Showing papers in "Critical Care Medicine in 1985"
TL;DR: The form and validation results of APACHE II, a severity of disease classification system that uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status, are presented.
Abstract: This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
14,583 citations
1,002 citations
TL;DR: It is concluded that the increase in PvMco2 and the concurrent decrease in ETco2 reflect a critical reduction in cardiac output, which reduces alveolar blood flow to the extent that carbon dioxide clearance by the lung fails to keep pace with systemic CO2 production.
Abstract: Previous studies demonstrated selective increases in mixed venous carbon dioxide tension (PvCO2) during CPR in a porcine model of cardiac arrest. This was associated with a decrease in end-tidal carbon dioxide concentration (ETCO2), possibly due to a critical reduction in cardiac output and therefore pulmonary blood flow during CPR. We investigated the relationship between ETco2 and cardiac output before cardiac arrest and during CPR. Observations in 19 minipigs confirmed a high linear correlation between ETco2 and cardiac output. We conclude that the increase in Pvco2 and the concurrent decrease in ETco2 reflect a critical reduction in cardiac output, which reduces alveolar blood flow to the extent that carbon dioxide clearance by the lung fails to keep pace with systemic CO2 production.
339 citations
TL;DR: This research represents an initial attempt to develop models that are not based on subjectively determined weights for predicting hospital mortality, and predicted outcomes using these two models were closely correlated with actual outcome.
Abstract: Data at ICU admission and after 24 h in the ICU were collected on 755 patients, to derive multiple logistic regression models for predicting hospital mortality. The derived models contained relatively few and easily obtained variables. The weight associated with each variable was determined objectively. There were seven admission variables, none of which were treatment dependent, and seven 24-h variables reflecting treatments and patients' conditions in the ICU. Predicted outcomes using these two models were closely correlated with actual outcome. Theoretically, a predictive model would be useful to physicians for triage decisions as well as determining aggressiveness of care through discussions with families, determining utilization of ICU facilities, and objectively comparing different ICUs. This research represents an initial attempt to develop models that are not based on subjectively determined weights.
326 citations
TL;DR: Invasive hemodynamic monitoring was performed on 220 critically ill surgical patients judged by clinical evaluation to have a high likelihood of surgical complications or death and the nonsurvivors generally had reduced myocardial performance as judged by lower cardiac index and left ventricular stroke work.
Abstract: Invasive hemodynamic monitoring was performed on 220 critically ill surgical patients judged by clinical evaluation to have a high likelihood of surgical complications or death. Patients with markedly abnormal pre-operative hemodynamic values were excluded from analysis. Data were separated into pre
238 citations
TL;DR: The mechanism by which endotracheal tubes repeatedly inoculate the lungs of intubated patients may prove to be dislodgment of such aggregates by suction apparatus.
Abstract: Biomaterials are essential for life support and monitoring of critically ill patients, but their use increases the risk of nosocomial infection. Of the various plastics used for life support and monitoring devices, polyvinylchloride is one to which bacteria most readily adhere. Through the use of qualitative culture techniques and scanning and transmission electron microscopy, we studied the surfaces of polyvinylchloride endotracheal tubes removed from 25 ICU patients, to determine if bacterial adhesion to those tubes was sufficient to provide a possible source for repeated contamination of the tracheobronchial tree. Of the surfaces studied, 16% were partially covered and 84% were completely covered by an amorphous bacteria-containing matrix. Some biofilm-enclosed bacterial aggregates projected from the matrix into the lumen of the tube. The mechanism by which endotracheal tubes repeatedly inoculate the lungs of intubated patients may prove to be dislodgment of such aggregates by suction apparatus.
237 citations
TL;DR: Six normotensive, anesthetized dogs were infused intravenously with short-term, incremental infusions of norepinephrine with or without the addition of iv dopamine (DA), finding that shock patients receiving therapy with NE should be good candidates to receive low-dose DA to enhance renal blood flow.
Abstract: Six normotensive, anesthetized dogs were infused intravenously with short-term, incremental infusions of norepinephrine (NE) with or without the addition of iv dopamine (DA) (4 micrograms/kg X min). The infusion of NE alone and in combination with low-dose DA produced similar, significant increases in mean arterial pressure. During the infusion of pressor doses of NE, the addition of DA resulted in significantly higher renal blood flow (p less than .001) and lower renal vascular resistance (p less than .001) than infusions of NE alone. Thus, the renal vasodilating action of low-dose DA persisted despite infusions of NE, a potent vasopressor which decreases renal blood flow. This suggests that shock patients receiving therapy with NE should be good candidates to receive low-dose DA to enhance renal blood flow.
