Category Archives: News

The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology

Posted on by

The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Resuscitation. Available online 12 December 2013

The optimal blood pressure target following successful resuscitation from out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to explore the association between level of systolic blood pressure (SBP) on arrival at hospital and survival to hospital discharge.

Methods
The authors analysed eligible OHCAs occurring between January 2003 and December 2011 from the Victorian Ambulance Cardiac Arrest Register (VACAR). Inclusion criteria were: adults (≥18 years), presumed cardiac aetiology, not paramedic witnessed, and ROSC at hospital arrival. Multivariate logistic regression models were performed by initial rhythm (shockable/non-shockable) to examine the relationship between SBP at hospital arrival in 10 mmHg increments and survival to hospital discharge. Models were adjusted for known predictors of survival, including duration of arrest.

Results
Of 3620 eligible cases, 14% were hypotensive (SBP < 90 mmHg) on hospital arrival (10% shockable and 19% non-shockable). For patients in shockable rhythms, discharge survival was maximal at 120–129 mmHg (54%), and in the adjusted model (≥120 mmHg as reference) SBP decrements below 90 mmHg were associated with lower survival: 80–89 mmHg AOR = 0.49 (95% CI: 0.24–0.95); <79 mmHg AOR = 0.24 (95% CI: 0.10–0.61); unrecordable AOR = 0.10 (95% CI: 0.04–0.30). In patients found in non-shockable rhythms, SBP was not significant associated with discharge survival (AOR = 1.01, 95% CI: 0.89–1.15).

Conclusions
In an EMS system using intravenous adrenaline and fluids to maintain post-resuscitation SBP at 120 mmHg, hypotension on hospital arrival was relatively uncommon. However, in presumed cardiac OHCA patients with an initial shockable rhythm, SBPs below 90 mmHg was associated with significant lower odds of survival to hospital discharge. This level of hypotension may indicate patients who require more aggressive post-resuscitation blood pressure management.

http://www.sciencedirect.com/science/article/pii/S0300957213008976

Dextrose gel for neonatal hypoglycaemia

Posted on by
Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebo-controlled trial

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

The Lancet, Volume 382, Issue 9910, Pages 2077 – 2083, 21 December 2013
Neonatal hypoglycaemia is common, and a preventable cause of brain damage. Dextrose gel is used to reverse hypoglycaemia in individuals with diabetes; however, little evidence exists for its use in babies. The authors aimed to assess whether treatment with dextrose gel was more effective than feeding alone for reversal of neonatal hypoglycaemia in at-risk babies.

Methods

The authors undertook a randomised, double-blind, placebo-controlled trial at a tertiary centre in New Zealand between Dec 1, 2008, and Nov 31, 2010. Babies aged 35—42 weeks’ gestation, younger than 48-h-old, and at risk of hypoglycaemia were randomly assigned (1:1), via computer-generated blocked randomisation, to 40% dextrose gel 200 mg/kg or placebo gel. Randomisation was stratified by maternal diabetes and birthweight. Group allocation was concealed from clinicians, families, and all study investigators. The primary outcome was treatment failure, defined as a blood glucose concentration of less than 2·6 mmol/L after two treatment attempts. Analysis was by intention to treat.

Findings

Of 514 enrolled babies, 242 (47%) became hypoglycaemic and were randomised. Five babies were randomised in error, leaving 237 for analysis: 118 (50%) in the dextrose group and 119 (50%) in the placebo group. Dextrose gel reduced the frequency of treatment failure compared with placebo (16 [14%] vs 29 [24%]; relative risk 0·57, 95% CI 0·33—0·98; p=0·04). We noted no serious adverse events. Three (3%) babies in the placebo group each had one blood glucose concentration of 0·9 mmol/L. No other adverse events took place.

Interpretation

Treatment with dextrose gel is inexpensive and simple to administer. Dextrose gel should be considered for first-line treatment to manage hypoglycaemia in late preterm and term babies in the first 48 h after birth.

Cognitive appraisals, objectivity and coping in ambulance workers: a pilot study

Posted on by

Cognitive appraisals, objectivity and coping in ambulance workers: a pilot study

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Emerg Med J 2014;31:41-44

Ambulance workers are regularly exposed to call-outs, which are potentially psychologically traumatic. The ability to remain objective and make adaptive appraisals during call-outs may be beneficial to this at-risk population. This pilot study investigated the links between cognitive appraisals, objectivity and coping in ambulance workers.

