Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device

© Gary Wilson/ Pre-hospital Research Forum

Resuscitation. Volume 84, Issue 9, September 2013, Pages 1214–1222

A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD + ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD + ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology.

Methods
This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3).

Results
Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR = 1335; ACD + ITD = 1403). Survival to HD with favorable neurologic function was greater with ACD + ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p = 0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p = 0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups.

Conclusions
Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD + ITD resulted in a significant increase in survival to hospital discharge with favourable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD + ITD, regardless of the etiology of the cardiac arrest.

http://www.sciencedirect.com/science/article/pii/S0300957213002657

A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial

American Journal of Emergency Medicine. Volume 31, Issue 9 , Pages 1389-1392, September 2013

Epistaxis is a common problem in the emergency department (ED). Sixty percent of people experience it at least once in their life. There are different kinds of treatment for epistaxis. This study intended to evaluate the topical use of injectable form of tranexamic acid vs anterior nasal packing with pledgets coated with tetracycline ointment.

Methods
Topical application of injectable form of tranexamic acid (500 mg in 5 mL) was compared with anterior nasal packing in 216 patients with anterior epistaxis presented to an ED in a randomized clinical trial. The time needed to arrest initial bleeding, hours needed to stay in hospital, and any rebleeding during 24 hours and 1 week later were recorded, and finally, the patient satisfaction was rated by a 0-10 scale.

Results
Within 10 minutes of treatment, bleedings were arrested in 71% of the patients in the tranexamic acid group, compared with 31.2% in the anterior nasal packing group (odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P < .001). In addition, 95.3% in the tranexamic acid group were discharged in 2 hours or less vs 6.4% in the anterior nasal packing group (P < .001). Rebleeding was reported in 4.7% and 11% of patients during first 24 hours in the tranexamic acid and the anterior nasal packing groups, respectively (P = .128). Satisfaction rate was higher in the tranexamic acid compared with the anterior nasal packing group (8.5 ± 1.7 vs 4.4 ± 1.8, P < .001).

Conclusions
Topical application of injectable form of tranexamic acid was better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis.

http://www.ajemjournal.com/article/S0735-6757(13)00420-8/abstract?elsca1=etoc&elsca2=email&elsca3=0735-6757_201309_31_9&elsca4=emergency_medicine

Effects of prehospital epinephrine during out-of-hospital cardiac arrest with initial non-shockable rhythm: An observational cohort study

Critical Care 2013, 17: R188

© Gary Wilson/ Pre-hospital Research Forum

Few clinical trials have provided evidence that epinephrine administration after out-of-hospital cardiac arrest (OHCA) improves long-term survival. Here the authors determined whether prehospital epinephrine administration would improve 1-month survival in OHCA patients.

Methods: The authors analysed the data of 209,577 OHCA patients; the data were prospectively collected in a nationwide Utstein-style Japanese database between 2009 and 2010. Patients were divided into the initial shockable rhythm (n=15,492) and initial non-shockable rhythm (n=194,085) cohorts. The endpoints were prehospital return of spontaneous circulation (ROSC), 1-month survival, and 1-month favourable neurological outcomes (cerebral performance category scale, category 1 or 2) after OHCA. The authors defined epinephrine administration time as the time from the start of cardiopulmonary resuscitation (CPR) by emergency medical services personnel to the first epinephrine administration.

Results: In the initial shockable rhythm cohort, the ratios of prehospital ROSC, 1-month survival, and 1-month favorable neurological outcomes in the non-epinephrine group were significantly higher than those in the epinephrine group (27.7% vs. 22.8%, 27.0% vs. 15.4%, and 18.6% vs. 7.0%, respectively). However, in the initial non-shockable rhythm cohort, the ratios of prehospital ROSC and 1-month survival in the epinephrine group were significantly higher than those in the non-epinephrine group (18.7% vs. 3.0% and 3.9% vs. 2.2%, respectively) and there was no significant difference between the epinephrine and non-epinephrine groups for 1-month favorable neurological outcomes. Prehospital epinephrine administration for OHCA patients with initial non-shockable rhythms was independently associated with prehospital ROSC with improved 1-month survival when epinephrine administration time was <20 min, and with deteriorated 1-month favorable neurological outcomes.

