Correspondence / American Journal of Emergency Medicine 32 (2014) 1413–1432
personally the application of toothpaste onto the wound with efficiency. Toothpastes, obviously common in a bathroom, are derived from a large variety of components as abrasives, fluoride, and detergents. Abrasives constitute at least 50% of typical toothpaste and include particles of aluminum hydroxide, calcium carbonate, calcium hydrogen phosphates, silicas, and zeolites or hydroxyapatite. Calcium plays an essential role in blood clotting as required for binding coagulation factors to phospholipids. Hemostatic and adsorbent agents as zeolites are also used for sealing severe traumatic bleeding [1]. Although, cutaneous burns have been reported with the use of zeolites in the treatment of major hemorrhage secondary to combat wounds through an exothermic reaction that is likely related to the absorption of free fluid at the hemorrhage site [2]. Far beyond our anecdotic report, our question debates upon the potential interest of such a low cost plaster in emergency care to treat severe bleeding injuries. Marc E. Gentili, MD, PhD CHP Saint-Grégoire, Anaesthesiology 6 ave de la Boutière 35760 Saint-Grégoire, France E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.08.070 References [1] Gordy SD, Rhee P, Schreiber MA. Military applications of novel hemostatic devices. Expert Rev Med Devices 2011;8:41–7. [2] McManus J, Hurtado T, Pusateri T, Knoop Kevin J. A case series describing thermal injury resulting from zeolite use for hemorrhage control in combat operations. Prehosp Emerg Care 2007;11:67–71.
Table 1 Characteristics of lifeguards (n = 45) Variable
n
%
Sex Male/Female 25:20 55.6/44.4 Age (y) ≤19 3 6.7 20-29 33 73.3 ≥30 9 20.0 Length of lifeguard service (y) ≤1 26 57.8 2-5 13 28.9 ≥6 6 13.3 Last CPR training 1-6 mo 14 31.1 7-12 mo 12 26.7 N1 y 19 42.2 Perception of quality of CPR training received Effective or highly effective 23 51.1 Satisfactory 14 31.1 Fair or poor 8 17.8 Aditional CPR or first aid training (Automated external defibrillator (AED) use) No 13 28.9 Yes 32 71.1 Use of CPR in emergency response Yes 2 4.4 No, but my patrol has 6 13.3 No 37 82.2 Use of feedback mechanisms Yes 28 62.2 No 17 38.8
Table 2 Lifeguards' feelings about CPR Lifeguard perceptions
Cardiopulmonary resuscitation quality among lifeguards: self-perception, knowledge, and performance☆
1429
Self-rated ability Highly effective or effective Satisfactory Fair or poor Willingness to perform CPR Definite Fairly certain Hesitant
n
%
33 9 3
73.4 20.0 6.6
4 24 17
8.9 53.3 37.8
To the Editor, Feelings and CPR success expectations in OHCA
Drowning continues to be a leading cause of accidental death worldwide. In case of drowning, duration of hypoxia is the critical outcome factor. Therefore, immediate good-quality cardiopulmonary resuscitation (CPR) at the scene, with early ventilations, is essential to increase the chances of survival and to reduce the neurologic damage of survivors [1,2]. Evidence indicates that in real life, quality of CPR, even when performed by staff with duty to assist, used to be poor [3–10]. In drowning events, the extreme physical conditions in which lifeguards have to perform CPR (sometimes after performing victim's water rescue), may result in even worse CPR quality [11]. We hypothesize that lifeguards are not aware of these facts and overestimate their knowledge and skills. Our objective was to know the perceptions and knowledge about CPR of Spanish-certified lifeguards. Forty-five lifeguards, certified and authorized to work in natural aquatic environments, or aquatic facilities, or both, were invited and consented to participate in this survey. Lifeguards' knowledge and perceptions of CPR were evaluated using an adapted version of the 15item questionnaire previoulsy used by Moran and Webber [12]. Table 1 shows the demographics and background information of the participants. When analyzing by age, younger participants (b30 years old) were significantly more likely than older lifeguards to have received training within the year preceding the study (69.5% vs 11.1 %, P = .001). ☆ All authors declare no conflicts of interest.