194 citations
TL;DR: It is concluded that aerosol delivery in mechanically ventilated patients is significantly reduced and that this is probably due to a combination of suboptimal breathing pattern, intrinsic airway disease, and the endotracheal tube functioning as both a site for aerosol deposition through impaction as well as a barrier to gastrointestinal absorption.
Abstract: To study the effects of respiratory failure and mechanical ventilation on aerosol delivery to the lungs, we performed nuclear scans after aerosolization of 5 to 9 mCi of Tc-99m diethylenetriamine pentaacetic acid in seven stable, intubated, and mechanically ventilated patients. The radioactivity reaching the lungs was 2.9 +/- .7% (mean +/- SD) of the administered dose, an amount significantly less than that in three healthy nonintubated subjects and also less than what would be expected in nonintubated subjects from other published reports. We then performed a subsequent study in 15 additional mechanically ventilated patients who were receiving aerosolized bronchodilators through their endotracheal tube. In these patients, heart rate and lung mechanical function values before and after treatment were not significantly different. We conclude from these studies that aerosol delivery in mechanically ventilated patients is significantly reduced and that this is probably due to a combination of suboptimal breathing pattern, intrinsic airway disease, and the endotracheal tube functioning as both a site for aerosol deposition through impaction as well as a barrier to gastrointestinal absorption.
182 citations
TL;DR: The serum magnesium level was measured in 94 consecutive patients admitted to the medical ICU of Los Angeles County/University of Southern California Medical Center over a 2-month period and one third had hypocalcemia that was corrected with magnesium supplementation.
Abstract: The serum magnesium level was measured in 94 consecutive patients admitted to the medical ICU of Los Angeles County/University of Southern California Medical Center over a 2-month period. Sixty-five percent of patients with serum creatinine concentrations of 1.1 mg/dl or less were hypomagnesemic. Of
166 citations
TL;DR: It is concluded that OCCPR is greatly superior to SCPR and SVC-CPR with respect to preservation of the brain during resuscitation.
Abstract: Thirty-two dogs subjected to 4 min of ventricular fibrillation were equally divided into four treatment groups: (a) immediate defibrillation (control); or 30 min of (b) standard CPR (SCPR), (c) simultaneous ventilation-compression CPR (SVC-CPR), or (d) open-chest CPR (OCCPR). After 30 min of CPR, restoration of spontaneous circulation was attempted using drug therapy and countershocks and the animals maintained for 24 h or until refractory hypotension occurred. During CPR, OCCPR yielded higher mean arterial and lower central venous pressures than either external method. Circulation was restored in all control dogs, and by 24 h they had nearly normal neurologic deficit scores. In the SCPR group, the heart was restarted in six dogs. Five of these dogs had severe neurologic damage and did not survive 24 h. The animal that survived 24 h, however, was nearly normal neurologically. Although circulation was restored in five SVC-CPR dogs, all were brain-dead and none survived 24 h. In the OCCPR group, seven animals survived 24 h and their neurologic deficit scores were not significantly different from control values. We conclude that OCCPR is greatly superior to SCPR and SVC-CPR with respect to preservation of the brain during resuscitation.
141 citations
TL;DR: A decision rule which would have admitted to intensive care those patients with a high probability ofinfarction who were not admitted by the emergency room physicians, would have increased the sensitivity for detecting infarction to 95% with no appreciable decrease in specificity or yield of infarctions among patients admitted tointensive care.
Abstract: To develop a decision rule to aid in the diagnosis of myocardial infarction, we evaluated clinical and ECG data on 540 adults treated in an urban hospital emergency room for acute chest pain. Of 62 (11.5%) patients who had acute infarctions, 54 were admitted to intensive care (sensitivity 87%); 103
TL;DR: Hypertonic saline fluid resuscitation may represent a potential alternative when aggravation of intracranial hypertension during resuscitation would place a patient at greater risk.
