Aim. To evaluate whether the introduction of a therapeutic hypothermia (TH) protocol consisting of cold saline infusion and surface cooling would be effective in targeting mild therapeutic hypothermia (32&#x2013;34&#x2218;C). Additionally, to evaluate if TH would improve survival after cardiac arrest. 
Design. Before-after design. 
Setting. General Intensive Care Unit (ICU) at an urban general hospital with 470 beds. 
Patients and Methods. Patients admitted in the ICU after cardiac arrest between 2004 and 2009 were included. Effectiveness of the TH protocol to achieve the targeted temperature was evaluated. Hospital mortality was compared before (October 2004&#x2013;March 2006) and after (April 2006&#x2013;September 2009) the protocol implementation. 
Results. Hundred and thirty patients were included, 75 patients were not submitted to TH (before TH group), and 55 were submitted to TH (TH group). There were no significant differences concerning baseline, ICU, and cardiac arrest characteristics between both groups. There was a significant reduction in hospital mortality from 61&#x25; (<svg style="vertical-align:-0.1575pt;width:38.474998px;" id="M1" height="9.8999996" version="1.1" viewBox="0 0 38.474998 9.8999996" width="38.474998" xmlns="http://www.w3.org/2000/svg">
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						</text>
					</g>
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			</svg>) in the before TH group to 40&#x25; (<svg style="vertical-align:-0.09pt;width:38.474998px;" id="M2" height="9.7124996" version="1.1" viewBox="0 0 38.474998 9.7124996" width="38.474998" xmlns="http://www.w3.org/2000/svg">
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						</text>
					</g>
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			</svg>) in the TH group. 
Conclusion. Our protocol consisting of cold saline infusion and surface cooling might be effective in inducing and maintaining mild therapeutic hypothermia. TH achieved with this protocol was associated with a significant reduction in hospital mortality.

Cristina Granja

Pedro Ferreira

Orqu&#237;dea Ribeiro

Jo&#227;o Pina

Improved Survival with Therapeutic Hypothermia after Cardiac Arrest with Cold Saline and Surfacing Cooling: Keep It Simple

The use of seatbelts has increased significantly in the last twenty years, leading to a decrease in mortality from road traffic accidents (RTA). However, this increase in seatbelt use has also led to a change in the spectrum of injuries from RTA; abdominal injuries, particularly intestinal injuries have dramatically increased with the routine use of seatbelts. Such intestinal injuries frequently result from improper placement of the &#8220;lap belt&#8221;. We present 3 cases in which passengers wearing a seatbelt sustained significant devascularisation injuries to the small bowel requiring emergency surgical intervention. A high index of suspicion is crucial in such cases to prevent delays in diagnosis that can lead to severe complications and adverse outcomes. It is evident that while advocating seatbelt use, the importance of education in correct seatbelt placement should also be a focus of public health strategies to reduce RTA morbidity and mortality.

Vincent O'Dowd

Christine Kiernan

Aoife Lowery

Waqar Khan

Kevin Barry

Seatbelt Injury Causing Small Bowel Devascularisation: Case Series and Review of the Literature

Cardiopulmonary resuscitation (CPR) is an effective intervention for prehospital cardiac arrest. 
Despite all available training opportunities for CPR, disparities exist in participation in CPR training, CPR knowledge, and receipt of bystander CPR for certain ethnic groups. We conducted five focus groups with Chinese immigrants who self-reported limited English proficiency (LEP). A bilingual facilitator conducted all the sessions. All discussions were taped, recorded, translated, and transcribed. Transcripts were analyzed by content analysis guided by the theory of diffusion. The majority of participants did not know of CPR and did not know where to get trained. Complexity of CPR procedure, advantages of calling 9-1-1, lack of confidence, and possible liability discourage LEP individuals to learn CPR. LEP individuals welcome simplified Hands-Only CPR and are willing to perform CPR with instruction from 9-1-1 operators. Expanding the current training to include Hands-Only CPR and dispatcher-assisted CPR may motivate Chinese LEP individuals to get trained for CPR.