Success rate
Lifeguard feelings, n (%)
Lifeguards' opinion about public's feelings, n (%)
0-25% 26%-50% 51%-75% 76%-100%
14 (31.1) 6 (13.3) 15 (33.3) 10 (22.2)
5 (11.1) 19 (42.2) 4 (8.9) 17 (37.8)
Table 3 Lifeguards' knowledge of CPR protocols Correct responses to questions or statements
n
What is the correct compression ratio? Each ventilation should be administered N1 s. If alone with an adult patient, go for help before starting CPR. Stop CPR if the patient has not recovered after 15-20 min of resuscitation. The AED will advise a shock for all victims of cardiac arrest. Do not take more than 10 s to check for breathing. Reassess the victim after 4 cycles of CPR to see if they have recovered. Give all victims of drowning 5 initial breaths before starting chest compressions. The first step at the scene of a medical emergency is to check victim responsiveness. If the airway is blocked by foreign objects or vomit, begin CPR before clearing. The recommended compression depth for adults is 5-6 cm.
28 31 21 41
% 62.2 68.9 46.7 91.1
31 33 16 34
68.9 73.3 35.6 75.6
34
75.6
45 100 36
80.0
1430
Correspondence / American Journal of Emergency Medicine 32 (2014) 1413–1432
Table 2 shows the lifeguards' perceptions regarding their personal competency and confidence to perform CPR as well as their beliefs about CPR efectiveness. Most participants considered their CPR skills effective or highly effective, and 20% considered them satisfactory. As for the initiative to perform CPR in a real emergency, 62.2% of participants were fully or fairly certain, whereas 37.8% reported being hesitant about that. In addition, most lifeguards had an unrealistic view of the success of CPR in an out-of-the-hospital cardiac arrest (OHCA), with only 31.1% considering that the chances of success were 25% or less. Table 3 shows the results of the CPR knowledge questionnaire. Responses were not related to sex, age, work experience, or recent training. Little is known regarding the self-perceptions, experience, training and conceptual knowledge underpinning the ability of lifeguards to perform CPR when needed [12,13]. Our study, conducted in lifeguards with recent training indicates that subjects had good level of knowledge of CPR, in agreement with the data reported by others [12,13]. We also observed that lifeguards rarely have to perform CPR, and because of that, when they have to, there is a risk of suboptimal performance and victim's outcome [12,14]. As a consequence, retraining should be encouraged at least at the beginning of each season and periodically with tests focused on [1,15]. Although most responders were willing to perform CPR, it is significant that 37.8% were hesitant about that procedure. Lifeguards have a duty to respond in an effective and timely manner in case of cardiac arrest, and therefore, this action is not optional and must be a core skill of any lifeguard. This lack of self-confidence may be a barrier to CPR success, and we suggest frequent retraining supported by CPR be implemented to solve this problem. On the other hand, most of surveyed lifeguards did not have a realistic view of the probability of success of CPR in OHCA, considering that the chances of success were greater than 25%. Similar results have been reported elsewhere [14]. Because lifeguards' perceptions seem to be not very realistic, courses should inform about the real rates of success/failure in case of OHCA. Anyway, lifeguards must be trained to continue CPR until the patient recovers or professional help arrives, no matter how poor the prognosis may seem [12]. Our data indicate that some lifeguards had misconceptions about etiology-driven CPR protocols. Training sessions must reinforce the priority of defibrillation in case of