Abstract: Hypertonic saline (2400 mOsm/L) has been used successfully for fluid resuscitation of dogs subjected to severe hemorrhagic shock. This study compared the effects of resuscitation with hypertonic saline vs. lactated Ringer's solution on intracranial pressure (ICP) in dogs subjected to 30 min of sustained hypovolemic shock. Hypotension was produced by rapid withdrawal of blood until mean arterial pressure was 50 mm Hg, maintained at that level by withdrawal or infusion of blood over the next 30 min as necessary. Eight animals were resuscitated with hypertonic saline solution and nine with lactated Ringer's solution. Both solutions restored systolic blood pressure and cardiac output to control values. However, diastolic blood pressure and mean arterial pressure did not return to control values. The most prominent difference between the two groups was in ICP measured after resuscitation. ICP was lower in dogs resuscitated with hypertonic saline than in dogs resuscitated with lactated Ringer's solution (p = .029). Hypertonic saline fluid resuscitation may represent a potential alternative when aggravation of intracranial hypertension during resuscitation would place a patient at greater risk.
TL;DR: Intravenous dobutamine was used in ten patients requiring aggressive therapy for massive pulmonary embolism with circulatory failure, and except in one patient who rapidly died, a 30-minDobutamine infusion increased both cardiac index and stroke index and reduced pulmonary vascular resistance.
Abstract: Intravenous dobutamine was used in ten patients requiring aggressive therapy for massive pulmonary embolism with circulatory failure. Except in one patient who rapidly died, a 30-min dobutamine infusion (8.3 +/- 2.7 micrograms/kg . min) increased both cardiac index (from 1.7 +/- 0.4 to 2.3 +/- 0.6 L/min . m2, p less than .001) and stroke index (from 16.6 +/- 6.7 to 21 +/- 5 ml/m2, p less than .01), and also reduced pulmonary vascular resistance. Additional hemodynamic improvement was observed until weaning from dobutamine, which was successfully completed 3.3 +/- 0.9 days after the start of infusion.
TL;DR: It is concluded that plasma cortisol elevations are common in acute medical illness and patients who survived hospitalization had lower mean initial and post-ACTH cortisol levels than patients who succumbed.
Abstract: Acute medical illness may produce dramatic changes in endocrine function Although cortisol levels rise in acute medical illness, changes in adrenocortical function and reserve have not been well documented in medical ICU patients We evaluated plasma ACTH and cortisol levels, and cortisol response to intravenous ACTH in 40 acutely ill patients and 20 anxious but nonacutely ill controls A wide range of plasma cortisol values (212 to 8430 nmol/L) was observed More severely ill patients did not necessarily have higher plasma cortisol values Patients who survived hospitalization had lower mean initial and post-ACTH cortisol levels than patients who succumbed ACTH levels varied widely and correlated poorly with levels of plasma cortisol There was no evidence of occult adrenocortical insufficiency We conclude that plasma cortisol elevations are common in acute medical illness
TL;DR: Serum magnesium was measured in 102 consecutive patients admitted to a medical ICU and of all ion levels measured routinely in these patients, serum magnesium had the highest prevalence of abnormal values.
Abstract: Serum magnesium was measured in 102 consecutive patients admitted to a medical ICU. Twenty percent of these patients had hypomagnesemia and 9% had hypermagnesemia. There were no other laboratory tests or clinical features suggesting hypomagnesemia. Of all ion levels measured routinely in these patients, serum magnesium had the highest prevalence of abnormal values.
TL;DR: Results suggest that the fall in systemic vascular resistance is related to some form of arteriovenous shunting and that this is more severe in patients who die, and the subsequent development of tissue hypoxia is an important prognostic factor in fulminant hepatic failure that may contribute to the occurrence of irreversible multiple organ failure.
Abstract: To assess the adequacy of tissue oxygenation in fulminant hepatic failure, we measured arterial oxygen delivery, the affinity of hemoglobin for oxygen, mixed venous oxygen tension, and lactate concentration in 32 patients suffering grade IV encephalopathy.In the patients who died, median systemic va
TL;DR: Accepted methods of predicting metabolic requirements significantly overestimated the caloric needs of these acutely ill patients, and should encourage the development of new bedside equipment for measuring Vo2 and Vco2, so that indirect calorimetry can be used to guide nutritional support in the clinical setting.
Abstract: Predicted energy requirements calculated from the Harris-Benedict basal energy expenditure (BEE) formulas, and caloric allowances recommended by the Food and Nutrition Board National Research Council, were compared to metabolic expenditures measured by indirect calorimetry, using a feedback-controll
TL;DR: The association of cardiopulmonary variables with outcome was investigated in 42 pediatric patients with septic shock and isolated patient groups with survival rates of 59% to 75%, compared to the overall survival rate.
