Effi cacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury

BACKGROUND:Resuscitative endovascular balloon occlusion of the aorta(REBOA)can temporarily control traumatic bleeding.However,its prolonged use potentially leads to ischemia-reperfusion injury(IRI).Partial REBOA(pREBOA)can alleviate ischemic burden;however,its security and eff ectiveness prior to operative hemorrhage control remains unknown.Hence,we aimed to estimate the effi cacy of pREBOA in a swine model of liver injury using an experimental sliding-chamber ballistic gun.METHODS:Twenty Landrace pigs were randomized into control(no aortic occlusion)(n=5),intervention with complete REBOA(cREBOA)(n=5),continuous pREBOA(C-pREBOA)(n=5),and sequential pREBOA(S-pREBOA)(n=5)groups.In the cREBOA and C-pREBOA groups,the balloon was inflated for 60 min.The hemodynamic and laboratory values were compared at various observation time points.Tissue samples immediately after animal euthanasia from the myocardium,liver,kidneys,and duodenum were collected for histological assessment using hematoxylin and eosin staining.RESULTS:Compared with the control group,the survival rate of the REBOA groups was prominently improved(all P<0.05).The total volume of blood loss was markedly lower in the cREBOA group(493.14±127.31 mL)compared with other groups(P<0.01).The pH was significantly lower at 180 min in the cREBOA and S-pREBOA groups(P<0.05).At 120 min,the S-pREBOA group showed higher alanine aminotransferase(P<0.05)but lower blood urea nitrogen compared with the cREBOA group(P<0.05).CONCLUSION:In this trauma model with liver injury,a 60-minute pREBOA resulted in improved survival rate and was effective in maintaining reliable aortic pressure,despite persistent hemorrhage.Extended tolerance time for aortic occlusion in Zone I for non-compressible torso hemorrhage was feasible with both continuous partial and sequential partial measures,and the significant improvement in the severity of acidosis and distal organ injury was observed in the sequential pREBOA.

Hypoxia-preconditioned bone marrow-derived mesenchymal stem cells protect neurons from cardiac arrest-induced pyroptosis

Cardiac arrest can lead to severe neurological impairment as a result of inflammation,mitochondrial dysfunction,and post-cardiopulmonary resuscitation neurological damage.Hypoxic preconditioning has been shown to improve migration and survival of bone marrow–derived mesenchymal stem cells and reduce pyroptosis after cardiac arrest,but the specific mechanisms by which hypoxia-preconditioned bone marrow–derived mesenchymal stem cells protect against brain injury after cardiac arrest are unknown.To this end,we established an in vitro co-culture model of bone marrow–derived mesenchymal stem cells and oxygen–glucose deprived primary neurons and found that hypoxic preconditioning enhanced the protective effect of bone marrow stromal stem cells against neuronal pyroptosis,possibly through inhibition of the MAPK and nuclear factor κB pathways.Subsequently,we transplanted hypoxia-preconditioned bone marrow–derived mesenchymal stem cells into the lateral ventricle after the return of spontaneous circulation in an 8-minute cardiac arrest rat model induced by asphyxia.The results showed that hypoxia-preconditioned bone marrow–derived mesenchymal stem cells significantly reduced cardiac arrest–induced neuronal pyroptosis,oxidative stress,and mitochondrial damage,whereas knockdown of the liver isoform of phosphofructokinase in bone marrow–derived mesenchymal stem cells inhibited these effects.To conclude,hypoxia-preconditioned bone marrow–derived mesenchymal stem cells offer a promising therapeutic approach for neuronal injury following cardiac arrest,and their beneficial effects are potentially associated with increased expression of the liver isoform of phosphofructokinase following hypoxic preconditioning.

Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers

BACKGROUND:Traumatic cardiac arrest(TCA)is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system.Although there have been advances in treatment modalities,survival rates for TCA patients remain low.This narrative literature review critically examines the indications and eff ectiveness of current therapeutic approaches in treating TCA.METHODS:We performed a literature search in the PubMed and Scopus databases for studies published before December 31,2022.The search was refi ned by combining search terms,examining relevant study references,and restricting publications to the English language.Following the search,943 articles were retrieved,and two independent reviewers conducted a screening process.RESULTS:A review of various studies on pre-and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm.There were conflicting results regarding other prognostic factors,such as witnessed arrest,bystander cardiopulmonary resuscitation(CPR),and the use of prehospital or in-hospital epinephrine.Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma.Resuscitative endovascular balloon occlusion of the aorta(REBOA)provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock.When implemented in the setting of aortic occlusion,emergency thoracotomy and REBOA resulted in comparable mortality rates.Veno-venous extracorporeal life support(V-V ECLS)and veno-arterial extracorporeal life support(V-A ECLS)are viable options for treating respiratory failure and cardiogenic shock,respectively.In the context of traumatic injuries,V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS.CONCLUSION:TCA remains a signifi cant challenge for emergency medical services due to its high morbidity and mortality rates.Pre-and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures.Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment effi cacy and ameliorate survival outcomes.

