Outcome from paediatric cardiac arrest associated with trauma

OBJECTIVE: To examine survival rates for paediatric trauma patients requiring cardiopulmonary resuscitation (CPR) in the pre-hospital setting, and to identify characteristics that may be associated with survival. DESIGN: Ten-year retrospective trauma database review. SETTING: An urban physician-led pre-hospital trauma service serving a population of approximately 7.5 million, in the United Kingdom. PATIENTS: Eighty paediatric trauma patients (15 years or less) who received pre-hospital resuscitation following cardiorespiratory arrest between July 1994 and June 2004. INTERVENTION: Pre-hospital cardiopulmonary resuscitation. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: Eighty children met inclusion criteria for the study. Nineteen (23.8%) were discharged alive from the emergency department and seven children (8.75%) survived to hospital discharge. Of the seven survivors, one had spinal cord injury. Two suffered asphyxial injury associated with blunt trauma and three sustained hypoxic insults following drowning or burns/smoke inhalation. In one patient with known congenital cardiac disease the cause of cardiac arrest was likely to have been medical. CONCLUSION: This study confirms the poor outcome for children requiring pre-hospital CPR following trauma. However, the results are better in this physician-attended group than in other studies where physicians were not present. They also suggest that cardiac arrest associated with trauma in children has a better outcome than in adults. In common with adults treated in this system, those patients with hypovolaemic cardiac arrest did not survive (Ann Emerg Med 2006;48:240-4). A large proportion of the survivors suffered hypoxic or asphyxial injuries. Targeted aggressive out-of-hospital resuscitation in certain patient groups can produce good outcomes.     

Long-term outcome of paediatric cardiorespiratory arrest in Spain

OBJECTIVE: To analyse the final outcome of cardiorespiratory arrest (CRA) in children and the neurological and functional state of survivors at 1 year. METHODS: An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital CRA in children was carried out; 283 children between 7 days and 17 years of age were included. CRA and resuscitation data were registered according to Utstein style. The outcome variables were: sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). The status of survivors was evaluated by means of the paediatric cerebral performance category (PCPC) scale and the paediatric overall performance category (POPC) scale at Paediatric Intensive Care Unit discharge, at hospital discharge, and at 1 year follow-up. RESULTS: In 283 children, 311 CRA episodes, 73 respiratory arrests (23.5%) and 238 cardiac arrests (76.5%) were analysed. Seventeen children suffered more than one CRA episode (range: 2-6). The initial survival was 60.2% and 1-year survival was 33.2%. The final survival was significantly higher in respiratory arrest than in cardiac arrest patients (70.0% versus 21.1%) (P < 0.0001). After 1 year follow-up, 87.3% of patients had scores 1 or 2 on the PCPC scale and 84.0% had scores 1 or 2 in the POPC scale; these results indicate that 1 year after CRA, the majority of survivors had normal neurological and functional status or showed only mild disability. CONCLUSIONS: Prognosis of CRA in children continues to be poor in terms of survival but quite good in terms of neurological and functional status among survivors. Additional strategies and efforts are needed to improve the short-term prognosis of paediatric CRA. However, the long-term outcome of survivors is reassuring.     

Outcome and risk factors in children after traumatic cardiac arrest and successful resuscitation