Abstract: The association of cardiopulmonary variables with outcome was investigated in 42 pediatric patients (18 survivors) with septic shock. All cardiopulmonary variables were obtained during active BP support. The variable distributions were separated into ranges by two empiric cutoff methods: normal ranges and the survivor median values. The proportion of survivors with normal values of wedge pressure and cardiac index was significantly (p less than .05) higher than the proportion of survivors outside the normal range. The percentage of survival also significantly (p less than .05) increased with above-normal values of oxygen consumption, arteriovenous O2 content difference, O2 extraction, pH, and core temperature. There were significantly (p less than .05) more nonsurvivors with wedge pressure, pulmonary shunt, and pH values below the survivor medians. Therapeutic goals based on the distributions of these eight variables isolated patient groups with survival rates of 59% to 75%, compared to the overall survival rate of 43%.
TL;DR: A retrospective review of 64 patients receiving more than 10 units of red cell concentrate plus crystalloid within 12 h revealed two consecutive patterns of elevation of the partial thromboplastin time, which indicate a transient dilutional coagulopathy, followed by coagULopathy related to the duration of closely AH.
Abstract: A retrospective review of 64 patients receiving more than 10 units of red cell concentrate plus crystalloid within 12 h revealed two consecutive patterns of elevation of the partial thromboplastin time (PTT). The PTT at 3 to 4 h (PTT3-4) correlated with the number of liters of crystalloid (LC) infused over the first 3 h (PTT3-4 = 37 + 7 LC, r = .7643, p less than .001); the PTT thereafter (PTT4+) correlated with the number of hours of closely antecedent hypotension (AH) (PTT4+ = 37 + 21AH, r = .8680, p less than .001). These data indicate a transient dilutional coagulopathy, followed by coagulopathy related to the duration of closely AH. Whether this latter is due to impaired production, disseminated intravascular coagulation, or dilution due to internal shifts of fluids and/or proteins, remains to be clarified. Therapeutic implications of these data are discussed.
TL;DR: All 23 patients requiring mechanical ventilation for acute respiratory failure had normal left ventricular systolic function by two-dimensional echocardiography, and five patients had a severely enlarged right ventricle with abnormal contractile pattern.
Abstract: Right ventricular size and contractility were evaluated using two-dimensional echocardiography during the first days of respiratory support in 23 patients requiring mechanical ventilation for acute respiratory failure. Nine patients had normal echocardiographic right ventricular function, and nine other patients had a slightly enlarged right ventricle with normal systolic function. The remaining five patients had a severely enlarged right ventricle with abnormal contractile pattern. In these five patients, two-dimensional echocardiography also showed a reduction in left ventricular size suggesting detrimental ventricular interdependence. All 23 patients had normal left ventricular systolic function by two-dimensional echocardiography.
TL;DR: It is concluded that acute changes in Pab may significantly effect left-sided hemodynamic events through changes in LV afterload, regional distribution of cardiac output, and diaphragmatic position.
Abstract: Many clinical conditions are associated with an increase in abdominal pressure. While the effects on venous return have been studied in the past, little attention has been given to the effect of abdominal pressure on left-sided hemodynamic events. The effects of acute changes in abdominal pressure (Pab) on left ventricular (LV) hemodynamics and outflow distribution were evaluated in ten open-chest dogs, which had undergone right heart bypass to eliminate the influence of changes in Pab on systemic venous return. Pressures were measured in the left atrium (Pla), aorta (Pao), and stomach (Pab). Electromagnetic flow probes were positioned around the ascending aorta (Qaa), descending aorta (Qda) and the innominate or subclavian artery (Qin) to reflect total cardiac output and the respective regional caudad and cephalad blood flows. Compressing the abdomen to increase acutely Pab (9.2 +/- 0.6 torr) also significantly increased Pao (7.8 +/- 1.2 torr), Pla (1.7 +/- 0.4 torr), and Qin (15.2 +/- 4.5%), while Qaa (-9.5 +/- 2.0%) and Qda (-26.3 +/- 7.0%) significantly decreased. Opposite findings were obtained immediately after release of abdominal compression. Thus, an acute increase in Pab with a constant pulmonary artery inflow increased the afterload imposed on the left ventricle and redistributed LV output, with a reduction in flow to the abdomen. Part of the fall in Qaa and increase in Pla could be attributed to passive elevation of the diaphragm by the increase in Pab, i.e., heart-lung-diaphragm interdependence.(ABSTRACT TRUNCATED AT 250 WORDS)
TL;DR: In this article, the authors evaluated chest x-rays of 15 patients with the adult respiratory distress syndrome (ARDS) for the presence of pulmonary interstitial emphysema (PIE), which was radiographically detected in 13 (88%) patients, 10 (77%) of whom also had pneumothorax.