primary cardiac arrest (eg, myocardial infarction) as opposed to hypoxic secondary cardiac arrest (eg, drowning) where rescue ventilations become essential [12]. Finally, it is noteworthy the fact that most respondents would stop CPR to reassess the victim status every 4 CPR cycles, when the 2010 European Resuscitation Guidelines give particular emphasis on minimizing interruptions in chest compressions in order to perform the highest-quality CPR possible [16]. This is another point to improve in training and retraining activities. Ana Catarina Queiroga, PhD Roberto Barcala-Furelos, PhD Cristian Abelairas-Gómez, PhD ⁎ Óscar Farto-Ramírez, MEd Faculty of Education and Sport Sciences University of Vigo Pontevedra, Spain ⁎Corresponding author. Faculty of Education and Sport Sciences University of Vigo, Campus A Xunqueira s/n, 36005 Pontevedra, Spain Tel.: +34 618 824 297 E-mail address: [email protected] José Antonio Prieto-Saborit PhD School of Sport Medicine, University of Oviedo Oviedo, Spain
Antonio Rodríguez-Núñez MD, PhD Pediatric Emergency and Critical Care Division Clinical University Hospital, University of Santiago de Compostela Santiago de Compostela, Spain http://dx.doi.org/10.1016/j.ajem.2014.08.077 References [1] Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81:1400–33. [2] Claesson A, Lindqvist J, Herlitz J. Cardiac arrest due to drowning—changes over time and factors of importance for survival. Resuscitation 2014;85(5):644–8. [3] Marsch SCU, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004;60:51–6. [4] Niles D, Sutton RM, Donoghue A, Kalsi MS, Roberts K, Boyle L, et al. “Rolling refreshers”: a novel approach to maintain CPR psychomotor skill competence. Resuscitation 2009;80:909–12. [5] Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation 2013;128:417–35. [6] Hong DY, Park SO, Lee KR, Baek KJ, Shin DH. A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: a randomised cross-over simulation study with a time-dependent analysis. Resuscitation 2012;83:353–9. [7] Adelborg K, Bjørnshave K, Mortensen MB, Espeseth E, Wolff A, Løfgren B. A randomised crossover comparison of mouth‐to‐face‐shield ventilation and mouth‐to‐pocket‐mask ventilation by surf lifeguards in a manikin. Anaesthesia 2014;69(7):712–6. [8] Frković V, Šustić A, Zeidler F, Protić A, Deša K. A brief reeducation in cardiopulmonary resuscitation after six months—the benefit from timely repetition. Signa Vitae 2008;3(2):24–8. [9] Liu KY, Haukoos JS, Sasson C. Availability and quality of cardiopulmonary resuscitation information for Spanish-speaking population on the Internet. Resuscitation 2014;85:131–7. [10] Russo SG, Neumann P, Reinhardt S, Timmermann A, Niklas A, Quintel M, et al. Impact of physical fitness and biometric data on the quality of external chest compression: a randomised, crossover trial. BMC Emerg Med 2011;11(20):1–9. [11] Barcala-Furelos R, Abelairas-Gomez C, Romo-Perez V, Palacios-Aguilar J. Effect of physical fatigue on the quality CPR: a water rescue study of lifeguards. Am J Emerg Med 2013;31:473–7. [12] Moran K, Webber J. Surf lifeguard perceptions and practice of cardiopulmonary resuscitation (CPR). Int J Aquat Res Educ 2012;6:24–34. [13] Moran K, Webber J. Too much puff, not enough push? Surf lifeguard simulated CPR performance. Int J Aquat Res Educ 2013;7:13–23. [14] Faddy SC. Towards new models of cardiopulmonary resuscitation teaching: the role of practical scenario training on surf lifesavers' perceptions of resuscitation efficacy. Resuscitation 2002;53:159–65. [15] Shaw R. CPR training for lifeguards: new research, new thinking. Parks Recreation 1996;31(7):44–7. [16] Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1 Executive summary. Resuscitation 2010;81:1219–76.