A novel predictor of unsustained return of spontaneous circulation in cardiac arrest patients through a combination of capnography and pulse oximetry: a multicenter observational study

BACKGROUND:Unsustained return of spontaneous circulation(ROSC)is a critical barrier to survival in cardiac arrest patients.This study examined whether end-tidal carbon dioxide(ETCO_(2))and pulse oximetry photoplethysmogram(POP)parameters can be used to identify unsustained ROSC.METHODS:We conducted a multicenter observational prospective cohort study of consecutive patients with cardiac arrest from 2013 to 2014.Patients’general information,ETCO_(2),and POP parameters were collected and statistically analyzed.RESULTS:The included 105 ROSC episodes(from 80 cardiac arrest patients)comprised 51 sustained ROSC episodes and 54 unsustained ROSC episodes.The 24-hour survival rate was significantly higher in the sustained ROSC group than in the unsustained ROSC group(29.2%vs.9.4%,P<0.05).The logistic regression analysis showed that the difference between after and before ROSC in ETCO_(2)(ΔETCO_(2))and the difference between after and before ROCS in area under the curve of POP(ΔAUCp)were independently associated with sustained ROSC(odds ratio[OR]=0.931,95%confi dence interval[95%CI]0.881-0.984,P=0.011 and OR=0.998,95%CI 0.997-0.999,P<0.001).The area under the receiver operating characteristic curve ofΔETCO_(2),ΔAUCp,and the combination of both to predict unsustained ROSC were 0.752(95%CI 0.660-0.844),0.883(95%CI 0.818-0.948),and 0.902(95%CI 0.842-0.962),respectively.CONCLUSION:Patients with unsustained ROSC have a poor prognosis.The combination ofΔETCO_(2) andΔAUCp showed signifi cant predictive value for unsustained ROSC.

Successful rescue of disseminated Nocardia infection with multiple abscesses in a patient with membranous nephropathy after cardiopulmonary resuscitation:A three-year follow-up

Nocardiosis manifests as an opportunistic infection,primarily affecting individuals who are immunocompromised and susceptible to the infection.We present a case study of one patient with nephrotic syndrome and membranous nephropathy,who underwent treatment with prednisone and cyclosporine in 2016.In early 2017,the patient was diagnosed with a"fungal infection"and discontinued the use of cyclosporine.After one month of anti-infection therapy,a cranial magnetic resonance imaging scan showed multiple abscesses in the right temporal region.The diagnosis of nocardiosis was confirmed based on the presence of metastatic abscess masses,multiple lung and brain lesions,and a positive culture of Nocardia in the drainage.We changed the anti-infection therapy to a combination of trimethoprim-sulfamethoxazole(TMP-SMX),minocycline,and voriconazole.However,the patient experienced a sudden cardiac arrest and subsequently recovered after cardiopulmonary resuscitation.During the five-month follow-up period following the discharge,the patient displayed an enhanced nutritional status and stable renal function.The focal infection ultimately resolved during the subsequent three years.Neuro-infection caused by Nocardia should be considered in immunocompromised patients,and TMP-SMX is the preferred initial therapy;however,because of the high mortality rate,a long-term combination therapy with imipenem,cefotaxime,amikacin,and TMP-SMX is suggested.

Recovering from prolonged cardiac arrest induced by electric shock:A case report

BACKGROUND Cardiac arrest(CA)induced by electric shock is a rare occurrence,particularly in cases of prolonged CA.Currently,there is limited literature on similar incidents,and we present a relevant case report.CASE SUMMARY A 27-year-old Asian male man,experiencing respiratory CA due to electric shock,was successfully restored to sinus rhythm after 50 min of cardiopulmonary resuscitation and 8 electrical defibrillation sessions.In the subsequent stages,the patient received multiple organ function protection measures,leading to a successful recovery and eventual discharge from the hospital.CONCLUSION Prolonging resuscitation time can enhance the chances of survival for patients,this study provide valuable insights into the management of electric shock-induced CA.

