Comparison of tranexamic acid plasma concentrations when administered via intraosseous and intravenous routes

Introduction

There is a lack of information regarding intraosseous (IO) administration of tranexamic acid (TXA). Our hypothesis was that a single bolus IO injection of TXA will have a similar pharmacokinetic profile to TXA administered at the same dose IV.

Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest

Introduction

Guidelines endorse intravenous (IV) and intraosseous (IO) medication administration for cardiac arrest treatment. Limited clinical evidence supports this recommendation. A multiagency, retrospective study was performed to determine the association between parenteral access type and return of spontaneous circulation (ROSC) in out of hospital cardiac arrest.

Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins

Introduction

Current European Resuscitation Council (ERC) guidelines recommend intraosseous (IO) vascular access, if intravenous (IV) access is not readily available. Because central venous catheterisation (CVC) is an established alternative for in-hospital resuscitation, we compared IO access versus landmark-based CVC in adults with difficult peripheral veins.

Methods

In this prospective observational study we investigated success rates on first attempt and procedure times of IO access versus central venous catheterisation (CVC) in adults (≥18 years of age) with inaccessible peripheral veins under trauma or medical resuscitation in a level I trauma centre emergency department.

Results

Forty consecutive adults under resuscitation were analysed, each receiving IO access and CVC simultaneously. Success rates on first attempt were significantly higher for IO cannulation than CVC (85% versus 60%, p = 0.024) and procedure times were significantly lower for IO access compared to CVC (2.0 versus 8.0 min, p < 0.001). As for complications, failure of IO access was observed in 6 patients, while 2 or more attempts of CVC were necessary in 16 patients. No other relevant complications like infection, bleeding or pneumothorax were observed.

Conclusions

IO vascular access is a reliable bridging method to gain vascular access for in-hospital adult patients under resuscitation with difficult peripheral veins. Moreover, IO access is more efficacious with a higher success rate on first attempt and a lower procedure time compared to landmark-based CVC.     

Effect of protocol compliance to cardiac arrest identification by emergency medical dispatchers

OBJECTIVES: The objective of the study was to assess the effect of protocol compliance to the accuracy of cardiac arrest (CA) identification by the dispatchers. METHODS: The study was conducted prospectively over a 1-year period in 1996. The calls categorized as non-traumatic CAs by the dispatcher and calls where the patient was in non-traumatic CA when ambulance crew arrived were included in the study. The data was collected from emergency call tape recordings and ambulance run sheets. The compliance to the protocol was defined as gathering information to two questions: (1) Is the patient awake or can she/he be awakened? and (2) Is she/he breathing normally? RESULTS: The number of calls included in the study was 776 and the dispatchers identified 83% of the CAs. The protocol was adhered in 52.4% of calls, more often in witnessed than unwitnessed cases (72.3% versus 45.0%, P<0.001). In correctly identified CAs, the protocol compliance was 49.4%. The compliance was higher in cases of unidentified CAs (60.3%, P=0.0326) and in cases of wrongly identified as CAs (false positives, 61.9%, P=0.0276). CONCLUSIONS: A high identification rate of CAs seems to be achievable despite poor protocol compliance by dispatchers.     

院前急救医护人员锐器伤发生危险因素分析

目的：了解武汉市院前急救医护人员锐器伤发生现况,探讨影响锐器伤发生的危险因素,为制定有效的预防干预措施提供理论依据。方法：采用一般情况问卷、锐器伤情况调查表和锐器伤KAP问卷对武汉市123名院前急救医护人员进行调查及回顾性统计分析。结果：123名医护人员发生锐器伤者72名,锐器伤发生率为58．54％（72／123）,年发生率为112．20％（138／123）,发生密度为1．91（138／72）。单因素显示不同岗位、工作年限、文化程度、用工性质、睡眠质量、对锐器伤态度、防护行为以及是否使用安全留置针的医护人员锐器伤发生率差异均有统计学意义（P〈O．05）。Logistic回归分析显示未使用安全留置针、较低的防护行为、工作年限≤5年和医护人员为非在编人员是锐器伤发生的危险因素。结论：武汉市院前急救医护人员锐器伤发生率较高,医护人员自身和工作环境因素均可能预测锐器伤的发生,应加强锐器伤可预测因素的研究,采取综合干预措施,减少伤害发生。     

Early impact of medical emergency team implementation in a country with limited medical resources: a before-and-after study

Purpose

The purpose of the study was to determine whether earlier clinical intervention by a medical emergency team (MET) can improve patient outcomes in an Asian country.

Methods

A nonrandomized study was performed during two 6-month periods before and after the introduction of a MET.

