Search Results (167)

The case for early vasopressor initiation in septic shock has been argued in detail in physiologic reviews and randomized trials. The evidence base is no longer the limiting factor. What remains limiting is delivery. Across most U.S. emergency departments and many international settings, patients with septic shock still do not reliably receive norepinephrine within the first hour of recognition. This review reframes the early-vasopressor question from a physiologic argument into an implementation problem and identifies three structural barriers that operate independently of any individual clinician’s understanding of the underlying evidence. The first is regulatory: the SEP-1 quality measure, despite a documented physician exception for the fluid requirement, continues to incentivize a fluids-first sequence as the institutional default. The second is cultural: the gap between policies that permit peripheral norepinephrine administration and the workflows, scope-of-practice arrangements, and standing orders required to actually start it at the bedside. The third is upstream: time-to-vasopressor is partly a downstream surrogate for time-to-recognition, and interventions that target only the pressor decision miss the larger source of delay. We propose a parallel resuscitation framework with explicit protocolized triggers and stratify implementation considerations across U.S. academic centers, U.S. community emergency departments, and resource-limited international settings. Closing the gap means stopping the physiology argument and rebuilding the operational architecture. Full article

Background: Out-of-hospital cardiac arrest (OHCA) remains a major public health problem. Many patients contact primary health care (PHC) services shortly before cardiac arrest, yet data on PHC staff preparedness to provide guideline-concordant basic life support (BLS) remain limited. This study assessed BLS knowledge and chest compression quality among medical and non-medical PHC staff. Methods: This multicentre cross-sectional simulation-based study was conducted in Poznań and Poznań County, Poland. PHC staff with direct patient contact were included (n = 162). Assessment comprised an author-developed 15-item knowledge test based on European Resuscitation Council guidelines and a two-minute continuous chest compression trial on a Resusci Anne QCPR manikin. Correlations were analysed using Spearman’s rank correlation coefficient, group differences using the Kruskal–Wallis test with Dunn–Bonferroni post hoc comparisons, and predictors using multivariable linear regression. Results: The median BLS knowledge score was 9/15 points (mean 8.74). Mean chest compression depth was 41.3 mm, below the recommended range, with only 23.5% of compressions meeting depth criteria. Correct compression rate was maintained in 30.2% of compressions, and full chest recoil was observed in 55.0% of attempts. Age was negatively correlated with compression rate. In participant-level regression, higher BLS knowledge was associated with better QCPR performance; however, this association was attenuated and no longer statistically significant in mixed-effects models accounting for clustering by practice. Conclusions: PHC staff demonstrated gaps in BLS knowledge and inadequate simulated chest compression performance, particularly regarding compression depth and rate. These findings support recurrent, simulation-based BLS training for all PHC personnel. Full article

Background: The aim of this study was to assess the effectiveness of supplemental low-flow oxygen on emergency clinicians in improving their quality and length of performance of external chest compressions (ECCs) on a resuscitation manikin. Methods: This was a double-blinded randomized crossover trial. Participants were emergency medicine doctors, nurses, or paramedics working at large emergency departments or ambulance services in Victoria, Australia. The intervention was oxygen and air via nasal cannula during external cardiac compressions. The primary outcome measure was ‘time to inadequate CPR’. Secondary outcome measures included compression rate and compression depth and global rating on a 10-point ordinal scale reporting their ‘comfort’ and ‘convenience’ ratings. Results: There was no statistical or clinical difference between the three study arms with respect to time to inadequate CPR or compression rates per minute. There was a statistically significant difference in the median depth of compression between the control (51.5 mm; IQR 43–58) and air study arms (48.0 mm; IQR 40–55; p = 0.015). Conclusions: Administration of supplemental oxygen (or air) to clinicians performing ECC on a manikin does not improve their performance when measured against internationally accepted guidelines. Supplemental oxygen or air to rescuers performing ECC was not supported. Full article