IntroductionProspective collected data of the TraumaRegister DGU^® were analyzed to derive survival rates and predictors for non-survival in the children who had suffered traumatic cardiorespiratory arrest. Different time points of resuscitation efforts (only preclinical, in the emergency room (ER) or preclinical + ER) were analyzed in terms of mortality and neurological outcome.MethodsThe database of the TraumaRegister DGU^® comprising 122,742 patients from 1993 to 2013 was analyzed. The main focus of this survey was on the paediatric group defined by an age ≤14 years who could be compared to adults. Different statistical analysis (univariate and multivariate analysis, logistic regression) were performed with mortality as the target variable. Differences between the paedatric group and adults were analysed by Fisher's exact test.ResultsData after preclinical and/or ER resuscitation from 152 children and 1690 adults were analyzed. A good or moderate outcome (GOS 5 + 4) was found in 19.4% of the children's group compared to 12.4% of the adults (p = 0.02).Analysis of the GOS 5 + 4 subgroups after preclinical resuscitation only revealed that these outcomes were achieved by 19.4% of the paediatric group and 13.2% of the adults (p = 0.24), after ER-only resuscitation by 37.0% of the children and 19.6% of the adults (p = 0.046), and after preclinical and ER resuscitation by only 10.9% of the children compared to 2.5% of the adults (p = 0.006). Taking only survivors into account, 84.8% of the children and 62% of the adults had a GOS 4 + 5.The highest risk for mortality in the logistic regression model was associated with preclinical intubation, followed by GCS 3, blood transfusion and severe head injury with AIS ≥3 and ISS.ConclusionsCPR in children after severe trauma seems to yield a better outcome than in adults, and appears to be more justified than the current guidelines would imply. Resuscitation in the ER is associated with better neurological outcomes compared with resuscitation in a preclinical context or in both the preclinical phase and the ER. Our children's outcomes seem to be better than those in most of the earlier studies, and the data presented might support algorithms in the future especially for paediatric resuscitation.     

Use and effect of paediatric advanced life support skills for paediatric arrest in the A&E department.

OBJECTIVES: To define the use of paediatric advanced life support by the Leicestershire Ambulance and Paramedic Service (LAPS) and the A&E department of a large university teaching hospital; and to identify the outcome and determine the factors that are consistent with a successful outcome. SUBJECTS AND METHODS: The prehospital, accident and emergency (A&E), and inpatient notes of all patients aged 0-16 years who had been admitted to the resuscitation room at the Leicester Royal Infirmary in cardiac arrest between 1 January 1992 and 31 December 1995 were reviewed. Cardiac arrest was defined according to the Utstein template for reporting of prehospital data. RESULTS: During the four year period, 51 cases of paediatric cardiac arrest were identified, with a median age of 3.2 years (range two days to 15 years). In eight patients, resuscitation was not attempted. Of the remaining 43, 15 (37%) were discharged from A&E to the intensive care unit. Five (11.5%) ultimately survived to discharge from hospital. Subsequent neurological development was recorded as normal in four of the five. Of the patients who had a prehospital cardiac arrest and were initially resuscitated by the LAPS there was only one survivor. He was discharged from hospital with severe neurological injury and died three months later. CONCLUSIONS: The outcome for established prehospital paediatric cardiac arrest, in a well defined emergency medical services system, is very poor at present. It does not seem to be affected by the institution of paediatric life support teaching programmes for hospital staff alone. The timing in instituting advanced life support measures remains the most critical factor affecting outcome in these patients.     

Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians

Aim

To collect data regarding prehospital paediatric tracheal intubation by emergency physicians skilled in advanced airway management.

Methods

A prospective 8-year observational study of a single emergency physician-staffed emergency medical service. Self-reporting by emergency physicians of all children aged 0–14 years who had prehospital tracheal intubation and were attended by either anaesthesia-trained emergency physicians (group 1) or by a mixture of anaesthesia and non-anaesthesia-trained emergency physicians (group 2).

Results

Eighty-two out of 2040 children (4.0%) had prehospital tracheal intubation (58 in group 1). The most common diagnoses were trauma (50%; in school children, 73.0%), convulsions (13.4%) and SIDS (12.2%; in infants, 58.8%). The overall tracheal intubation success rate was 57 out of 58 attempts (98.3%). Compared to older children, infants had a higher number of Cormack–Lehane scores of 3 or 4, “difficult to intubate” status (both 3 out of 13; 23.1%) and a lower first attempt success rate for tracheal intubation (p = 0.04). Among all 82 children 71 (86.6%) survived to hospital admission and 63 (76.8%) to discharge. Of the 63 survivors, 54 (85.7%) demonstrated a favourable or unchanged neurological outcome (PCPC 1–3). The survival and neurological outcomes of infants were inferior compared to older children (p < 0.001). On average an emergency physician performed one prehospital tracheal intubation in 3 years in a child and one in 13 years in an infant.