Results

The rates of cardiac arrests and “potentially preventable” cardiac arrests were lower after MET introduction, but the differences did not reach statistical significance. There was a statistically significant decrease in the incidence of cardiac arrests in the first 3 months of the academic year (2.3 vs 1.2 per 1000 admissions, P = .012). Introduction of MET reduced the time interval from physiologic derangement meeting MET activation criteria to intensive care unit (ICU) admission (“derangement-to-ICU interval”) (10.8 vs 6.3 hours, P < .001). Multivariate analysis revealed that the mortality of unplanned ICU admissions was independently associated with simplified acute physiology score 3 and “derangement-to-ICU interval.”

Conclusions

Introduction of a MET reduced the number of cardiac arrests in the general ward during the first 3 months of the academic year. Introduction of MET also decreased the “derangement-to-ICU interval,” which was an independent predictor of survival in patients with unplanned ICU admissions. Therefore, MET introduction may lead to improved outcomes for hospitalized patients in a country with limited medical resources.     

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective,multicenter, and randomized study

BACKGROUND: It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients.     

Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting

BACKGROUND: Emergency response systems (ERS) are based on a set of triggers used to identify patients "at risk". This study aimed to establish the association between recordings of disturbed physiological variables and adverse events. METHODS: A cross-sectional survey of 3,046 non Do Not Attempt Resuscitation (non DNAR) adult admissions in five hospitals over 14 days. Medical records were reviewed for 26 early signs (ES) and 21 late signs (LS) of critical conditions and serious adverse events (SAE): death, cardiac arrest, severe respiratory problems, or transfer to a critical care area. The LS included published medical emergency team (MET) call criteria. FINDINGS: There were 12,384 ES and 1,410 LS. The 'top five' ES and the odds (OR) for death were: base deficit -5 to -8 mmol/L=40.2 (95% C.I. 7.7-208.8), partial airway obstruction OR=38.7 (3.9-64.4), poor peripheral circulation OR=34.4 (6.8-174.0), >expected drain fluid loss OR=30.1 (6.1-148.9), pH <7.3 >7.2 OR=29.0 (3.1-268.3). For LS: urine output <200 mL in 24 h OR=188.6 (95% C.I. 30.1-1179.8), pH <7.2 OR=116.1 (7.1-1906.1), unresponsive to voice OR=34.8 (10.7-113.0), anuric OR=29.0 (3.1-268.3), base deficit <-8.0 mmol/L OR=29.0 (3.1-268.3). OR for the other SAE were similar. Pulse oximetry abnormalities were associated with all SAE. The risk for death for ES: SpO2 90-95% OR=8.1 (3.0-21.3) and LS: SpO2 <90% OR=9.0 (4.2-19.4). INTERPRETATION: Both ES and LS were associated with adverse events. This study confirms the validity of current MET call criteria but points to the need to expand them. It provides a possible explanation for the failure to demonstrate efficacy of a MET in some trials because current call criteria maybe too late in the progress of the patient's critical condition. It allows the modelling of ERS and education programmes focused on signs of critical conditions. It potentially brings together ICU outreach and ward based responses. Broader use of clinical signs, monitoring such as pulse oximetry and objective data such as blood gas results may assist early intervention and help prevent loss of life.     

Cardiac arrest predictability in seizure patients based on emergency medical dispatcher identification of previous seizure or epilepsy history

OBJECTIVE: To determine predictability of at-scene cardiac arrest from a dispatch determined patient history of seizure or epilepsy ("E" history). DESIGN AND METHODS: A retrospective study of a 1 year dataset from the London Ambulance Service (LAS) National Health Service (NHS) Trust was undertaken. Each of the nine determinant codes on the Medical Priority Dispatch System (MPDS) seizure protocol [Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced Medical Priority Dispatch System affect cardiac arrest detection? Emerg Med J 2004;21:115-8.] was examined for the addition of the "E" suffix finding. The cardiac arrest predictability of cases with reported "E" history was compared to those without using a protocol process to detect the infrequent but predictable presence of seizures caused by anoxic cardiac arrest. RESULTS: Only protocol codes 12-A-1, 12-D-2, 12-D-3, and 12-D-4 demonstrated significant associations between outcomes and determinant codes (p=0.016, 0.007, <0.001, and 0.048, respectively). These codes showed reduced risk of predicting CA with the "E" suffix protocol determinant codes (RD (95% CI): -0.0025 (-0.0044, -0.0005), chi-square p=0.009; RD (95% CI): -0.0024 (-0.0042, -0.0005), p=0.005; RD (95% CI): -0.020 (-0.029, -0.011), p<0.001; RD (95% CI): -0.01 (-0.017, -0.005), and p=0.034, respectively). CONCLUSIONS: Knowing whether a seizure patient is an epileptic or has had previous seizures is of clinical value and relevant to dispatch. By improving the discernment of the seizure protocol regarding seizure associated with anoxic cardiac arrest predictability, this information may now be applied at the response level as well as to emergency medical dispatcher's (EMD) decisions to stay on the telephone to enhance the monitoring of these patients.     