Objectives: In lifeguarding, when prevention fails, rapid and safe rescue is essential to prevent submersion and enable appropriate care. These operations demand high physical fitness. High-Intensity Functional Training (HIFT), such as CrossFit^®, has become a widely used training model. This study examined the integration of HIFT into lifeguard training to enhance preparedness for aquatic rescues. The aim was to analyse the external and internal load generated by a lifeguard-specific HIFT protocol and to assess its utility both as a training method and as a fitness evaluation tool. Methods: Twenty-seven lifeguards completed a 15 min HIFT protocol in an AMRAP (As Many Rounds As Possible) format with four stations: running, swimming with a tow, victim extraction, and cardiopulmonary resuscitation (CPR). Variables measured included time per round (TRound), number of completed rounds, maximum and average heart rate (MaxHR, AvgHR), post-exercise blood lactate, rating of perceived exertion (RPE) per round and overall, and CPR quality (Q-CPR). Results: TRound ranged from 238 to 268 s, with significant differences between consecutive rounds, though remaining at submaximal levels. Most participants (74%) completed three rounds, and none completed four. AvgHR was 164 bpm (82% of MaxHR). RPE increased significantly across rounds (p < 0.001), reaching 9 post-AMRAP (p < 0.001). Post-AMRAP blood lactate was 15.50 mmol/L (p < 0.001), indicating high physiological stress. Despite accumulated fatigue, Q-CPR remained consistently high, ranging from 86% to 94%, with no significant differences across rounds. Conclusions: The results of this pilot study suggest that physically active lifeguards can sustain a controlled, high-intensity effort at submaximal heart rates and high perceived exertion without compromising CPR quality. These preliminary findings support the feasibility and potential utility of a lifeguard-specific HIFT programme structured as an AMRAP for high-intensity training and ecological fitness assessment in rescue-specific conditions; formal validation studies are needed before broader recommendations can be made. Full article

High-quality cardiopulmonary resuscitation (CPR) aims at saving lives in time-critical emergencies, which requires correct compression rate, depth, and hand placement. However, due to the high cost and environmental constraints of sensor-equipped manikins or dedicated hardware, it is unrealistic to deploy these devices in ordinary training settings. For monocular vision-based methods, estimating compression depth without direct depth signals and tracking hands under severe overlap are difficult. To address these problems, this paper proposes VISIOCPR, a monocular vision-based CPR training system with human-computer collaborative feedback, which provides quantitative CPR coaching using only a standard RGB camera. To address the inherent visual constraints, the system integrates a tiered compression-point detector that maintains robust tracking continuity despite severe hand overlap and motion blur. Furthermore, it recovers accurate metric depth without attached markers through a fused calibration scheme, which combines an empirical baseline, a reference-object measurement, and visible body proportions. A randomized controlled study ($n=40$) showed that participants trained with VISIOCPR achieved higher simultaneous compliance and reached competency faster than the control group under the tested setting. Full article

Background: To identify factors contributing to the low success rate of resuscitation, we optimized related links in resuscitation management and constructed a five-minute green transfer resuscitation model. Methods: A quasi-experimental pre–post quality improvement study was conducted on patients with critical and severe conditions admitted in the Department of Otorhinolaryngology at a China otolaryngology hospital. The pre-intervention group of patients were treated using the conventional resuscitation process, while the post-intervention group was treated using the “5 min green transfer” resuscitation process under the guidance of the quality improvement (QI) team. Results: The resuscitation mainly occurred in the first and second quarters, between 20:00 in the evening and 07:59 the following morning. In the pre-intervention group, the most common direct cause of initiating resuscitation was bleeding, primarily due to epistaxis, while the primary direct cause for initiating resuscitation was abnormal vital signs in the post-intervention group. The resuscitation success rate was 82.93% (34/41) in the pre-intervention group and 93.48% (43/46) in the post-intervention group. However, there was no statistically significant difference in resuscitation success rate (p = 0.14) and complication incidence (p = 0.71) between the two groups. In the pre-intervention group, six patients (14.63%) were transferred within 5 min, whereas 100% of patients (46 cases) in the post-intervention group achieved 5 min transfer, with a statistically significant difference observed between the two groups (p = 0.03). Conclusions: The intervention significantly improved the 5 min transfer efficiency, which was conducive to ensuring timely medical intervention for patients and safeguarding their clinical safety. Full article