Methods Forty-five ambulance workers from the London Ambulance Service, UK, were studied. Trauma exposure, post-traumatic stress disorder and depression symptoms were assessed using self-report measures. Positive and negative appraisals were measured in relation to two previous call-outs: one during which they coped well and one during which they did not.

Results Enhanced coping was associated with making more positive appraisals during the call-out. Better coping was also related to greater levels of objectivity during these call-outs. Coping less well was associated with the use of more negative appraisals during the call-out.

Conclusions Ambulance workers may benefit from psychological interventions, which focus on cognitive reappraisal and enhancing objectivity to improve coping and resilience.

http://emj.bmj.com/content/31/1/41.full.pdf+html (full text article)

Comparison of Bag-Valve-Mask Hand-Sealing Techniques in a Simulated Model

Posted on by

Comparison of Bag-Valve-Mask Hand-Sealing Techniques in a Simulated Model

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Annals of Emergency Medicine. Volume 63, Issue 1 , Pages 6-12.e3, January 2014

Bag-valve-mask ventilation remains an essential component of airway management. Rescuers continue to use both traditional 1- or 2-handed mask-face sealing techniques, as well as a newer modified 2-handed technique. We compare the efficacy of 1-handed, 2-handed, and modified 2-handed bag-valve-mask technique.

Methods
In this prospective, crossover study, health care providers performed 1-handed, 2-handed, and modified 2-handed bag-valve-mask ventilation on a standardized ventilation model. Subjects performed each technique for 5 minutes, with 3 minutes’ rest between techniques. The primary outcome was expired tidal volume, defined as percentage of total possible expired tidal volume during a 5-minute bout. A specialised inline monitor measured expired tidal volume. The authors compared 2-handed versus modified 2-handed and 2-handed versus 1-handed techniques.

Results
The authors enrolled 52 subjects: 28 (54%) men, 32 (62%) with greater than or equal to 5 actual emergency bag-valve-mask situations. Median expired tidal volume percentage for 1-handed technique was 31%; for 2-handed technique, 85%; and for modified 2-handed technique, 85%. Both 2-handed and modified 2-handed technique resulted in significantly higher median expired tidal volume percentages compared with 1-handed technique. The median expired tidal volume percentages between 2-handed and modified 2-handed techniques did not significantly differ from each other.

Conclusion
In a simulated model, both 2-handed mask-face sealing techniques resulted in higher ventilatory tidal volumes than 1-handed technique. Tidal volumes from 2-handed and modified 2-handed techniques did not differ. Rescuers should perform bag-valve-mask ventilation with 2-handed techniques.

http://www.annemergmed.com/article/S0196-0644(13)00693-8/abstract?elsca1=etoc&elsca2=email&elsca3=0196-0644_201401_63_1&elsca4=emergency_medicine

Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI

Posted on by

Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI

Resuscitation. Volume 85, Issue 1, January 2014, Pages 88–95

To determine if early cardiac catheterisation (CC) is associated with improved survival in comatose patients who are resuscitated after cardiac arrest when electrocardiographic evidence of ST-elevation myocardial infarction (STEMI) is absent.

Methods
The authors conducted a retrospective observational study of a prospective cohort of 754 consecutive comatose patients treated with therapeutic hypothermia (TH) following cardiac arrest.

Results
A total of 269 (35.7%) patients had cardiac arrest due to a ventricular arrhythmia without STEMI and were treated with TH. Of these, 122 (45.4%) received CC while comatose (early CC). Acute coronary occlusion was discovered in 26.6% of patients treated with early CC compared to 29.3% of patients treated with late CC (p = 0.381). Patients treated with early CC were more likely to survive to hospital discharge compared to those not treated with CC (65.6% vs. 48.6%; p = 0.017). In a multivariate regression model that included study site, age, bystander CPR, shock on admission, comorbid medical conditions, witnessed arrest, and time to return of spontaneous circulation, early CC was independently associated with a significant reduction in the risk of death (OR 0.35, 95% CI 0.18–0.70, p = 0.003).