The significance of pre-arrest factors in out-of-hospital cardiac arrests witnessed by emergency medical services: A report from the Victorian Ambulance Cardiac Arrest Registry

BackgroundThe significance of pre-arrest factors in out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical services (EMS) is not well established. The purpose of this study was to assess the association between prodromal symptoms and pre-arrest clinical observations on the arresting rhythm and survival in EMS witnessed OHCA.MethodsBetween 1st January 2003 and 31st December 2011, 1056 adult EMS witnessed arrests of a presumed cardiac aetiology were identified from the Victorian Ambulance Cardiac Arrest Registry. Pre-arrest prodromal features and clinical characteristics were extracted from the patient care record. Backward elimination logistic regression was used to identify pre-arrest factors associated with an initial shockable rhythm and survival to hospital discharge.ResultsThe median age was 73.0 years, 690 (65.3%) were male, and the rhythm of arrest was shockable in 465 (44.0%) cases. The most commonly reported prodromal symptoms prior to arrest were chest pain (48.8%), dyspnoea (41.8%) and altered consciousness (37.8%). An unrecordable systolic blood pressure was observed in 34.4%, a respiratory rate <13 or >24 min⁻¹ was present in 43.1%, and 45.5% had a Glasgow coma score <15. In the multivariable analysis, the following pre-arrest factors were significantly associated with survival: age, public location, aged care facility, chest pain, arm or shoulder pain, dyspnoea, dizziness, vomiting, ventricular tachycardia, pulse rate, systolic blood pressure, respiratory rate, Glasgow coma score, aspirin and inotrope administration.ConclusionPre-arrest factors are strongly associated with the arresting rhythm and survival following EMS witnessed OHCA. Potential opportunities to improve outcomes exist by way of early recognition and management of patients at risk of OHCA.     

Outcomes of sudden cardiac arrest treated with defibrillation by emergency medical technicians (emt-ds) or paramedics in a two-tiered urban ems system

Objective. Controversy exists as to the effectiveness of de-fibrillation by emergency medical technicians (EMT-Ds) in reducing mortality from cardiac arrest in two-tiered EMS systems. This study was performed to assess the impact of EMT-Ds on outcome of sudden cardiac death in a small, urban, modified two-tiered EMS system. Methods. This was a retrospective, unmatched case-control study comparing the outcomes of patients suffering sudden cardiac death treated by EMT-Ds with paramedic (EMT-P) backup with the outcomes of patients treated by EMT-Ps as first responders. Outcomes were defined as survival to the following endpoints: hospital admission, hospital discharge, and discharge with normal neurologic function (neurologic survival). Differences between groups were considered significant if p ≤ 0.05 by Fisher's exact test or t-test. Results. Three hundred twenty-two patients suffered out-of hospital sudden cardiac deaths over a three-year period and met study inclusion criteria. There were no significant differences in mean age, sex distribution, or incidence of ventricular fibrillation as the presenting rhythm between the groups. Rates of survival to admission, survival to discharge, and neurologic survival were 25.8%, 8.1%, and 5.6%, respectively. Corresponding survival rates for 46 patients treated first by EMT-Ds were 19.6%, 8.7%, and 4.3%. For 276 patients treated by EMT-Ps as first responders, the rates were 26.8%, 8.0%, and 5.8%. There were no significant differences in survival rates between the two response modes, despite a significantly shorter response interval for EMT-Ds (3.6 ± 1.8 min, vs 4.6 ± 2.0 min for EMT-Ps). There were likewise no significant differences in survival rates between the two response modes when only patients in ventricular fibrillation or ventricular tachycardia were considered. There were no significant differences in survival rates grouped by presenting rhythm, with the exception of 9.6% neurologic survival in witnessed ventricular fibrillation as compared with 0% in asystole. Conclusion. EMT defibrillation had no impact on outcome of sudden cardiac death in this small, urban, two-tiered EMS system. Survival rates were similar to those reported for other such systems. However, power to detect significant differences was low, and further study is indicated. Controlled multicenter trials are recommended.     

The impact of medical emergency teams on ICU admission rates, cardiopulmonary arrests and mortality in a regional hospital

Context

In-hospital cardiac arrests are commonly associated with poor outcomes and preceded by observable signs of clinical deterioration. Medical emergency teams (METs) have emerged to provide early specialist care intervention to critically ill patients.