Mei Po Yip

Brandon Ong

Shin Ping Tu

Devora Chavez

Brooke Ike

Ian Painter

Ida Lam

Steven M. Bradley

Gloria D. Coronado

Hendrika W. Meischke

Diffusion of Cardiopulmonary Resuscitation Training to Chinese Immigrants with Limited English Proficiency

Hyperkalemia is a commonly encountered electrolyte abnormality that can significantly alter normal cardiac conduction. Potentially lethal dysrhythmias associated with hyperkalemia include complete heart block and Mobitz Type II second-degree AV block. We report a unique case of Mobitz Type 1 second-degree atrioventricular (AV) block, known commonly as Wenckebach, due to hyperkalemia. The patient's symptoms and electrocardiogram (ECG) evidence of Wenckebach block resolved with lowering of serum potassium levels, with subsequent ECG showing first-degree AV block. This paper highlights an infrequently reported dysrhythmia associated with hyperkalemia that emergency physicians should be familiar with.

Aparajita Sohoni

Berenice Perez

Amandeep Singh

Wenckebach Block due to Hyperkalemia: A Case Report

Ambulance crashes are a significant risk to prehospital care providers, the patients they are carrying, persons in other vehicles, and pedestrians. No uniform national transportation or medical database captures all ambulance crashes in the United States. A website captures many significant ambulance crashes by collecting reports in the popular media (the website is mentioned in the introduction). This report summaries findings from ambulance crashes for the time period of May 1, 2007 to April 30, 2009. Of the 466 crashes examined, 358 resulted in injuries to prehospital personnel, other vehicle occupants, patients being transported in the ambulance, or pedestrians. A total of 982 persons were injured as a result of ambulance crashes during the time period. Prehospital personnel were the most likely to be injured. Provider safety can and should be improved by ambulance vehicle redesign and the development of improved occupant safety restraints. Seventy-nine (79) crashes resulted in fatalities to some member of the same groups listed above. A total of 99 persons were killed in ambulance crashes during the time period. Persons in other vehicles involved in collisions with ambulances were the most likely to die as a result of crashes. In the urban environment, intersections are a particularly dangerous place for ambulances.

Teri L. Sanddal

Nels D. Sanddal

Nicolas Ward

Laura Stanley

Ambulance Crash Characteristics in the US Defined by the Popular Press: A Retrospective Analysis

Background. Strategies combining pretest clinical assessment and D-dimers measurement efficiently and safely rule out venous thromboembolism events (VTE) in low- and intermediate-risk patients. Objectives. As process of ageing is associated with altered concentrations of coagulation markers including an increase in D-dimers levels, we investigated whether D-dimers could reliably rule out VTE across age categories. Method. We prospectively assessed the test performance in 1,004 patients visiting the emergency department during the 6-month period with low or intermediate risk of VTE who also received additional diagnostic procedures. Results. 67 patients had VTE with D-dimers levels above the threshold, and 3 patients displayed D-dimers levels below the threshold. We observed that specificity of D-dimers test decreased in an age-dependent manner. However, sensitivity and negative predictive value remained at very high level in each age category including older patients. Conclusion. We conclude that, even though D-dimers level could provide numerous false positive results in elderly patients, its high sensitivity could reliably help physicians to exclude the diagnosis of VTE in every low- and intermediate-risk patient.

G. Der Sahakian

Y. E. Claessens

J. C. Allo

J. Kansao

G. Kierzek

J. L. Pourriat

Accuracy of D-Dimers to Rule Out Venous Thromboembolism Events across Age Categories

We report a case of prehospital &#x0201C;cannot intubate&#x0201D; and &#x0201C;cannot ventilate&#x0201D; scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20&#x02009;min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2&#x02009;min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm.

J&#233;r&#244;me Sudrial

Caroline Birlouez

Anne-Laurette Guillerm

Jean-Luc Sebbah

Roland Amathieu

Gilles Dhonneur

Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step

We report a case of a splenic artery aneurysm rupture presenting with shock which required timely embolization therapy. This case demonstrates how the rapid use of bedside ultrasound by emergency department (ED) physicians can help identify the cause of shock and, therefore, initiate appropriate treatment quickly even if the cause is rare, as in this case.

Masayuki Iyanaga

Susan Watts

Takeshi Kasai

A Patient with Splenic Artery Aneurysm Rupture and  the Importance of Rapid Sonography in the ED

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Emergency Medicine International publishes original research articles and&nbsp;review articles&nbsp;related to prehospital care, disaster preparedness and response, acute medical and paediatric emergencies, critical care and wound care

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Emergency Medicine International publishes original research articles and review articles related to prehospital care, disaster preparedness and response, acute medical and paediatric emergencies, critical care and wound care

Emergency Medicine International