Abstract: Chest x-rays of 15 patients with the adult respiratory distress syndrome (ARDS) were evaluated retrospectively for the presence of pulmonary interstitial emphysema (PIE). PIE was radiographically detected in 13 (88%) patients, 10 (77%) of whom also had pneumothorax. In five of these, pneumothorax occurred within the first 12 h after interstitial emphysema appeared. Pneumomediastinum was less common and occurred in five (39%) patients. The appearance of PIE and its complications, i.e., pneumothorax and pneumomediastinum, occurred over a wide range of mean airway pressures and positive end-expiratory pressures; there was no direct relationship between barotrauma and mean airway pressure or positive end-expiratory pressure. In 12 of the 13 patients all manifestations of barotrauma occurred at or above a peak airway pressure of 40 cm H2O, indicating a threshold level of peak airway pressure which would place the ARDS patient at high risk for developing pulmonary barotrauma. Time on the respirator at peak airway pressures above 40 cm H2O, clinical severity of ARDS, and associated pulmonary pathology (emphysema, bacterial pneumonia) appear to play a role in developing barotrauma.
TL;DR: Differences in types and rates of infection have an important bearing on infection-control activities in the ICU, and also provide a yardstick against which similar institutions can gauge their ICU infection status.
Abstract: Infections identified between 1981 and 1983 in a hospital's medical/surgical, pediatric, neonatal, coronary care, and cardiac surgery ICUs were compared. Among 14,360 admissions, 1840 infections occurred in 1360 patients. Total infection rates ranged from 1.0% (cardiac surgery ICU) to 23.5% (medical/surgical ICU). Rates of ICU-acquired infection ranged from 0.8% (cardiac surgery ICU) to 11.2% (medical/surgical ICU), indicating that only about half of infections in the latter unit were acquired from within. Primary bacteremias comprised 14.5% of neonatal ICU infections, a rate 500% higher than in other ICUs. Meningitis and genitourinary infections were more common in pediatric and coronary care ICUs. Candida and Pseudomonas species and Klebsiella-Enterobacter-Serratia were most common in the medical/surgical ICU. Survival rate of infected patients was over 87% in pediatric and neonatal ICUs, compared with only 55.4% in the medical/surgical ICU. These differences in types and rates of infection have an important bearing on infection-control activities in the ICU, and also provide a yardstick against which similar institutions can gauge their ICU infection status.
TL;DR: Oxygenation was significantly better when PEEP was greater than Pflex, and PaCO2 and anatomic dead space were higher at higher PEEP, and decreased with increasing Paw, suggesting Paw was a major determinant of oxygenation.
Abstract: To investigate the effects of both positive end-expiratory pressure (PEEP) and mean airway pressure (Paw) on gas exchange, we used lung lavage to induce severe respiratory insufficiency in six lambs. The animals were then mechanically ventilated at constant tidal volume, respiratory rate, and inspired O2 fraction. PEEP levels were varied -5, +5 and +10 cm H2O around the pressure (Pflex) corresponding to a major change in slope of the inspiratory limb of the respiratory volume-pressure curve. In each animal the effects of the three PEEP levels were studied at two Paw levels, differing by 5 cm H2O. Increasing Paw significantly improved PaO2 and reduced venous admixture. A 5-cm H2O PEEP increase from +5 to +10 did not affect oxygenation; however, oxygenation was significantly better when PEEP was greater than Pflex. Both PaCO2 and anatomic dead space were higher at higher PEEP, and decreased with increasing Paw. Hence, Paw was a major determinant of oxygenation, although a PEEP greater than Pflex appeared necessary to optimize oxygenation at a constant Paw.
TL;DR: Recognition of SICU readmission patterns will allow more precise discharge planning: to delay discharge, to effect a lateral transfer, or to initiate a stepdown unit which may be able to help prevent costly and potentially lethal patient outcomes.