A 13-year-old, spayed female Maltese dog presented with acute collapse and profound lethargy of approximately 1 h duration. On admission, the dog was in hypovolemic shock, with severe hypotension, marked pallor, tachycardia, and hemoperitoneum identified by focused abdominal ultrasonography. Ultrasonography also revealed a ruptured hemorrhagic mass in the right retroperitoneal space. Because the patient was hemodynamically unstable and ongoing life-threatening hemorrhage was suspected, preoperative computed tomography was considered unsafe, and emergency exploratory laparotomy was performed following transfusion-based resuscitative stabilization. Intraoperatively, the lesion was found to involve the right kidney and caudate hepatic lobe. En bloc resection, including right nephrectomy, partial hepatectomy, and excision of the retroperitoneal-associated mass, was completed while preserving the right adrenal gland and adjacent major vasculature. Histopathologic and immunohistochemical evaluation supported a diagnosis of solid-pattern hemangiosarcoma, although a single primary site of origin could not be definitively assigned. The dog recovered without major perioperative complications, was discharged in stable condition, and maintained good quality of life for approximately 1 year; however, late clinical decline suspicious for recurrence or progression was not objectively confirmed. This case highlights the practical utility of focused ultrasonography, rapid surgical decision-making, and carefully planned en bloc resection for emergency hemorrhage control in a dog when advanced imaging was considered unsafe. Full article

Background and Objectives: Extracorporeal membrane oxygenation (ECMO) provides temporary respiratory or circulatory support when conventional therapies fail. Some patients do not recover and are not candidates for transplant or durable mechanical support. In these cases, continuing ECMO may no longer align with the patient’s goals. Compassionate ECMO discontinuation (CED) is the planned withdrawal of extracorporeal support with death anticipated. The term “compassionate” refers to the goal of minimizing suffering in the end-of-life process. This review proposes a reliability-oriented framework to standardize CED and reduce preventable distress for patients, families, and clinicians. Materials and Methods: We conducted a targeted narrative review of ethical analyses, consensus guidance, and empirical literature on planned ECMO withdrawal. The results of the narrative review were combined with our existing practical process for CED into this proposed reliability-oriented framework as a guide for clinicians. Recommendations were organized into a four-phase process model that emphasizes operational implementation, anticipatory guidance, and quality improvement. We included modality-specific considerations for veno-arterial (VA), veno-venous (VV) ECMO, and extracorporeal cardiopulmonary resuscitation (ECPR). Results: The framework includes four phases. Phase I, Anticipation and Alignment, emphasizes structured shared decision-making, early expectation setting, time-limited trials, palliative care integration, and predefined pathways for managing disagreement. Phase II, Preparation, includes interdisciplinary role assignment, a pre-withdrawal time out, family coaching on expected physiological changes, and preemptive comfort medications that account for ECMO-altered pharmacokinetics. Phase III, Implementation, prioritizes comfort first, pacing with explicit pause points, environmental controls to reduce alarms and visual distress, and modality-tailored sequencing. Phase VI, Aftercare and Learning Capture, includes bereavement support, standardized documentation, structured team debriefing, and recommended process measures to guide improvement. Conclusions: Viewing CED as a low-frequency, high-stakes clinical process supported by scripts, checklists, and iterative feedback can improve goal-concordant end-of-life (EOL) care, reduce suffering and family trauma, support clinicians, and strengthen ECMO program learning systems. Full article