New way to individualize pulmonary embolism initial anticoagulant treatment—using adequate approved doses of rivaroxaban
To the Editor, One of the basic principles in patient treatment is to adjust the intensity and duration, site, and method of administration according to patient characteristics, that is, to individualize it. Results of pulmonary thromboembolism (PTE) treatment are still suboptimal, as judged by high mortality as well as high rate (in up to 70.9% of patients) of residual pulmonary artery thrombosis [1], which may be risk factor for chronic thromboembolic pulmonary hypertension [2]. Accordingly, there is an obvious need for improvement in treatment protocols for PTE [3]. In PTE and deep vein thrombosis (DVT), 2 forms of the same
personally the application of toothpaste onto the wound with efficiency. Toothpastes, obviously common in a bathroom, are derived from a large variety of components as abrasives, fluoride, and detergents. Abrasives constitute at least 50% of typical toothpaste and include particles of aluminum hydroxide, calcium carbonate, calcium hydrogen phosphates, silicas, and zeolites or hydroxyapatite. Calcium plays an essential role in blood clotting as required for binding coagulation factors to phospholipids. Hemostatic and adsorbent agents as zeolites are also used for sealing severe traumatic bleeding [1]. Although, cutaneous burns have been reported with the use of zeolites in the treatment of major hemorrhage secondary to combat wounds through an exothermic reaction that is likely related to the absorption of free fluid at the hemorrhage site [2]. Far beyond our anecdotic report, our question debates upon the potential interest of such a low cost plaster in emergency care to treat severe bleeding injuries. Marc E. Gentili, MD, PhD CHP Saint-Grégoire, Anaesthesiology 6 ave de la Boutière 35760 Saint-Grégoire, France E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.08.070 References [1] Gordy SD, Rhee P, Schreiber MA. Military applications of novel hemostatic devices. Expert Rev Med Devices 2011;8:41–7. [2] McManus J, Hurtado T, Pusateri T, Knoop Kevin J. A case series describing thermal injury resulting from zeolite use for hemorrhage control in combat operations. Prehosp Emerg Care 2007;11:67–71.
Table 1 Characteristics of lifeguards (n = 45) Variable
n
%
Sex Male/Female 25:20 55.6/44.4 Age (y) ≤19 3 6.7 20-29 33 73.3 ≥30 9 20.0 Length of lifeguard service (y) ≤1 26 57.8 2-5 13 28.9 ≥6 6 13.3 Last CPR training 1-6 mo 14 31.1 7-12 mo 12 26.7 N1 y 19 42.2 Perception of quality of CPR training received Effective or highly effective 23 51.1 Satisfactory 14 31.1 Fair or poor 8 17.8 Aditional CPR or first aid training (Automated external defibrillator (AED) use) No 13 28.9 Yes 32 71.1 Use of CPR in emergency response Yes 2 4.4 No, but my patrol has 6 13.3 No 37 82.2 Use of feedback mechanisms Yes 28 62.2 No 17 38.8
Table 2 Lifeguards' feelings about CPR Lifeguard perceptions
Cardiopulmonary resuscitation quality among lifeguards: self-perception, knowledge, and performance☆
1429
Self-rated ability Highly effective or effective Satisfactory Fair or poor Willingness to perform CPR Definite Fairly certain Hesitant
n
%
33 9 3
73.4 20.0 6.6
4 24 17
8.9 53.3 37.8
To the Editor, Feelings and CPR success expectations in OHCA
Drowning continues to be a leading cause of accidental death worldwide. In case of drowning, duration of hypoxia is the critical outcome factor. Therefore, immediate good-quality cardiopulmonary resuscitation (CPR) at the scene, with early ventilations, is essential to increase the chances of survival and to reduce the neurologic damage of survivors [1,2]. Evidence indicates that in real life, quality of CPR, even when performed by staff with duty to assist, used to be poor [3–10]. In drowning events, the extreme physical conditions in which lifeguards have to perform CPR (sometimes after performing victim's water rescue), may result in even worse CPR quality [11]. We hypothesize that lifeguards are not aware of these facts and overestimate their knowledge and skills. Our objective was to know the perceptions and knowledge about CPR of Spanish-certified lifeguards. Forty-five lifeguards, certified and authorized to work in natural aquatic environments, or aquatic facilities, or both, were invited and consented to participate in this survey. Lifeguards' knowledge and perceptions of CPR were evaluated using an adapted version of the 15item questionnaire previoulsy used by Moran and Webber [12]. Table 1 shows the demographics and background information of the participants. When analyzing by age, younger participants (b30 years old) were significantly more likely than older lifeguards to have received training within the year preceding the study (69.5% vs 11.1 %, P = .001). ☆ All authors declare no conflicts of interest.
