One hundred ECMO retrivals before and during the Covid-19 pandemic: an observational study

ObjectivesPatients with severe acute respiratory distress syndrome may require veno-venous extracorporeal membrane oxygenation (V-V ECMO) support. For patients in peripheral hospitals, retrieval by mobile ECMO teams and transport to high-volume centers is associated with improved outcomes, including the recent COVID-19 pandemic. To enable a safe transport of patients, a specialised ECMO-retrieval program needs to be implemented. However, there is insufficient evidence on how to safely and efficiently perform ECMO retrievals. We report single-centre data from out-of-centre initiations of VV-ECMO before and during the COVID-19 pandemic.Design & settingSingle-centre retrospective study. We include all the retrievals performed by our ECMO centre between January 1st, 2014, and April 30th, 2021.ResultsOne hundred ECMO missions were performed in the study period, for a median retrieval volume of 13 (IQR: 9–16) missions per year. the cause of the acute respiratory distress syndrome was COVID-19 in 10 patients (10 %). 98 (98 %) patients were retrieved and transported to our ECMO centre. To allow safe transport, 91 of them were cannulated on-site and transported on V-V ECMO. The remaining seven patients were centralised without ECMO, but they were all connected to V-V ECMO in the first 24 hours. No complications occurred during patient transport. The median duration of the ECMO mission was 7 hours (IQR: 6–9, range: 2 – 17). Median duration of ECMO support was 14 days (IQR: 9–24), whereas the ICU stay was 24 days (IQR:18–44). Overall, 73 patients were alive at hospital discharge (74 %). Survival rate was similar in non-COVID-19 and COVID-19 group (73 % vs 80 %, p = 0.549).ConclusionIn this single-centre experience, before and during COVID-19 era, retrieval and ground transportation of ECMO patients was feasible and was not associated with complications. Key factors of an ECMO retrieval program include a careful selection of the transport ambulance, training of a dedicated ECMO mobile team and preparation of specific checklists and standard operating procedures.     

Massive paracetamol overdose: an observational study of the effect of activated charcoal and increased acetylcysteine dose (ATOM-2)

Context: Paracetamol is commonly taken in overdose, with increasing concerns that those taking “massive” overdoses have higher rates of hepatotoxicity and may require higher doses of acetylcysteine. The objective was to describe the clinical characteristics and outcomes of “massive” (≥?40?g) paracetamol overdoses.

Methods: Patients were identified through the Australian Paracetamol Project, a prospective observational study through Poisons Information Centres in NSW and Queensland, over 3 and 1.5 years, respectively, and retrospectively from three clinical toxicology unit databases (over 2.5 to 20 years). Included were immediate-release paracetamol overdoses ≥?40?g ingested over ≤?8?h. Outcomes measured included paracetamol ratio[defined as the ratio of the first paracetamol concentration taken 4–16?h post-ingestion to the standard (150?mg/L at 4?h) nomogram line at that time] and hepatotoxicity (ALT >1000?U/L).

Results: Two hundred paracetamol overdoses were analysed, reported median dose ingested was 50?g (interquartile range (IQR): 45–60?g) and median paracetamol ratio 1.9 (IQR: 1.4–2.9, n?=?173). One hundred and ninety-three received acetylcysteine at median time of 6.3?h (IQR: 4–9.3?h) post-ingestion. Twenty-eight (14%) developed hepatotoxicity, including six treated within 8?h of ingestion. Activated charcoal was administered to 49(25%), at median of 2?h post-ingestion (IQR:1.5-5?h). Those receiving activated charcoal (within 4?h of ingestion), had significantly lower paracetamol ratio versus those who did not: 1.4 (n?=?33, IQR: 1.1–1.6) versus 2.2 (n?=?140, IQR: 1.5–3.0) (p?Seventy-nine had a paracetamol ratio ≥2, 43 received an increased dose of acetylcysteine in the first 21?h; most commonly a double dose in the last bag (100 to 200?mg/kg/16?h). Those receiving increased acetylcysteine had a significant decrease risk of hepatotoxicity [OR:0.27 (95% CI: 0.08–0.94)]. The OR remained similar after adjustment for time to acetylcysteine and paracetamol ratio.