Background: Birth asphyxia is a leading cause of neonatal mortality. More than half of these deaths are due to low-quality care. Objectives: To describe the frequency, sequence, timing, and duration of interventions after birth and newborn outcomes. Methods: This prospective observational study in rural Tanzania included newborns ≥28 weeks gestation. Trained research assistants observed and recorded all deliveries and resuscitations 24 h a day, 7 days a week, logging interventions in real time using the Liveborn Observation app. Results: Of 2564 newborns born, 2431 (94.9%) were enrolled in the study. Macerated stillbirth (n = 52), newborns with no parental consent (n = 67) or incomplete Liveborn data (n = 14) were excluded. Additionally, 2193/2431 (90.2%) newborns did not receive bag-mask ventilation (BMV), and 1755/2431 (72.2%) started breathing before 30 s from birth at median (quartiles) 6 (3, 13) s, 438/2431 (18.0%) started breathing beyond 30 s at 49 (38, 67) s. Moreover, 238/2431 (9.8%) received BMV at 82 (54, 120) s after birth, 1/3 within the first min. Finally, 159/238 (66.8%) were suctioned for 26 (17, 40) s. The first suction sequence was initiated at 44 (24, 78) s after birth. In 24/238 (10.1%) newborns, BMV continued for more than 10 min, with an increased risk of dying within 24 h (RR = 4.26, 95% CI; 1.3–10.0, p = 0.016) and seven days (RR = 8.14, 95% CI; 3.5–17.6, p < 0.001) compared to those ventilated for less than 10 min. Conclusions: Almost 10% of newborns received BMV at birth, but only one-third were ventilated within the first recommended minute. Excessive use of suctioning likely delayed the start of BMV, and prolonged ventilation beyond 10 min was associated with higher mortality. Full article

Over the past years, burn care has evolved from a discipline focused on survival to one centered on restoring long-term health, function, and quality of life. Significant advances in critical care, early excision and grafting, infection control, and metabolic support have transformed survival outcomes for even the most severe injuries. As a result, the field now faces a new frontier: understanding and managing the long-term physical, psychological, and systemic sequelae of survival. This review traces the evolution of burn care over the last century and outlines the challenges and priorities for the next 25 years. The first era of progress, defined by innovations in resuscitation, surgery, and critical care, has given rise to a growing cohort of long-term survivors. Research over the past decade has revealed that major burns induce chronic multisystem alterations, including metabolic, cardiovascular, neurocognitive, and immunological dysfunctions. Emerging concepts such as burn-associated heart failure exemplify this shift from acute to chronic disease understanding. Looking ahead, the future of burn medicine lies in personalized and lifelong care, supported by translational research, digital health, regenerative therapies, and interdisciplinary collaboration. Overall, burn care stands at a pivotal crossroads. By integrating precision medicine, rehabilitation science, and psychosocial care, we aim to move the field from survival toward sustained, holistic recovery over the next 25 years. Full article

Background/Objectives: High-quality cardiopulmonary resuscitation (CPR) is essential for improving clinical outcomes in patients experiencing cardiac arrest. Feedback devices designed to guide CPR must offer real-time feedback on chest compression quality for use by both medical personnel and laypersons. To describe the impact of using an infrared-based device to provide feedback on chest compression quality during CPR performed by healthcare personnel. Methods: A before-and-after study conducted in a simulated hospital from February 2019 to February 2020 evaluated the difference in the percentage of adequate chest compressions in depth and rate. This was assessed by comparing the number of adequate compressions to the total performed in one minute, both with and without the use of a feedback device. Results: A total of 90 participants were recruited, with an average age of 31.2 years (SD: 8.86), of which 60% (54/90) were women. In infants and schoolchildren/adults, high-quality compressions improved by 66% (85% vs. 19%; p < 0.001) and 54% (79% vs. 25%; p < 0.001), respectively, when guided by the GA compared to the control group. In participants without training and experience in CPR, the use of the Guardian Angel achieved high-quality compressions of 45% (10/22) and 66% (25/42), respectively, when evaluating depth for the schoolchildren/adults group. The use of the device during CPR, even in situations of moderate or severe fatigue, resulted in an improvement in high-quality compressions in terms of frequency, reaching 73% (16/22) in infants and 68% (15/22) in schoolchildren/adults. Conclusions: The Guardian Angel improves both the frequency and depth of compressions in participants without previous CPR experience or training. Additionally, the device demonstrated notable improvements in compression frequency, even in situations of moderate or severe fatigue. Full article

