilution of clotting factors. Aggressive preoperative fluid infusion is still considered appropriate for unconscious patients without palpable blood pressure or for those with controllable hemorrhage (e.g. isolated extremity or head injury), However, the latest recommendations are to limit or delay intravenous fluid resuscitation preoperatively in those with uncontrollable hemorrhage (e.g. those with penetrating torso injuries), even if they are hypo-perfusing. Although most clinicians still generally support fluid resuscitation for multisystem blunt trauma, particularly with head injury, the most recent experimental data have begun to challenge this traditional practice as well, suggesting a 'slow infusion' approach when there is risk for uncontrolled internal bleeding. By providing oxygen delivery with slow, limited infusion, new hemoglobin-based oxygen carriers might help to resolve the current dilemma of having to limit preoperative resuscitation when there is risk of uncontrolled hemorrhage.

Journal Article↗