Treatment of a patient with aconitine poisoning using veno-arterial membrane oxygenation:A case report

BACKGROUND Aconitine poisoning is highly prone to causing malignant arrhythmias.The elimination of aconitine from the body takes a considerable amount of time,and during this period,patients are at a significant risk of death due to malignant arrhythmias associated with aconitine poisoning.CASE SUMMARY A 30-year-old male patient was admitted due to accidental ingestion of aconitinecontaining drugs.Upon arrival at the emergency department,the patient intermittently experienced malignant arrhythmias including ventricular tachycardia,ventricular fibrillation,ventricular premature beats,and cardiac arrest.Emergency interventions such as cardiopulmonary resuscitation and defibrillation were promptly administered.Additionally,veno-arterial extracorporeal membrane oxygenation(VA-ECMO)therapy was initiated.Successful resuscitation was achieved before ECMO placement,but upon initiation of ECMO,the patient experienced recurrent malignant arrhythmias.ECMO was utilized to maintain hemodynamics and respiration,while continuous blood purification therapy for toxin clearance,mechanical ventilation,and hypothermic brain protection therapy were concurrently administered.On the third day of VA-ECMO support,the patient’s respiratory and hemodynamic status stabilized,with only frequent ventricular premature beats observed on electrocardiographic monitoring,and echocardiography indicated recovery of cardiac contractile function.On the fourth day,a significant reduction in toxin levels was observed,along with stable hemodynamic and respiratory functions.Following a successful pump-controlled retrograde trial occlusion test,ECMO assistance was terminated.The patient gradually improved postoperatively and achieved recovery.He was discharged 11 days later.CONCLUSION VA-ECMO can serve as a bridging resuscitation technique for patients with reversible malignant arrhythmias.

Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit

The post-resuscitation period is recognized as the main predictor of cardiopul-monary resuscitation(CPR)outcomes.The first description of post-resuscitation syndrome and stony heart was published over 50 years ago.Major manifestations may include but are not limited to,persistent precipitating pathology,systemic ischemia/reperfusion response,post-cardiac arrest brain injury,and finally,post-cardiac arrest myocardial dysfunction(PAMD)after successful resuscitation.Why do some patients initially survive successful resuscitation,and others do not?Also,why does the myocardium response vary after resuscitation?These ques-tions have kept scientists busy for several decades since the first successful resuscitation was described.By modifying the conventional modalities of resu-scitation together with new promising agents,rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal,stony heart.Community awareness and staff education are crucial for shortening the resuscitation time and improving short-and long-term outcomes.Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes.This review extensively addresses the underlying pathophysiology,management,and outcomes of post-resuscitation syndrome.The pattern,management,and outcome of PAMD and post-cardiac arrest shock are different based on many factors,including in-hospital cardiac arrest vs out-of-hospital cardiac arrest(OHCA),witnessed vs unwitnessed cardiac arrest,the underlying cause of arrest,the duration,and protocol used for CPR.Although restoring spontaneous circulation is a vital sign,it should not be the end of the game or lone primary outcome;it calls for better understanding and aggressive multi-disciplinary interventions and care.The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.

Correction:Establishment of a prediction model for prehospital return of spontaneous circulation in out-of-hospital patients with cardiac arrest

This is an erratum to an already published paper named“Establishment of a prediction model for prehospital return of spontaneous circulation in out-ofhospital patients with cardiac arrest”.We found errors in the affiliated institution of the authors.We apologize for our unintentional mistake.Please note,these changes do not affect our results.

Impact of different intravenous bolus rates on fluid and electrolyte balance and mortality in critically ill patients

The effect of intravenous bolus rates on patient outcomes is a complex and crucial aspect of critical care.Fluid challenges are commonly used in critically ill patients to manage their hemodynamic status,but there is limited information available on the specifics of when,how much,and at what rate fluids should be administered during these challenges.The aim of this review is to thoroughly examine the relationship between intravenous bolus rates,fluid-electrolyte balance,and mortality and to analyze key research findings and methodologies to understand these complex dynamics better.Fluid challenges are commonly employed in managing hemodynamic status in this population,yet there is limited information on the optimal timing,volume,and rate of fluid administration.Utilizing a narrative review approach,the analysis identified nine relevant studies that investigate these variables.The findings underscore the importance of a precise and individualized approach in clinical settings,highlighting the need to tailor intravenous bolus rates to each patient's specific needs to maximize outcomes.This review provides valuable insights that can inform and optimize clinical practices in critical care,emphasizing the necessity of meticulous and exact strategies in fluid administration.