Introduction: Despite improved health service accessibility, neonatal mortality in Ethiopia remains high at 33 per 1000 live births. Thus, improving health facilities’ readiness across infrastructure, basic amenities, equipment, medications, laboratory services, Kangaroo Mother Care, infection prevention and control, staffing, and guidelines availability is critical for improving the quality of neonatal care and survival. Objective: The aim of this study was to evaluate the readiness of Ethiopian hospitals to provide services to small and sick newborns. Methods: This was a cross-sectional study including 208 hospitals across four regions in Ethiopia in 2021–2024, prior to the implementation of the Saving Little Lives program. Data was collected using an adapted World Health Organization’s Service Availability and Readiness Assessment tool and are presented using composite scores. Results: The mean composite readiness score for the 208 hospitals for providing services to small and sick newborns in labour and delivery wards was 59%, with domain-specific scores of 47% for basic amenities, 56% for essential neonatal care, and 74% for newborn resuscitation. Significant variation was seen across hospital levels, and basic amenities were available in 68%, 49%, and 43%, essential neonatal care in 68%, 81%, and 71%, and newborn resuscitation in 68%, 66%, and 50% of referral, general, and primary hospitals, respectively. The mean composite readiness score to provide newborn care in the neonatal care units was 57%. Scores varied by hospital levels, with scores of 73%, 64%, and 50% for referral, general, and primary hospitals, respectively. Domain-specific scores were 63% for basic amenities, 65% for equipment, 67% for medications, 63% for laboratory services, 25% for Kangaroo Mother Care, 68% for infection prevention and control, 55% for staffing, and 51% for guidelines availability. Functional bCPAP machines were available in 14% of labour and delivery wards and in 35% of neonatal care units. Conclusions: There was a substantial gap in readiness to provide care for small and sick newborns, and significant variations across hospital levels. Immediate actions must be taken to address the observed gaps to reach the sustainable development goal of reducing neonatal mortality to at least 12 per 1000 live births by 2030. Full article

Background: The ISCHEMIA trial demonstrated no overall prognostic benefit of an initial invasive strategy over optimal medical therapy (OMT) in patients with chronic coronary syndrome (CCS) and moderate-to-severe ischemia. However, managing patients with stable angina and low systolic blood pressure (SBP) remains challenging due to limited tolerance to vasodilatory anti-anginal drugs and the uncertain role of revascularization in improving long-term outcomes for this subgroup. Objectives: This study aimed to estimate the treatment effect of an initial invasive strategy (INV) compared with conservative medical therapy (CON) on long-term clinical outcomes and quality of life in patients with stable angina, particularly those with low baseline systolic blood pressure (≤120 mmHg). Methods: We conducted a post hoc analysis of 3544 patients with stable angina from the ISCHEMIA trial, divided into an initial invasive strategy or a conservative approach. The primary endpoint was a 3-year composite of cardiovascular death, myocardial infarction, hospitalization for unstable angina or heart failure, or resuscitated cardiac arrest. Health-related quality of life was assessed using the Seattle Angina Questionnaire (SAQ). In the subgroup, patients were stratified by baseline SBP, diastolic blood pressure (DBP) and heart rate; the Cox model was adjusted for the covariates. Results: Baseline characteristics were generally comparable between the two groups. Over 3 years of follow-up, no significant difference in primary endpoint events was observed between the INV and CON group in the overall cohort (HR = 0.94, 95%CI 0.77–1.14, p = 0.53), and the INV group had the higher SAQ score. Among patients with low baseline SBP (≤120 mmHg), after adjusting for clinical factors using Cox regression, randomized treatment assignment to the INV approach significantly reduced adverse cardiovascular events compared with conservative therapy (HR = 0.58, 95%CI 0.38 to 0.89). Conclusions: In patients with stable angina, an invasive strategy improved long-term quality of life. Among those with low baseline SBP (≤120 mmHg) and limited tolerance to vasodilatory anti-anginal drugs, invasive management reduced 3-year adverse events, supporting tailored revascularization strategies for these patients; a larger cohort is needed for validation. However, this subgroup-specific causal contrast derives from a post hoc exploratory analysis and should be interpreted cautiously; prospective randomized studies are needed to further validate these findings. Full article