Objective

To determine the effect of MET implementation on hospital-wide mortality rates, cardiopulmonary arrests and admissions to the intensive care unit (ICU) in a regional Queensland hospital.

Method

A prospective cohort before and after interventional trial was conducted on adult and paediatric inpatients admitted in 2004-2008 at a 150 bed regional teaching hospital in Australia. MET was introduced in 2006 and attended clinically unstable patients. Response was activated by the bedside nurse or doctor according to predefined criteria.

Results

There were a total of 296 MET activations. After MET implementation, mean hospital-wide mortality rates decreased from 9.9 to 7.5 per 1000 admissions (relative risk reduction, RRR: 24.2%; p = 0.003). Similarly, ICU admissions decreased from 22.4 to 17.6 per 1000 admissions (RRR: 21.4%; p < 0.0001). There was also a significant decline in hospital-wide cardiopulmonary arrests post intervention (77 versus 42, RRR: 45.5%; p = 0.0025) however this may be explained by the increase in the number of patients deemed not for resuscitation by the MET. Secondary analysis revealed evidence of MET underuse that may have affected the mortality findings.

Conclusion

Implementation of the MET in a regional hospital was associated with statistically significant reductions in hospital-wide mortality rates, ICU admissions and cardiopulmonary arrests.     

Survival and health care costs until hospital discharge of patients treated with onsite, dispatched or without automated external defibrillator

Background

This study aimed to determine whether automated external defibrillator (AED) use during resuscitation is associated with lower in-hospital health care costs.

Methods

For this observational prospective study, we included all treated out-of-hospital cardiac arrests of suspected cardiac cause. Clinical, survival and cost data were collected from July 2005 until March 2008. Cost data were based on hospital transport, duration of admission in hospital wards, diagnostics and interventions. We divided the study population in three groups based on AED use: (1) onsite AED, (2) dispatched AED, (3) no AED. The endpoint was survival to discharge. P < 0.05 is indicated by *.

Results

Of the 2126 included patients, 136 were treated with an onsite AED, 365 with a dispatched AED and 1625 without AED. Overall (95% confidence interval [CI]) survival rate was 43% (35-51%), 16% (13-20%) and 14% (12-16%), respectively*. Per 100 survivors, the mean duration admitted at intensive care unit [ICU] were 267 (166-374), 495 (344-658), and 537 (450-609) days, respectively*; total duration of hospital admission was 2188 (1800-2594), 3132 (2573-3797), and 2765 (2519-3050) days, respectively*. Mean costs per survivor for hospital stay were €9233 (€7351-€11,280), €14,194 (€11,656-€17,254), and €13,693 (€12,226-€15,166), respectively*; total health care costs were €29,575 (€24,695-€34,183), €34,533 (€29,832-€39,487) and €31,772 (€29,217-€34,385), respectively. For both survivors and non-survivors, total costs per patient were €14,727 (€11,957-€18,324), €7703 (€6141-€9366) and €6580 (€5875-€7238), respectively*.

Conclusions

Onsite AED use was associated with higher survival rates. Surviving patients of the onsite AED group had lower total costs, mainly due to the shorter ICU stay.     

Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome

BackgroundThe presence of physicians is believed to facilitate optimal management of out-of-hospital cardiac arrest, but has not been sufficiently documented.MethodsAdult non-traumatic cardiac arrests treated by Oslo EMS between May 2003 and April 2008 were prospectively registered. Patients were categorized according to being treated by the physician-manned ambulance (PMA) or by regular paramedic-manned ambulances (non-PMA). Patient records and continuous electrocardiograms (ECGs) with impedance signals were reviewed. Quality of cardiopulmonary resuscitation (CPR) and clinical outcomes were compared.ResultsResuscitation was attempted in 1128 cardiac arrests, of which 151 treated by non-PMA and PMA together were excluded from comparative analysis. Of the remaining 977 patients, 232 (24%) and 741 (76%) were treated by PMA and non-PMA, respectively. The PMA group was more likely to have bystander witnessed arrests and initial VF/VT, and received better CPR quality with shorter hands-off intervals and pre-shock pauses, and having a greater proportion of patients being intubated. Despite uneven distribution of positive prognostic factors and better CPR quality, short-term and long-term survival were not different for patients treated by the PMA vs. non-PMA, with 34% vs. 33% (p = 0.74) achieving return of spontaneous circulation (ROSC), 28% vs. 25% (p = 0.50) being admitted to ICU and 13% vs. 11% (p = 0.28) being discharged from hospital, respectively.ConclusionsSurvival after out-of-hospital cardiac arrest was not different for patients treated by the PMA and non-PMA in our EMS system.