Conclusions

Anaesthesia-trained emergency physicians working in our system report high success rates for prehospital tracheal intubation in children. Survival and neurological outcomes were considerably better than reported in previous studies.     

The epidemiology of cardiac arrest in children and young adults

AIM: To describe the epidemiology of children and young adults suffering from out-of-hospital cardiac arrest. PATIENTS: All patients suffering from out-of-hospital cardiac arrest in whom, resuscitation efforts were attempted in the community of G?teborg between 1980 and 2000. METHODS: Between 31 October 1980 and 31 October 2000, all consecutive cases of cardiac arrest in which the emergency medical service (EMS) system responded and attempted resuscitation were reported and followed-up to discharge from hospital. RESULTS: Among 5505 cardiac arrests information on age was available in 5290 cases (96%). Of these 5290 cases 98 (2%) were children (age 0-17 years), 197 (4%) were young adults (age 18-35 years) and the remaining 4995 (94%) were adults (age >35 years). Children and young adults differed from adults by suffering from a witnessed arrest less frequently, being found by the ambulance crew in ventricular fibrillation/tachycardia less frequently and being judged as having an underlying cardiac aetiology less frequently. Of the children only 5% were discharged from hospital alive compared with 8% for young adults and 9% for adults. Among survivors the cerebral performance categories (CPC) score at discharge tended to differ with 38% of young adults registering a CPC score of 1 (no neurological deficit) compared with 52% among adults. CONCLUSION: Children and young adults suffering from out-of-hospital cardiac arrest differed from adults in terms of aetiology and observed initial arrhythmia. Children had a particularly bad outcome whereas young adults had a similar outcome as adults.     

Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project

Background

Children have better outcomes after out-of-hospital cardiac arrest (OHCA) than adults. However, little is known about the difference in outcomes between children and adults after OHCA due to drowning.

Objectives

The aim of this study is to assess the outcome after OHCA due to drowning between children and adults. Our hypothesis is that outcomes after OHCA due to drowning would be in better among children (<18 years old) compared with adults (≥18 years old).

Method

This prospective population-based, observational study included all emergency medical service-treated OHCA due to drowning in Osaka, Japan, between 1999 and 2010 (excluding 2004). Outcomes were evaluated between younger children (0–4 years old), older children (5–17 years old), and adults (≥18 years old). Major outcome measures were one-month survival and neurologically favorable one-month survival defined as cerebral performance category 1 or 2. Multivariate logistic regression analyses were used to account for potential confounders.

Results

During the study period, 66,716 OHCAs were documented, and resuscitation was attempted for 62,048 patients (1300 children [2%] and 60,748 adults [98%]). Among these OHCAs, 1737 (3% of OHCAs) were due to drowning (36 younger children [2%], 32 older children [2%], and 1669 adults [96%]). The odds of one-month survival were significantly higher for younger children (28% [10/36]; adjusted odds ratio [AOR], 20.20 [95% confidence interval {CI} 7.45–54.78]) and older children (9% [3/32]; AOR, 4.47 [95% CI 1.04–19.27]) when compared with adults (2% [28/1669]). However, younger children (6% [2/36]; AOR, 5.23 [95% CI 0.52–51.73]) and older children (3% [1/32]; AOR, 2.53 [95% CI 0.19–34.07]) did not have a higher odds of neurologically favorable outcome than adults (1% [11/1669]).

Conclusion

In this large OHCA registry, children had better one-month survival rates after OHCA due to drowning compared with adults. Most survivors in all groups had unfavorable neurological outcomes.     

Can We Define Termination Of Resuscitation Criteria In Out-Of-Hospital Hanging?