Conclusions
In comatose survivors of cardiac arrest without STEMI who are treated with TH, early CC is associated with significantly decreased mortality. The incidence of acute coronary occlusion is high, even when STEMI is not present on the postresuscitation electrocardiogram.

http://www.sciencedirect.com/science/article/pii/S0300957213003961

Survival of resuscitated cardiac arrest patients with STEMI conveyed directly to a Heart Attack Centre

Posted on by

Survival of resuscitated cardiac arrest patients with ST-elevation myocardial infarction (STEMI) conveyed directly to a Heart Attack Centre by ambulance clinicians

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Resuscitation. Available online 19 September 2013

This study reports survival outcomes for patients resuscitated from out-of-hospital cardiac arrest (OHCA) subsequent to ST-elevation myocardial infarction (STEMI), and who were conveyed directly by ambulance clinicians to a specialist Heart Attack Centre for expert cardiology assessment, angiography and possible percutaneous coronary intervention (PCI).

Methods
This is a retrospective descriptive review of data sourced from the London Ambulance Service’s OHCA registry over a one-year period.

Results

The authors observed excellent survival rates for our cohort of patients with 66% of patients surviving to be discharged from hospital, the majority of whom were still alive after one year. Those who survived tended to be younger, to have had a witnessed arrest in a public place with an initial cardiac rhythm of VF/VT, and to have been transported to the specialist centre more quickly than those who did not.

Conclusion
A system allowing ambulance clinicians to autonomously convey OHCA STEMI patients who achieve a return of spontaneous circulation directly to a Heart Attack Centre is highly effective and yields excellent survival outcomes.

http://www.sciencedirect.com/science/article/pii/S0300957213007326

Should we be establishing heart attack centres, similar to stroke centres, to ensure all patients with heart attacks, including those in cardiac arrest, receive optimum treatment, such as cardiologist review, angiography and PCI, or at least ensuring that our patients are conveyed to hospitals with these facilities?
Achieving a rate of 66% for patients surviving to discharge, with the majority of whom were still alive after one year, could suggest that that this is a good idea.

Intranasal Ketamine for Analgesia

Posted on by
Reply

Intranasal Ketamine for Analgesia in the Emergency Department: A Prospective Observational Series

Academic Emergency Medicine. Volume 20, Issue 10, pages 1050–1054, October 2013

The objective was to examine the feasibility, effectiveness, and adverse effect profile of intranasal ketamine for analgesia in emergency department (ED) patients.

Methods
This was a prospective observational study examining a convenience sample of patients aged older than 6 years experiencing moderate or severe pain, defined as a visual analog scale (VAS) score of 50 mm or greater. Patients received 0.5 to 0.75 mg/kg intranasal ketamine. Pain scores were recorded on a standard 100-mm VAS by trained investigators at baseline, then every 5 minutes for 30 minutes, and then every 10 minutes for an additional 30 minutes. The primary outcome was the number and proportion of patients experiencing clinically significant reductions in VAS pain scores, defined as VAS reductions of 13 mm or more, within 30 minutes. Secondary outcomes included the median reduction in VAS, the median time required to achieve a 13 mm reduction in VAS, vital sign changes, and adverse events. Continuous data are reported with medians and interquartile ranges (IQRs). The Wilcoxon signed-ranks test was used to assess changes in VAS scores. Adverse effects are reported with proportions and 95% confidence intervals (CIs).

Results
Forty patients were enrolled with a median age of 47 years (IQR = 36 to 57 years; range = 11 to 79 years) for primarily orthopedic injuries. A reduction in VAS of 13 mm or more within 30 minutes was achieved in 35 patients (88%). The median change in VAS at 30 minutes was 34 mm (44%). Median time required to achieve a 13 mm VAS reduction was 9.5 minutes (IQR = 5 to 13 minutes; range = 5 to 25 minutes). No serious adverse effects occurred. Minor adverse effects included dizziness (21 patients, 53%; 95% CI = 38% to 67%), feeling of unreality (14 patients, 35%; 95% CI = 22% to 50%), nausea (four patients, 10%; 95% CI = 4% to 23%), mood change (three patients, 8%; 95% CI = 3% to 20%), and changes in hearing (one patient, 3%; 95% CI = 0% to 13%). All adverse effects were transient and none required intervention. There were no changes in vital signs requiring clinical intervention.