Introduction: Severe traumatic brain injury (sTBI) frequently coexists with polytrauma and often necessitates damage control neurosurgery (DCNS), where rapid decompression and temporary stabilization take precedence over definitive reconstruction. Within this context, anesthetic management must balance cerebral protection with ongoing resuscitation, yet high-quality DCNS-specific evidence remains limited. Materials and Methods: A comprehensive search of PubMed, Scopus, and Google Scholar (2015–2025) was conducted using MeSH terms and keywords related to neurotrauma, anesthesia, intracranial pressure, and perioperative management. Studies were included if they examined anesthetic or hemodynamic strategies in severe TBI or DCNS and reported relevant clinical or physiologic outcomes. Results: Nineteen articles addressing perioperative strategies for optimizing DCNS outcomes were analyzed. Discussion: Preoperative care emphasizes hemodynamic stabilization and permissive hypertension, damage control resuscitation including massive transfusion protocols, optimization of cerebral perfusion pressure (CPP) and neuromonitoring, and the use of hyperosmolar therapy. Transexamic acid can be used in sTBI safely but with unclear improvement in outcomes. Intraoperatively, propofol-based total intravenous anesthesia is generally preferred over volatile agents due to favorable effects on intracranial pressure (ICP), cerebral blood flow (CBF), autoregulation, and emergence. While historically contraindicated, ketamine and etomidate are now increasingly used as hemodynamically protective induction agents. Analgesic and sedative strategies prioritize dexmedetomidine and carefully titrated opioids to minimize respiratory depression and reduce postoperative complications. CPP and ICP-directed management relies on individualized blood pressure targets, vasopressor selection, lung-protective ventilation, and strict temperature control. Conclusions: Emerging evidence has suggested the benefit of DCNS for patient survival. Overall, perioperative care is guided largely by physiology and extrapolation, highlighting the need for standardized protocols. Full article

Background/Objectives: Neonatal hypothermia remains a significant contributor to neonatal mortality and morbidity mainly in low and middle-income countries, such as those in sub-Saharan Africa. The objective of this systematic review and meta-analysis is to assess the prevalence of neonatal hypothermia and its risk factors in sub-Saharan Africa. Methods: The Preferred Reporting Items for Systematic Review and Meta-Analysis statement (PRISMA) guideline was used to search databases (PubMed, Scopus, Cocrane library and Google Scholar) for studies reporting both the prevalence and factors associated with neonatal hypothermia in sub-Saharan Africa. We have included cross-sectional, cohort and descriptive studies published between 1 June 2014 and 31 May 2024. The Joanna Briggs Institute (JBI) quality appraisal checklist was used for the appraisal of studies. Subgroup analysis was conducted by country, study design and population. A total of 21 articles with 12,803 participants from 9 countries were included in the analysis. Results: The pooled prevalence of neonatal hypothermia was 55.39% (95% CI: 48.52, 62.25). Preterm birth (odds ratio (OR): 3.49; 95% CI: 1.98–6.16), low birth weight (OR: 3.56; 95% CI: 2.36–5.39), no skin-to-skin contact (OR: 1.31; 95% CI: 0.55–3.13), lack of resuscitation (OR: 2.56; 95% CI: 1.75–3.76), delayed initiation of breast feeding (OR: 2.38; 95% CI: 1.57–3.61), admission during cold season (OR: 1.80; 95% CI: 1.33–2.44), home delivery (OR: 1.94; 95% CI: 1.51–2.50) and early bathing (OR: 3.03; 95% CI: 0.98–9.38) were the factors significantly associated with neonatal hypothermia. Conclusions: The observed high prevalence of hypothermia was associated with physiological, behavioral and environmental factors. Full article