Objective: Survival rate of cardiac arrest due to hanging (H-CA) victims is low. Hence, this leads to the question of the utility of resuscitation in these patients. The objective was to investigate whether there are predictive criteria for survival with a good neurological outcome or predictive criteria for non-survival or survival with a poor neurological outcome enabling us to define the termination of resuscitation rules in these patients. Methods: Between July 1, 2011 and January 1, 2016, we included 1,689 out-of-hospital cardiac arrests due to hanging. We compared the characteristics of survivors with a good neurological outcome at day 30 with the others. Results: The study population was mainly composed of males with a median age of 48 [37–60]. The overall survival was 2.1%, among which 48.6% had a good neurological outcome. Survivors benefited more often from immediate basic life support than the rest of the subjects, which was corroborated by the shorter no-flow durations. We did not record any difference in terms of advanced cardiac life support initiation frequency and technique between survivors with a good neurological outcome and the rest. Nevertheless, ACLS duration was longer in survivors with a good neurological outcome than in others. Conclusions: Basic life support (BLS) was the decisive criterion for 15/17 survivors. However, a detailed analysis showed 2 survivors presenting no BLS before the arrival of mobile medical teams and non-shockable rhythms who survived at day 30 with a good neurological outcome. These results lead us to consider that mobile medical team intervention and ACLS attempt are not futile, and the benefit justifies the cost. Thus, we cannot define any rule for the termination of resuscitation.     

One-year survival and neurological outcome after pediatric cardiopulmonary resuscitation

OBJECTIVE: Reported survival after cardiopulmonary resuscitation (CPR) in children varies considerably. We aimed to identify predictors of 1-year survival and to assess long-term neurological status after in- or outpatient CPR. DESIGN: Retrospective review of the medical records and prospective follow-up of CPR survivors. SETTING: Tertiary care pediatric university hospital. PATIENTS AND METHODS: During a 30-month period, 89 in- and outpatients received advanced CPR. Survivors of CPR were prospectively followed-up for 1 year. Neurological outcome was assessed by the Pediatric Cerebral Performance Category scale (PCPC). Variables predicting 1-year survival were identified by multivariable logistic regression analysis. INTERVENTIONS: None. RESULTS: Seventy-one of the 89 patients were successfully resuscitated. During subsequent hospitalization do-not-resuscitate orders were issued in 25 patients. At 1 year, 48 (54%) were alive, including two of the 25 patients with out-of-hospital CPR. All patients died, who required CPR after trauma or near drowning, when CPR began >10 min after arrest or with CPR duration >60 min. Prolonged CPR (21-60 min) was compatible with survival (five of 19). At 1 year, 77% of the survivors had the same PCPC score as prior to CPR. Predictors of survival were location of resuscitation, CPR during peri- or postoperative care, and duration of resuscitation. A clinical score (0-15 points) based on these three items yielded an area under the ROC of 0.93. CONCLUSIONS: Independent determinants of long-term survival of pediatric resuscitation are location of arrest, underlying cause, and duration of CPR. Long-term survivors have little or no change in neurological status.     

Effectiveness and long-term outcome of cardiopulmonary resuscitation in paediatric intensive care units in Spain