Conclusions: Prehospital epinephrine administration for OHCA patients with initial non-shockable rhythms was independently associated with achievement of prehospital ROSC and had association with improved 1-month survival when epinephrine administration time was <20 min.

http://ccforum.com/content/pdf/cc12872.pdf (full article)

Increases in survival from out-of-hospital cardiac arrest: A five year study

Resuscitation. Volume 84, Issue 8, August 2013, Pages 1089–1092

© Gary Wilson/ Pre-hospital Research Forum

This study reports improvements in survival from out-of-hospital cardiac arrest in London over a five year period from 2007 to 2012 and explores the potential reasons for the very striking increases observed. The authors believe that it is evident that public education, an awareness of cardiac arrest, a co-ordinated fast EMS response along with robust guidelines and programme of EMS training are fundamental and may have contributed to the increases in Utstein comparator survival rates.

Methods
Data from the London Ambulance Service’s cardiac arrest registry from 2007 to 2012 were analysed retrospectively for all patients who met the Utstein comparator group criteria (an arrest of a presumed cardiac cause that was bystander witnessed with an initial rhythm of VF/VT).

Results
It was observed an increase in survival from out-of-hospital cardiac arrest during the five year period, with incremental improvements each year from 12% to 32% for the Utstein comparator group of patients.

Conclusion
The authors’ suggest that a range of important changes made to pre-hospital cardiac care in London over the last five years have contributed to the observed increase in survival over the study period. In addition they advocate a range of further initiatives to continue improving survival from out-of-hospital cardiac arrest.

http://www.sciencedirect.com/science/article/pii/S0300957213002074

Drowning related out-of-hospital cardiac arrests: Characteristics and outcomes

Resuscitation. Volume 84, Issue 8, August 2013, Pages 1114–1118

© Gary Wilson/ Pre-hospital Research Forum

There are few studies on drowning-related out-of-hospital cardiac arrest (OHCA) in which patients are followed from the scene through to hospital discharge. This study aims to describe this population and their outcomes in the state of Victoria (Australia).

Methods
The Victorian Ambulance Cardiac Arrest Registry was searched for all cases of OHCA with a precipitating event of drowning attended by emergency medical services (EMS) between October 1999 and December 2011.

Results
EMS attended 336 drowning-related OHCA during the study period. Cases frequently occurred in summer (45%) and the majority of patients were male (70%) and adult (77%). EMS resuscitation was attempted on 154 (46%) patients. Of these patients, 41 (27%) survived to hospital arrival and 12 (8%) survived to hospital discharge (5 adults [6%] and 7 [12%] children). Few patients were found in a shockable rhythm (6%), with the majority presenting in asystole (79%) or pulse-less electrical activity (13%). An initial shockable rhythm was found to positively predict survival (AOR 48.70, 95% CI: 3.80–624.86) while increased EMS response time (AOR 0.73, 95% CI: 0.54–0.98) and salt water drowning (AOR 0.69, 95% CI: 0.01–0.84) were found to negatively predict survival.

http://www.sciencedirect.com/science/article/pii/S0300957213000518

Conclusions
Rates of survival in OHCA caused by drowning are comparable to other OHCA causes. Patients were more likely to survive if they did not drown in salt water, had a quick EMS response and they were found in a shockable rhythm. Prevention efforts and reducing EMS response time are likely to improve survival of drowning patients.

AHA Consensus Statement: Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital

Circulation. 2013; 128: 417-435

© Gary Wilson/ Pre-hospital Research Forum

The “2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care” increased the focus on methods to ensure that high-quality cardiopulmonary resuscitation (CPR) is performed in all resuscitation attempts.