Success rate
Lifeguard feelings, n (%)
Lifeguards' opinion about public's feelings, n (%)
0-25% 26%-50% 51%-75% 76%-100%
14 (31.1) 6 (13.3) 15 (33.3) 10 (22.2)
5 (11.1) 19 (42.2) 4 (8.9) 17 (37.8)
Table 3 Lifeguards' knowledge of CPR protocols Correct responses to questions or statements
n
What is the correct compression ratio? Each ventilation should be administered N1 s. If alone with an adult patient, go for help before starting CPR. Stop CPR if the patient has not recovered after 15-20 min of resuscitation. The AED will advise a shock for all victims of cardiac arrest. Do not take more than 10 s to check for breathing. Reassess the victim after 4 cycles of CPR to see if they have recovered. Give all victims of drowning 5 initial breaths before starting chest compressions. The first step at the scene of a medical emergency is to check victim responsiveness. If the airway is blocked by foreign objects or vomit, begin CPR before clearing. The recommended compression depth for adults is 5-6 cm.
28 31 21 41
% 62.2 68.9 46.7 91.1
31 33 16 34
68.9 73.3 35.6 75.6
34
75.6
45 100 36
80.0
1430
Correspondence / American Journal of Emergency Medicine 32 (2014) 1413–1432
Table 2 shows the lifeguards' perceptions regarding their personal competency and confidence to perform CPR as well as their beliefs about CPR efectiveness. Most participants considered their CPR skills effective or highly effective, and 20% considered them satisfactory. As for the initiative to perform CPR in a real emergency, 62.2% of participants were fully or fairly certain, whereas 37.8% reported being hesitant about that. In addition, most lifeguards had an unrealistic view of the success of CPR in an out-of-the-hospital cardiac arrest (OHCA), with only 31.1% considering that the chances of success were 25% or less. Table 3 shows the results of the CPR knowledge questionnaire. Responses were not related to sex, age, work experience, or recent training. Little is known regarding the self-perceptions, experience, training and conceptual knowledge underpinning the ability of lifeguards to perform CPR when needed [12,13]. Our study, conducted in lifeguards with recent training indicates that subjects had good level of knowledge of CPR, in agreement with the data reported by others [12,13]. We also observed that lifeguards rarely have to perform CPR, and because of that, when they have to, there is a risk of suboptimal performance and victim's outcome [12,14]. As a consequence, retraining should be encouraged at least at the beginning of each season and periodically with tests focused on [1,15]. Although most responders were willing to perform CPR, it is significant that 37.8% were hesitant about that procedure. Lifeguards have a duty to respond in an effective and timely manner in case of cardiac arrest, and therefore, this action is not optional and must be a core skill of any lifeguard. This lack of self-confidence may be a barrier to CPR success, and we suggest frequent retraining supported by CPR be implemented to solve this problem. On the other hand, most of surveyed lifeguards did not have a realistic view of the probability of success of CPR in OHCA, considering that the chances of success were greater than 25%. Similar results have been reported elsewhere [14]. Because lifeguards' perceptions seem to be not very realistic, courses should inform about the real rates of success/failure in case of OHCA. Anyway, lifeguards must be trained to continue CPR until the patient recovers or professional help arrives, no matter how poor the prognosis may seem [12]. Our data indicate that some lifeguards had misconceptions about etiology-driven CPR protocols. Training sessions must reinforce the priority of defibrillation in case of primary cardiac arrest (eg, myocardial infarction) as opposed to hypoxic secondary cardiac arrest (eg, drowning) where rescue ventilations become essential [12]. Finally, it is noteworthy the fact that most respondents would stop CPR to reassess the victim status every 4 CPR cycles, when the 2010 European Resuscitation Guidelines give particular emphasis on minimizing