OBJECTIVE: To analyse the immediate effectiveness of resuscitation and long-term outcome of children who suffered a cardiorespiratory arrest when admitted to paediatric intensive care units (PICU). DESIGN AND SETTING: Secondary analysis of data from an 18-month prospective, multicentre study analysing cardiorespiratory arrest in children in 16 paediatric intensive care units in Spain. PATIENTS AND METHODS: We studied 116 children between 7 days and 17 years of age. Data were recorded according to the Utstein style. Analysed outcome variables were sustained return of spontaneous circulation (ROSC), survival to hospital discharge and survival at 1 year. Neurological and general performance outcome was assessed by means of the Paediatric Cerebral Performance Category (PCPC) and the Paediatric Overall Performance Category (POPC) scales. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: In 80 patients (69%) ROSC was achieved and it was sustained > 20 min in 69 (59.5%). At one-year follow-up, 40 children (34.5%) were alive. Survival was not associated with sex, age or weight of patients. Mortality from cardiac arrest was higher than respiratory arrest (69.8% versus 40%, p = 0.01). Patients with sepsis had a higher mortality than other diagnostic groups. Mechanically ventilated children and those treated with vasoactive drugs had a higher mortality. Initial mortality was slightly higher in patients with slow ECG rhythms (35.7%) compared to those with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (27.2%). Duration of resuscitation effort was correlated with mortality (p < 0.0001). Patients who required one or more doses of adrenaline had also a higher mortality (77.8% versus 20.7%, p < 0.0001) and survivors needed less doses of adrenaline (0.85 +/- 1.14 versus 4.4+/-2.9, p < 0.0001). At hospital discharge 86.8 and 84.6% of patients had scores 1 or 2 (normal or near-normal) in the PCPC and POPC scales. At 1-year follow-up these figures were 90.8 and 86.3%, respectively. CONCLUSION: One-third of children who suffer a cardiac or respiratory arrest when admitted to PICU survive, and most of them had a good long-term neurological and functional outcome. The duration of cardiopulmonary resuscitation attempts is the best indicator of mortality.     

Epidemiology and outcome of pediatric trauma treated by an emergency-physician-staffed advanced life-support unit

BACKGROUND: The aim of this study was to describe the epidemiology and outcome of pediatric trauma in the setting of an emergency-physician-staffed mobile advanced life support (ALS) unit serving a predominantly urban area in Austria. METHODS: In this retrospective chart review, all pediatric trauma patients (0-14 years of age) who were treated by a physician-staffed ALS unit in Innsbruck within a 3-year period were analyzed. In addition, hospital charts were assessed to determine the clinical course and the outcome of these patients. RESULTS: 113 injured children were treated by the physician-staffed ALS unit (1.5% of all runs) during the study period; a frequency of three pediatric trauma patients per month. On average, injuries were of moderate severity (2.6 +/- 1.3 on the NACA severity scale). Thirteen children (11.5%) sustained severe to life-threatening injuries and two of whom underwent out-of-hospital resuscitation. The majority of the injuries were caused by vehicular accidents and sports/recreation-related trauma; head trauma was the most frequent injury. Violence-related trauma including weapon-inflicted injuries was uncommon. 40% of the children were hospitalized. The overall outcome was favorable: 78% of the hospitalized children had no impairment at the time of discharge. By comparing the prehospital trauma diagnosis with the final diagnosis, we found that the vast majority of emergency-physician trauma diagnoses were accurate. CONCLUSION: Because the frequency of pediatric trauma is so low, ALS units may not gain adequate experience in the management of (severe) pediatric trauma, thus rendering regular training of paramount importance.     

Cold water submersion and cardiac arrest in treatment of severe hypothermia with cardiopulmonary bypass

In the paediatric population, submersion injury with drowning or near-drowning represents a significant cause of morbidity and mortality. This study reviews retrospectively our own experiences and the literature on the use of cardiopulmonary bypass (CPB) to rewarm paediatric victims of cold water submersion who suffer severe hypothermia (<28 degrees C) and cardiac arrest (asystole or ventricular fibrillation). In addition to three children treated at our institution, nine other victims were found in the literature. In this cohort of 12 children aged between 2 and 12 years, there was a tendency to better outcome with lower core temperature at the beginning of extracorporeal circulation (mean temperature in nine survivors, 20 degrees C; in three non-survivors, 25.5 degrees C). The lowest temperature survived was 16 degrees C. Neither base excess, pH nor serum potassium levels were reliable prognostic factors. The lowest base excess in a survivor was -36.5 mmol/l, the lowest pH 6.29. We consider CPB as the method of choice for resuscitation and rewarming of children with severe accidental hypothermia and cardiac arrest (asystole or ventricular fibrillation). Compared with adults, children, especially smaller ones, require special consideration with regard to intravenous cannulation as drainage can be inadequate using femoral-femoral cannulation. In hypothermic children we advocate, therefore, emergency median sternotomy. Until more information regarding prognostic factors are available, children who are severely hypothermic and clinically dead after submersion in cold water--even if for an unknown length of time--should receive cardiopulmonary resuscitation (CPR) and be transported without delay to a facility with capabilities for CPB instituted via a median sternotomy.     