There are 5 critical components of high-quality CPR: minimize interruptions in chest compressions, provide compressions of adequate rate and depth, avoid leaning between compressions, and avoid excessive ventilation. Although it is clear that high-quality CPR is the primary component in influencing survival from cardiac arrest, there is considerable variation in monitoring, implementation, and quality improvement. As such, CPR quality varies widely between systems and locations. Victims often do not receive high-quality CPR because of provider ambiguity in prioritization of resuscitative efforts during an arrest. This ambiguity also impedes the development of optimal systems of care to increase survival from cardiac arrest.

This consensus statement addresses the following key areas of CPR quality for the trained rescuer: metrics of CPR performance; monitoring, feedback, and integration of the patient’s response to CPR; team-level logistics to ensure performance of high-quality CPR; and continuous quality improvement on provider, team, and systems levels. Clear definitions of metrics and methods to consistently deliver and improve the quality of CPR will narrow the gap between resuscitation science and the victims, both in and out of the hospital, and lay the foundation for further improvements in the future.

http://circ.ahajournals.org/content/128/4/417.full.pdf+html (Full text link)

The Association between Patients’ Perception of Their Overall Quality of Care and Their Perception of Pain Management in the Prehospital Setting

Prehospital Emergency Care. July-September 2013, Vol. 17, No. 3 , Pages 386-391

© Gary Wilson/ Pre-hospital Research Forum

The authors’ objective was to determine whether there is an association between a patient’s impression of his or her overall quality of care and his or her satisfaction with the pain management provided. It was hypothesised that satisfaction with pain management would show a significant positive association with a patient’s impression of overall quality of care.

Methods. This was a retrospective review of patient satisfaction data initially collected by a third-party company from January 1, 2007, to September 1, 2010. Participants were randomly selected from all transported patients, proportional to their paramedic-defined acuity level, with a goal of 100 interviews per month. The proportions of patients sampled from each acuity level were 25% priority 1 (high), 50% priority 2 (medium), and 25% priority 3 (low). Patients were excluded if there was no telephone number recorded in the prehospital patient record, no transportation was recorded, or the call was labelled as a psychiatric complaint. All satisfaction questions used a five-point Likert scale with ratings from excellent to poor, which were dichotomized for analysis. The outcome variable was the patient’s perception of his or her overall quality of care. The main independent variable was the patient’s rating of his or her pain management by emergency medical services (EMS) staff at the scene. Demographic variables were assessed for potential confounding.

Results. There were 2,741 patients with complete data for the outcome and main independent variables; 41.7% of the respondents were male and the average age was 54.1 years (standard deviation = 22.6). The overall quality of care was rated as excellent by 65.9% of the patients, whereas 59.2% rated their pain management as excellent. Of the patients who rated their pain management as excellent, 79.0% rated the overall quality of care as excellent, whereas only 21.0% of the patients rated the overall quality of care as excellent if pain management was not excellent. When the patients rated EMS staff as excellent for both helping to control or reduce pain and explaining the medications given, they were 2.7 (95% confidence interval 1.4–5.4) times more likely to rate their overall quality of care as excellent.

Conclusion. The model indicated that pain management was associated with increased perception of overall quality of care only when EMS providers explained the medications provided and their potential side effects.

http://informahealthcare.com/doi/abs/10.3109/10903127.2013.764948

Paramedic Identification of Acute Pulmonary Oedema in a Metropolitan Ambulance Service

Prehospital Emergency Care. July-September 2013, Vol. 17, No. 3 , Pages 339-347

© Gary Wilson/ Pre-hospital Research Forum

Acute pulmonary oedema (APO) is a common cause of acute dyspnea. In the prehospital setting, it is often difficult to differentiate APE from other causes of shortness of breath (SOB). Radiography and echocardiography aid in the identification of APO but are often not available. There is little information on how accurately ambulance paramedics identify patients with APO.

