Circulatory Compromise:Opportunities to improve outcome

描述（由申请人提供）： 创伤方案：出血性休克是创伤后死亡的主要原因。 辅助正压通气（PPV）对低血容量患者心输出量的不利影响尚未得到充分认识。 PPV尚未被认为是结局的阴性混杂变量。 最近的研究表明，严重出血的灌注和生存率显着改善与较低的清除率。 具有讽刺意味的是，急诊护理人员仍在接受培训，以在创伤患者中使用高比例的PPV。 我们的中心假设：pre.hospital环境中常用的辅助通气速率对创伤后低血压患者的死亡率和神经系统结局有不利影响，使用较低的通气速率（如每分钟6次呼吸）将显著改善结局。 具体目标：确定与当前不控制PPV率的实践相比，当急诊护理提供者提供受控PPV率时，创伤后低血压病例的生存率和神经结局显著改善。 此外，与12/分钟相比，使用6/分钟的受控通气率获得了进一步的改善。 心脏骤停方案：即使接受标准的人工CPR技术，大多数院外心脏骤停的患者仍然在到达医院之前死亡。许多因素导致这些较差的生存统计数据，包括CPR技术本身的效率低下。 即使在早期进行，心肺复苏也只能提供正常心肌灌注的10%至20%，只能提供生理正常脑灌注的20%至30%。 在本提案中，我们选择了我们认为最有前途的方法来提高心肺复苏效率，患者生存率和心脏骤停后的神经结局。 这种方法是主动按压-减压（ACD）CPR和阻抗阈值装置（ITD）的组合，称为ACD+ITD CPR的技术，其在CPR的减压阶段期间增强重要器官灌注。具体目标：确定与标准闭胸CPR相比，ACD+ITD CPR是否会改善成人在有目击者的院外心脏骤停后的出院生存率和神经学结局（主要终点）。

DESCRIPTION (provided by applicant): Trauma Protocol: Hemorrhagic shock is a dominant cause of death after trauma. The detrimental effects of assisted positive pressure ventilation (PPV) on cardiac output in hypovolemic patients has been under-appreciated. PPV has not been recognized as a negative confounding variable in outcome. Recent studies of severe hemorrhage show that perfusion and survival are significantly improved with lower ventilatory rates. Ironically, emergency care personnel are still being trained to use high rates of PPV in hypotensive trauma patients. Our central hypothesis: assisted ventilation rates commonly used in the pre.hospital setting adversely affect mortality and neurological outcome in patients with post-traumatic hypotension and that using a lower ventilation rate such as 6 breaths per minute will improve outcome significantly. Specific Aims: To establish that survival and neurological outcome are significantly improved in cases of post-traumatic hypotension when emergency care providers deliver controlled rates of PPV as compared with the current practice of uncontrolled rates of PPV. In addition, further improvements are gained using controlled ventilation rates of 6/minute compared with 12/minute. Cardiac arrest protocol: Even when receiving standard, manual CPR techniques, most patients who have out-of-hospital cardiac arrest still die prior to arriving at a hospital. Many factors contribute to these poor survival statistics, including the inefficiency of the CPR technique itself. CPR provides only 10% to 20% of normal myocardial perfusion, and only 20% to 30% of physiologically normal cerebral perfusion even when performed early. In this proposal, we have selected what we believe is the most promising approach to improving CPR efficiency, patient survival, and neurological outcome following cardiac arrest. This approach is the combination of active compression-decompression (ACD) CPR and the impedance threshold device (ITD), a technique termed ACD+ITD CPR, which enhances vital organ perfusion during the decompression phase of CPR. Specific aim: To determine whether ACD+ITD CPR will improve survival to hospital discharge and neurological outcome after witnessed, out-of-hospital cardiac arrest in adults (primary endpoint) when compared with standard closed chest CPR.