Out-of-hospital unwitnessed cardiopulmonary collapse and no-bystander CPR: a practical addition to resuscitation termination guidelines

Cardiopulmonary resuscitation (CPR) provides possible survival from otherwise fatal cardiopulmonary collapse. Termination guidelines have been developed for use when resuscitation has no potential benefit for a victim. The purpose of this prospective cohort study was to determine if unwitnessed collapse combined with no-bystander cardiopulmonary resuscitation would support a decision to terminate attempted resuscitation. There were 541 patients analyzed during 6 months, with functional neurological survival the outcome of interest. There were no functional neurological survivors at hospital discharge among the 180 victims in the unwitnessed, no-bystander CPR subgroup (95% confidence interval [CI] 0.0%-2.1%). Functional neurological survival for witnessed collapse, bystander CPR was 6.0% (95% CI 2.8%-12.5%), for witnessed collapse, no-bystander CPR was 3.8% (95% CI 1.9%-7.7%), and for unwitnessed collapse, bystander CPR 1.3% (95% CI 0.2%-6.9%). With confirmation by further studies, unwitnessed collapse and lack of bystander CPR may be a practical addition to resuscitation termination guidelines.     

Emergency system prospective performance evaluation for cardiac arrest in Lombardia,an Italian region

BACKGROUND: Because children have less subcutaneous fat, and a higher surface area to body weight ratio than adults, it has been suggested that children cool more rapidly during submersion, and therefore have a better outcome following near-drowning incidents. AIM OF THE STUDY: To study the impact of age, submersion time, water temperature and rectal temperature in the emergency room on outcome in near-drowning. MATERIAL AND METHODS: This retrospective study included all near-drowning victims admitted to the intensive care units of Helsinki University Central Hospital after successful cardiopulmonary resuscitation between 1985 and 1997. RESULTS: There were 61 near-drowning victims (age range: 0.5-60 years, median 29 years). Males were in the majority (40), and 26 were children (<16 years). The median water temperature was 17 degrees C (range: 0-33 degrees C). The median submersion time for the 43 survivors (70%) was 10 min (range: 1-38 min). Intact survivors and those with mild neurological disability (n=26, 43%) had a median submersion time of 5 min (range: 1-21 min). In non-survivors the median submersion time was 16 min (range: 2-75 min). Submersion time was the only independent predictor of survival in linear regression analysis (P<0.01). Patient age, water temperature and rectal temperature in the emergency room were not significant predictors of survival. CONCLUSIONS: Although submersion time is usually an estimate, it is the best prognostic factor after a near drowning incident. Children did not have a better outcome than adults.     

Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management?

BackgroundPrehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome.ObjectivesIn this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome.MethodsThe study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management.ResultsA total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP.ConclusionsPrehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.     

Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71–1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03–1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.     