Objectives. This study aimed to 1) describe the prehospital clinical presentation and management of patients with a clinical diagnosis of APO and 2) compare the accuracy of coding of APO by paramedics against the emergency department (ED) medical discharge diagnosis.

Methods. This study included a retrospective cohort of all patients who had episodes identified as APO by ambulance paramedics and were transported to a metropolitan hospital ED in 2011. Two databases were used: an ambulance database and the Emergency Department Information System. The ED medical discharge diagnosis (using International Statistical Classification of Diseases and Related Problems, 10th Revision, Australian Modification [ICD-10-AM] codes) was used as the comparator with paramedic-assigned problem codes for APE. The outcomes for the study were the positive predictive value, i.e., the proportion of patients identified as having APE in the ambulance database who also had an ED discharge diagnosis of APO, and the sensitivity of paramedic identification of APO, i.e., the proportion of patients with an ED discharge diagnosis of APO that were correctly identified as APO by the ambulance paramedics.

Results. Four hundred ninety-five patients were transported to an ED with APO identified by the paramedics as the primary problem code. Shortness of breath, crepitations, high systolic blood pressure, and chest pain were the most common presenting signs and symptoms. Pink frothy sputum was rare (3% of patient episodes of APO). One hundred eighty-six patients received an ED discharge diagnosis of APO, i.e., a positive predictive value of 41%. Of 631 ED presentations with APO, paramedics identified 186, i.e., a sensitivity of 29%.

Conclusion. Acute pulmonary oedema is difficult to identify in the prehospital setting because of the variability in the signs and symptoms associated with this condition. Improved identification of OPE is essential in the initiation of appropriate and timely care. Ambulance paramedics need to be aware of such variability when considering patients who may be suffering from OPE.

http://informahealthcare.com/doi/abs/10.3109/10903127.2013.773114

Implementation of Prehospital Dispatch Protocols That Triage Low-acuity Patients to Advice-line Nurses

Prehospital Emergency Care Posted online on July 18, 2013. 

Although EMS agencies have been designed to efficiently provide medical assistance to individuals, the overuse of 9-1-1 as an alternative to primary medical care has resulted in the need for new methods to respond to this increasing demand. The study analyses the efficacy of classifying specific low-acuity calls that can be transferred to an advice-line nurse for further medical instruction. The objectives of the study were to analyse the impact of implementing this protocol and resultant patient feedback regarding the transfer to an advice-line nurse.

Methods. The authors collected data for retrospective review from April 2011 to April 2012 from a single municipal EMS agency with an average annual call volume of approximately 90,000. Medical Priority Dispatch System response codes were assigned to calls based on patient acuity. Patients classified under Omega response codes were assessed for eligibility of transfer to nurse advice lines. Exclusion criteria included the following: if the call was placed by a third-party caller; if the patient refused to be transferred to the advice-line nurse; anytime the MPDS system was not used; if the patient was referred from a skilled nursing facility, school, or university nursing office, or physician’s office. Telephone surveys were conducted for those patients who spoke to an advice-line nurse and did not receive an ambulance response 24 hours after calling 9-1-1 to obtain patient feedback.

Results. The database included 1660 patients initially classified as Omega and eligible for transfer to an advice-line nurse. After applying the exclusion criteria, 329 (19.8%) patients were ultimately transferred to an advice-line nurse and 204 (12.3%) received no ambulance response. Of those patients who were not transported by ambulance 118 (57.8%), patients completed telephone follow-up, with 104 (88.1%) reporting the nontransport option met their health-care needs and 108 (91.5%) responding they would accept the transfer again for a similar complaint.

Conclusion. We identified an average of two patients per day as eligible for transfer to the nurse advice line, with less than one patient successfully completing the Omega protocol per day. While impact was limited, there was a decrease in ambulance response.

http://informahealthcare.com/doi/abs/10.3109/10903127.2013.811563