Conclusions
Intranasal ketamine reduced VAS pain scores to a clinically significant degree in 88% of ED patients in this series. Adverse effects were minor and transient. Intranasal ketamine may have a role in the provision of effective, expeditious analgesia to ED patients.

http://onlinelibrary.wiley.com/doi/10.1111/acem.12229/abstract

Prehospital non-drug assisted intubation for adult trauma patients with a GCS less than 9

Posted on by
1

Prehospital non-drug assisted intubation for adult trauma patients with a Glasgow Coma Score less than 9

Emerg Med J 2013;30:935-941

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Prehospital airway management for adult trauma patients remains controversial. The authors sought to review the frequency that paramedic non-drug assisted intubation or attempted intubation is performed for trauma patients in Ontario, Canada, and determine its association with mortality.

Methods
The authors conducted a retrospective cohort study using the Ontario Trauma Registry’s Comprehensive Data Set for 2002–2009. Eligible patients were greater than 16 years of age, had an initial Glasgow Coma Score of less than 9 and were cared for by ground-based non-critical care paramedics. The primary outcome was mortality. Outcomes were compared between patients undergoing prehospital intubation versus basic airway management. Logistic regression analyses were used to quantify the association between prehospital intubation and mortality.

Results
Of the 2229 patients included in the analysis, 671 (30.1%) underwent prehospital intubation. Annual rates of prehospital intubation declined from 33.7% to 14.0% over the study period. Unadjusted death rates were 66.0% versus 34.8% in the intubation and basic airway groups, respectively. Intubation in the prehospital setting was associated with a heightened risk of mortality.

Conclusions
Prehospital non-drug assisted intubation for trauma is being performed less frequently in Ontario, Canada. Within the study population, paramedic non-drug assisted intubation or attempted intubation was associated with a heightened risk of mortality.

http://emj.bmj.com/content/30/11/935?etoc

Excited delirium syndrome and sudden death

Posted on by
Reply

Excited delirium syndrome and sudden death: Best evidence topics report

Emerg Med J 2013;30:958-960

A short-cut review was carried out to establish whether morbidity and mortality from excited delirium syndrome (EXDS) can be predicted in the emergency department (ED). Seventy-three papers were found of which 11 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are detailed.

The clinical bottom line is that the early recognition of EXDS remains paramount as patients may have sudden cardiovascular collapse with little warning. Several authors do describe laboured respiratory efforts before death, so prompt airway and haemodynamic control may be necessary. Patients may benefit from chemical rather than physical restraint. Acidosis and hyperthermia should also be aggressively managed. Law enforcement and prehospital personnel should also be educated regarding potential complications of EXDS.

http://emj.bmj.com/content/30/11/958.2?etoc

http://www.bestbets.org/bets/bet.php?id=2478 (link to report)

Does Use of the Recognition Of Stroke In the Emergency Room Stroke Assessment tool enhance stroke recognition?

Posted on by
Reply

Does Use of the Recognition Of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?

Stroke. 2013; 44: 3007-3012

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

UK ambulance services assess patients with suspected stroke using the Face Arm Speech Test (FAST). The Recognition Of Stroke In the Emergency Room (ROSIER) tool has been shown superior to the FAST in identifying strokes in emergency departments but has not previously been tested in the ambulance setting. We investigated whether ROSIER use by ambulance clinicians can improve stroke recognition.

Methods
Ambulance clinicians used the ROSIER in place of the FAST to assess patients with suspected stroke. As the ROSIER includes all FAST elements, we calculated a FAST score from the ROSIER to enable comparisons between the two tools. Ambulance clinicians’ provisional stroke diagnoses using the ROSIER and calculated FAST were compared with stroke consultants’ diagnosis. We used stepwise logistic regression to compare the contribution of individual ROSIER and FAST items and patient demographics to the prediction of consultants’ diagnoses.

Results
Sixty-four percent of strokes and 78% of nonstrokes identified by ambulance clinicians using the ROSIER were subsequently confirmed by a stroke consultant. There was no difference in the proportion of strokes correctly detected by the ROSIER or FAST with both displaying excellent levels of sensitivity. The ROSIER detected marginally more nonstroke cases than the FAST, but both demonstrated poor specificity. Facial weakness, arm weakness, seizure activity, age, and sex predicted consultants’ diagnosis of stroke.

Conclusions
The ROSIER was not better than the FAST for prehospital recognition of stroke. A revised version of the FAST incorporating assessment of seizure activity may improve stroke identification and decision making by ambulance clinicians.

http://stroke.ahajournals.org/content/44/11/3007.abstract.html?etoc