interruptions in chest compressions in order to perform the highest-quality CPR possible [16]. This is another point to improve in training and retraining activities. Ana Catarina Queiroga, PhD Roberto Barcala-Furelos, PhD Cristian Abelairas-Gómez, PhD ⁎ Óscar Farto-Ramírez, MEd Faculty of Education and Sport Sciences University of Vigo Pontevedra, Spain ⁎Corresponding author. Faculty of Education and Sport Sciences University of Vigo, Campus A Xunqueira s/n, 36005 Pontevedra, Spain Tel.: +34 618 824 297 E-mail address: [email protected] José Antonio Prieto-Saborit PhD School of Sport Medicine, University of Oviedo Oviedo, Spain
Antonio Rodríguez-Núñez MD, PhD Pediatric Emergency and Critical Care Division Clinical University Hospital, University of Santiago de Compostela Santiago de Compostela, Spain http://dx.doi.org/10.1016/j.ajem.2014.08.077 References [1] Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81:1400–33. [2] Claesson A, Lindqvist J, Herlitz J. Cardiac arrest due to drowning—changes over time and factors of importance for survival. Resuscitation 2014;85(5):644–8. [3] Marsch SCU, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004;60:51–6. [4] Niles D, Sutton RM, Donoghue A, Kalsi MS, Roberts K, Boyle L, et al. “Rolling refreshers”: a novel approach to maintain CPR psychomotor skill competence. Resuscitation 2009;80:909–12. [5] Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation 2013;128:417–35. [6] Hong DY, Park SO, Lee KR, Baek KJ, Shin DH. A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: a randomised cross-over simulation study with a time-dependent analysis. Resuscitation 2012;83:353–9. [7] Adelborg K, Bjørnshave K, Mortensen MB, Espeseth E, Wolff A, Løfgren B. A randomised crossover comparison of mouth‐to‐face‐shield ventilation and mouth‐to‐pocket‐mask ventilation by surf lifeguards in a manikin. Anaesthesia 2014;69(7):712–6. [8] Frković V, Šustić A, Zeidler F, Protić A, Deša K. A brief reeducation in cardiopulmonary resuscitation after six months—the benefit from timely repetition. Signa Vitae 2008;3(2):24–8. [9] Liu KY, Haukoos JS, Sasson C. Availability and quality of cardiopulmonary resuscitation information for Spanish-speaking population on the Internet. Resuscitation 2014;85:131–7. [10] Russo SG, Neumann P, Reinhardt S, Timmermann A, Niklas A, Quintel M, et al. Impact of physical fitness and biometric data on the quality of external chest compression: a randomised, crossover trial. BMC Emerg Med 2011;11(20):1–9. [11] Barcala-Furelos R, Abelairas-Gomez C, Romo-Perez V, Palacios-Aguilar J. Effect of physical fatigue on the quality CPR: a water rescue study of lifeguards. Am J Emerg Med 2013;31:473–7. [12] Moran K, Webber J. Surf lifeguard perceptions and practice of cardiopulmonary resuscitation (CPR). Int J Aquat Res Educ 2012;6:24–34. [13] Moran K, Webber J. Too much puff, not enough push? Surf lifeguard simulated CPR performance. Int J Aquat Res Educ 2013;7:13–23. [14] Faddy SC. Towards new models of cardiopulmonary resuscitation teaching: the role of practical scenario training on surf lifesavers' perceptions of resuscitation efficacy. Resuscitation 2002;53:159–65. [15] Shaw R. CPR training for lifeguards: new research, new thinking. Parks Recreation 1996;31(7):44–7. [16] Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1 Executive summary. Resuscitation 2010;81:1219–76.
New way to individualize pulmonary embolism initial anticoagulant treatment—using adequate approved doses of rivaroxaban
To the Editor, One of the basic principles in patient treatment is to adjust the intensity and duration, site, and method of administration according to patient characteristics, that is, to individualize it. Results of pulmonary thromboembolism (PTE) treatment are still suboptimal, as judged by high mortality as well as high rate (in up to 70.9% of patients) of residual pulmonary artery thrombosis [1], which may be risk factor for chronic thromboembolic pulmonary hypertension [2]. Accordingly, there is an obvious need for improvement in treatment protocols for PTE [3]. In PTE and deep vein thrombosis (DVT), 2 forms of the same