Pre-resuscitation Lactate and Hospital Mortality in Prehospital Patients

Abstract

Objective. Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (IV) resuscitation and examine the association of elevation on in-hospital death. Methods. A convenience sample of adult patients over 14 months who received an IV line by eight EMS agencies in Western Pennsylvania had lactate measurement prior to any IV treatment. We assessed the lactate values and any relationship between these and hospital mortality (our primary outcome) and admission to the intensive care unit (ICU). We also compared the ability of lactate to discriminate outcomes with a prehospital critical illness score using age, Glasgow Coma Score, and initial vital signs. Results. We included 673 patients, among whom 71 (11%) were admitted to the ICU and 21 (3.1%) died in-hospital. Elevated lactate (≥2 mmol/L) occurred in 307 (46%) patients and was strongly associated with hospital death after adjustment for known covariates (odds ratio = 3.57, 95% confidence interval [CI]: 1.10, 11.6). Lactate ≥2 mmol/L had a modest sensitivity (76%) and specificity (55%), and discrimination for hospital death (area under the curve [AUC] = 0.66, 95%CI: 0.56, 0.75). Compared to the prehospital critical illness score alone (AUC = 0.69, 95% CI: 0.59, 0.80), adding lactate to the score offered modest improvement (net reclassification improvement = 0.63, 95%CI: 0.23, 1.01, p < 0.05). Conclusions. Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.     

A randomized controlled trial of sodium bicarbonate in neonatal resuscitation-effect on immediate outcome

Very little evidence is available that supports or disproves the use of medications in neonatal resuscitation. In this randomized controlled trial, we evaluated the effect of sodium bicarbonate given during neonatal resuscitation, on survival and neurological outcome at discharge. SUBJECTS AND METHODS: Consecutively born asphyxiated neonates continuing to need positive pressure ventilation at 5min of life received either sodium bicarbonate or 5% dextrose. The study group was given intravenous sodium bicarbonate solution 4ml/kg (1.8meq./kg) over 3-5min. This solution was prepared by diluting 7.5% sodium bicarbonate (0.9meq./ml) with distilled water in a 1:1 ratio. The placebo group received 4ml/kg of undiluted 5% dextrose at a similar rate. The surviving neonates were evaluated for their neurological status at discharge. Primary outcome variable: Death or abnormal neurological examination at discharge. Secondary outcome variables: Encephalopathy, multi-organ dysfunction, intraventricular haemorrhage (IVH) and arterial pH at 6h. RESULTS: Twenty-seven babies were randomized to receive sodium bicarbonate (bicarb group) and 28 to receive 5% dextrose. Eighteen of the 27 (66.7%) babies in the bicarb group and 19 of the 28 babies (68%) in the dextrose group survived to discharge ( P=0.84 ). Twenty-eight percent of the survivors in the bicarb group and 32% of the survivors in the dextrose group were neurologically abnormal at discharge ( P=0.10 ). The composite primary outcome of death or abnormal neurological examination at discharge was similar in both groups (52% versus 54%, P=0.88 ). The incidence of encephalopathy (74% versus 63%), cerebral oedema (52% versus 30%), need for inotropic support (44% versus 29%), intraventricular haemorrhage (IVH) and the mean arterial pH at 6hrs were similar between the two groups. CONCLUSION: Administration of sodium bicarbonate during neonatal resuscitation did not help to improve survival or immediate neurological outcome.     

Pain score documentation and analgesia: A comparison of children and adults with appendicitis

Objective: There is a growing body of evidence suggesting that administration of analgesia in paediatric ED is inadequate. The present study was designed to assess pain score documentation and provision of opioid analgesia to children and adults with confirmed appendicitis in a mixed Australian ED. Method: A retrospective chart review of all adults and children with histologically confirmed appendicitis diagnosed in the Townsville ED during 2006 was performed. Data collected included pain score documentation, weight, opioid dose, oral analgesia, time of presentation, level of doctor and prehospital analgesia. Results: Data were collected for 106 adults and 39 children. Among them, 13 (33%) children compared with 79 (75%) adults had a pain score documented (OR 0.16, 95% CI 0.07–0.37, P < 0.001). And 11 (28%) children compared with 79 (75%) adults received i.v. morphine (OR 0.13, 95% CI 0.06–0.31, P < 0.001). Administration of oral analgesia lowered the likelihood and pain score documentation increased the likelihood of receiving morphine in both children and adults. Conclusion: Documentation of pain scores and provision of i.v. morphine is generally poor. Children are less likely than adults to have a pain score documented, or receive i.v. morphine when presenting with appendicitis.