A Case Report: Emergency Management of a Pregnant Trauma Patient—An Anesthesiologist’s Perspective and Role

Trauma is the leading cause of death for all women of childbearing age. Motor vehicle accidents account for almost two-thirds of all maternal non-obstetric, trauma-related deaths, while falls and domestic violence comprise a large percentage of the rest. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma . The causes are different with different life styles and different socio-economic and cultural background. Pregnant trauma victims tend to be younger, less severely injured, and more likely African American or of Hispanic descent compared with nonpregnant victims of trauma. Drugs and alcohol are a factor in about 20 percent of maternal trauma. With pregnancy comes the challenge and responsibility of caring for two patients at once, the mother and the fetus. In general, providing optimal maternal care is the best strategy to optimize fetal survival. Decision-making including the condition of the mother, gestational age, status of the fetus, and interventions are based on these key factors. Many providers are involved in the care of the pregnant patient: at the trauma scene, in the emergency department, and in the operating room. The anesthesiologist plays a key role in the care and management of the pregnant trauma patient. All anesthesiologists have ample training in obstetric anesthesia during their residency and frequently cover obstetric units in hospitals where pregnant patients are cared for. On the other hand, most nonobstetric physicians have little obstetric exposure and may be uncomfortable caring for the pregnant patient because of unfamiliarity with the physiologic changes of pregnancy or the evaluation of fetal well-being. This is not only a source of stress for other trauma providers, but can put maternal well-being at risk. Non-obstetric physicians may hesitate to order necessary diagnostic and therapeutic interventions for fear of doing the “wrong thing,” all because the patient is pregnant. A multidisciplinary approach to the pregnant trauma patient involving trauma surgeons, obstetricians, anesthesiologists, emergency medicine, and other providers, is critical to deliver optimal care and achieve the best outcomes for both the mother and the baby. In summary, a multidisciplinary approach to provide optimal maternal care will facilitate to achieve the best outcomes for the mother and is also the best strategy for optimizing fetal survival. The following is a case report of a pregnant trauma patient who needed immediate intervention because of massive placental abruption when only a minimal workup was completed because of the urgency of the situation.

Advances in the Use of Prone Cardiopulmonary Resuscitation During Spinal Surgery in the Prone Position

Spinal surgery is usually performed in the prone position, which is a longer and more difficult procedure and is prone to complications such as circulatory dysfunction and stress injuries. Among them, stress injury is the main complication of prone spine surgery, but the reasons for stress injury in prone spine surgery are not clear, and whether prone cardiopulmonary resuscitation (CPR) can be used needs to be further verified. Supine cardiopulmonary resuscitation is commonly used in posterior spinal surgery, retroperitoneal surgery, and so on, which can effectively improve the patient’s hypoxemia. Such surgeries require a high level of anesthetic management, and cardiopulmonary resuscitation is necessary if a patient in a prone position experiences cardiac arrest. In the process of cardiopulmonary resuscitation, supine cardiopulmonary resuscitation is often used, especially for some obese patients, if they are immediately changed to the supine position, it takes up more time, there may be wound infection, and there is a possibility of missing the optimal rescue and resuscitation time. Based on this, this paper reviews the use of prone-position cardiopulmonary resuscitation for spinal surgery in the prone position.

Analysis of the Application Value of Virtual Reality Combined with Flipped Classroom Teaching Mode in Cardiopulmonary Resuscitation Teaching

Objective:To analyze the value of using virtual reality combined with the flipped classroom teaching model in teaching cardiopulmonary resuscitation(CPR).Methods:Two classes of our nursing program were randomly selected for the study from September 2022 to September 2023,Class A(52 students,conventional teaching method)and Class B(52 students,virtual reality combined with flipped classroom teaching mode).The assessment scores and independent learning ability scores of the students in the two classes were compared.Results:CPR theory and operation scores,passing rate,and independent learning ability scores of Class B were higher than those of Class A(P<0.05).Conclusion:the use of virtual reality combined with the flipped classroom teaching mode in CPR teaching is conducive to the improvement of students’assessment scores and independent learning ability.

Impact of Optimizing Emergency Nursing Processes on Resuscitation Success in Patients with Acute Chest Pain

Objective:To analyze the effect of optimizing the emergency nursing process in the resuscitation of patients with acute chest pain and the impact on the resuscitation success rate.Methods:66 patients with acute chest pain received by the emergency department of our hospital from January 2022 to December 2023 were selected as the study subjects and divided into two groups according to the differences in the emergency nursing process,i.e.,33 patients receiving routine emergency care were included in the control group,and 33 patients receiving the optimization of emergency nursing process intervention were included in the observation group.Patients’resuscitation effect and satisfaction with nursing care in the two groups were compared.Results:The observation group’s consultation assessment time,reception time,admission to the start of resuscitation time,and resuscitation time were shorter than that of the control group,the resuscitation success rate was higher than that of the control group,and the incidence of adverse events was lower than that of the control group,with statistically significant differences(P<0.05);and the observation group’s satisfaction with nursing care was higher than that of the control group,with statistically significant differences(P<0.05).Conclusion:Optimization of emergency nursing process intervention in the resuscitation of acute chest pain patients can greatly shorten the rescue time and improve the success rate of resuscitation,with higher patient satisfaction.