Abstract: Because experience is lacking regarding the profile of patients readmitted to a surgical ICU (SICU), we retrospectively reviewed total admissions, readmissions, patient profiles, and characteristics of illness requiring readmission to a multidisciplinary SICU. During a 1-yr period, the 721 recorded
TL;DR: It is found that end-tidal CO2 concentration (ETco2) strikingly decreased to approximately 24% of control levels, immediately after cardiac arrest and before precordial compression, which indicates that ETco2 may be a useful monitor for assessing the adequacy of CPR.
Abstract: Utilizing a well-established porcine model of cardiac arrest, we found that end-tidal CO2 concentration (ETCO2) strikingly decreased to approximately 24% of control levels, immediately after cardiac arrest and before precordial compression. During precordial compression, ETCO2 progressively increased to 46% of control values in successfully resuscitated animals but only to 26% in animals which failed to respond to resuscitation efforts. After successful resuscitation, ETCO2 rapidly returned to baseline values. These data indicate that ETCO2 may be a useful monitor for assessing the adequacy of CPR.
TL;DR: Three patients with respiratory failure resulting from miliary tuberculosis had a characteristic clinical presentation that included a long history of a prominent cough, dyspnea, weight loss, tachycardia, tachypnea, pulmonary adventitious sounds, and hepatomegaly; in only one patient was the initial sputum positive for acid-fast bacilli.
Abstract: Three patients with respiratory failure resulting from miliary tuberculosis had a characteristic clinical presentation that included a long history of a prominent cough, dyspnea, weight loss, tachycardia, tachypnea, pulmonary adventitious sounds, and hepatomegaly. Hematologic investigation showed a normal white cell count with marked left shift in the morphology of white cells in all three patients, and evidence of disseminated intravascular coagulation in one patient. In only one patient was the initial sputum positive for acid-fast bacilli; in the others, invasive diagnostic procedures including lumbar puncture, bone marrow trephine, and open-lung biopsy were necessary for diagnosis. Miliary tuberculosis should be suspected in patients with adult respiratory distress syndrome of unknown etiology. Simple diagnostic procedures such as sputum, bronchial brushings, and urine examination should be followed by bone marrow trephine, liver biopsy, transbronchial lung biopsy, and lumbar puncture if physical signs of meningitis are present.
TL;DR: While routine chest films affect the management of pulmonary and unstable cardiac patients in the ICU, routine films rarely influence management of uncomplicated cardiac patients and those without heart or lung disease, and are not warranted.
Abstract: To ascertain the value of the daily routine chest x-ray in the medical ICU, we determined prospectively the number of unsuspected abnormalities observed on 507 consecutive chest films and the consequent management changes in 94 ICU patients. Primary diagnoses were classified as pulmonary, hemodynamically unstable cardiac, uncomplicated cardiac, or miscellaneous. Admission films and those taken after procedures or a change in clinical status were excluded. Ventilator status and the tubes and catheters visible on the films were also noted. After clinical evaluation, management plans were made by ICU physicians and then the chest x-ray was examined and unsuspected abnormalities and resulting management changes were noted. Of the 507 chest films, 76 (15%) revealed an unsuspected abnormality, 71 (93%) of which led to a management change. There were significantly (p less than .02) more unsuspected abnormalities and management changes in the pulmonary and unstable cardiac patients, independent of ventilator status. Patients with two or more catheters and/or tubes visible on the chest film also had significantly more management changes (51/312 vs. 11/150, p less than .05). We conclude that while routine chest films affect the management of pulmonary and unstable cardiac patients in the ICU, routine films rarely influence management of uncomplicated cardiac patients and those without heart or lung disease, and are not warranted in this group.
TL;DR: It is suggested that the bag-valve-mask (BVM) used by a single rescuer with minimal training fails to deliver adequate tidal volumes for resuscitation, and two-person BVM ventilation should be considered for initial resuscitation in cardiopulmonary arrest.
Abstract: This study suggests that the bag-valve-mask (BVM) used by a single rescuer with minimal training fails to deliver adequate tidal volumes for resuscitation. When two rescuers use the BVM, tidal volumes are more than recommended and are comparable to those seen with endotracheal intubation. Two-person BVM ventilation should be considered for initial resuscitation in cardio-pulmonary arrest.