参附注射液对心肺复苏大鼠心肌κ阿片受体的影响

目的：观察心脏骤停复苏后（ CA-CPR）心功能和心肌κ阿片受体（κ-OR）表达的变化及参附注射液对其影响，探讨参附注射液保护复苏后心功能的新机制。方法健康雄性SD大鼠，随机分为健康对照组（BL）、参附注射液组（SF）和对照组（CON）。所有大鼠均气管插管，经颈动脉左心室插管和股动脉插管监测血流动力学参数，经股静脉置管建立给药通道。采用气管夹闭窒息法制作心脏骤停动物模型。 BL组不复制模型，SF组和CON组窒息5 min后予心肺复苏（CPR）。 SF组CPR同时静脉泵注参附注射液20 mL/kg（60 mL/h），CON组泵注等量生理盐水。动态记录HR、MAP、dP/dt40、LVEDP和-dP/dtmax等血流动力学参数。拟定复苏后0．5、2、4、6、24 h五个时间点随机处死大鼠并取心肌组织备检，每个时间点均取满6只。 RT-PCR法测定心肌κ-OR mRNA表达，Western blot法测定心肌κ-OR蛋白含量。结果 CON和SF两组复苏成功率、窒息至心跳停搏时间（ Tc）、窒息至呼吸停止时间（ Tb）、开始心肺复苏至恢复自主循环时间（Tr）比较差异无统计学意义（P＞0．05）； CON组与SF组复苏后24 h生存率比较差异无统计学意义（χ2＝1．25，P＝0．26）。 BL组血流动力学参数始终保持在基线水平，SF组复苏后五个时间点HR、MAP、dP/dt40及-dP/dtmax均显著优于CON组（P＜0．01），且6 h后除-dP/dtmax始终低于BL组（P＜0.01）外，SF组HR、MAP与BL组比较差异无统计学意义（P＞0．05）。复苏大鼠心肌中κ-OR mRNA表达水平和κ-OR蛋白含量均呈先升后降曲线，均以复苏后2 h表达量最高，而BL组两者水平均显著低于CON组和SF组（P＜0．05）；与SF组比较，CON组心肌中к-OR mRNA和к-OR蛋白含量显著升高（ P＜0．05）。结论 CA-CPR对心肌κ-OR mRNA表达水平及κ-OR蛋白含量均有显著影响，参附注射液可以改善复苏后血流动力学参数，对复苏后心肌具有保护作用。下调复苏后心肌κ-OR的表达水平，或是参附注射液参与心肌保护的新机制。

临床护士心肺复苏技能不同培训方法的比较研究

目的寻找临床护士心肺复苏(cardiopulmonary resuscitation,CPR)技能培训的最佳方法。方法采用目的抽样法抽取3所三级甲等医院的内科、外科和急诊科在职临床护士162名,分别采用传统讲授练习(A组,n=54)、多媒体指导练习(B组,n=54)和自我指导练习(C组,n=54)3 种方法进行培训。测试培训前后成人单人CPR操作成绩;比较培训前后三组成绩。结果培训后三组CPR操作测试成绩均高于培训前(均P<0.01),而B组成绩明显高于A组(Z=-2.040, P<0.05)和C组(Z=-3.209, P<0.01)。结论3种方法对临床护士进行CPR培训均有效,而多媒体指导练习为最佳培训方法。

生脉注射液对心肺复苏中心肌再灌注损伤的保护作用

心脏骤停（cardiac arrest,CA）是指由各种原因所致的循环和呼吸突然停止进而导致意识丧失和神经系统功能损害,是最紧迫的心脏急症且病死率极高[1]。针对CA最有效的救治措施即为心肺复苏（cardiopulmonary resuscitation,CPR）,在CA发生后短时间内,机体细胞尚未真正死亡并仍存有微弱的代谢活动,

核因子-κB与心肺复苏后炎症反应的关系

心肺复苏（cardiopulmonary resuscitation，CPR）过程可激活多种核转录因子，使相应基因得以表达，引起一系列病理生理变化。通过对CPR相关核转录因子的研究，可以了解CPR后炎症反应的相关机理，并采取相应措施加以控制，籍此提高CPR患者的存活率。CPR后出现全身及组织器官缺血-再灌注（Ischemia／Reperfusion，I／R）时，