Conclusion: Massive paracetamol overdose can result in hepatotoxicity despite early treatment. Paracetamol concentrations were markedly reduced in those receiving activated charcoal within 4?h. In those with high paracetamol concentrations, treatment with increased acetylcysteine dose within 21?h was associated with a significant reduction in hepatotoxicity.     

What can clinicians learn from therapeutic studies about the treatment of acute oral methotrexate poisoning?

Context: Methotrexate (MTX) is an anti-folate drug that has been utilized in both malignant and chronic inflammatory conditions. Doctors are often concerned with a potential adverse outcome when managing patients with acute oral MTX poisoning given its potential for serious adverse reactions at therapeutic doses. However, there is surprisingly little data from acute poisoning cases and more data from the therapeutic use of high-dose MTX.

Objectives: To review pharmacokinetic and pharmacological properties of MTX and systematically review series of acute MTX poisonings and therapeutic studies on high-dose MTX that provide pharmacokinetic or clinical data.

Methods: An Embase (1974–October 2016) and Medline (1946–October 2016) search was performed by combining “MTX” and “overdose/poison” or “MTX” and “toxicity” or “MTX” and “high-dose MTX” or “MTX” and “bioavailability” or “pharmacokinetics”; 25, 135, 109 and 365 articles were found, respectively, after duplicates were removed. There were 15 papers that provided clinical data on acute ingestion and toxicity that occurred with low-dose administration. Eighteen papers were on high-dose MTX (>1?g per m² body surface area) used as a single chemotherapy agent which provided pharmacokinetic or clinical data on MTX toxicity. Thirty papers were reviewed to determine the toxic dose, pharmacokinetics, risk factors, clinical symptoms and management of acute MTX toxicity. Given the limited acute poisoning data, a retrospective audit was performed through the consultant records of the New South Wales Poisons Information Centre from April 2004 to July 2015 to examine the clinical syndrome and toxicity of acute oral MTX poisoning.

Pharmacokinetics: Reduced MTX bioavailability is a result of saturable absorption. Although maximal bioavailable absorption occurs at a dose of ～15?mg?m^?2, splitting the dose increases bioavailability. MTX clearance is proportional to renal function.

Acute toxicity: Oncologists prescribe doses up to 12?g?m^?2 of MTX. Patients treated with an intravenous dose of MTX?<1g?m^?2 do not require folinic acid rescue. MTX toxicity correlates better with duration and extent of exposure than peak serum concentration.

Acute oral poisoning: Acute oral MTX poisoning in 177 patients did not report any severe toxicity. In the New South Wales Poisons Information Centre audit data (2004–2015), 51 cases of acute MTX poisoning were reported, of which 15 were accidental paediatric ingestions. The median reported paediatric ingestion was 50?mg (IQR: 10–100; range: 10–150) with a median age of 2 years (IQR: 2–2; range: 1–4). Of the 36 patients with acute deliberate MTX poisoning, median age and dose were 47 years (IQR: 31–62; range: 10–85) and 325?mg (IQR: 85–500; range: 40–1000), respectively. Of the 19 patients who had serum MTX concentrations measured, all were significantly below the concentrations used in oncology and the folinic acid rescue nomogram line and no patient reported adverse sequelae.

Management of acute oral poisoning: Due to the low bioavailability of MTX, treatment is not necessary for single ingestions. Oral folinic acid may be used to lower the bioavailability further with large ingestions?>1?g?m^?2. Oral followed by intravenous folinic acid may be used in patients with staggered ingestion?>36?h or patients with acute overdose and renal impairment (eGFR <45?mL/min/1.73?m²).

Conclusions: As a consequence of saturable absorption MTXs bioavailability is so low that neither accidental paediatric MTX ingestion nor acute deliberate MTX overdose causes toxicity. An acute oral overdose will not provide a bioavailable dose even close to 1?g?m^?2 of parenteral MTX. Hence, no treatment is required in acute ingestion unless the patient has renal failure or staggered ingestion. There is also no need to monitor MTX concentrations in acute oral MTX poisoning.     

Extracorporeal membrane oxygenation for severe influenza A (H1N1) acute respiratory distress syndrome: a prospective observational comparative study

Purpose

To compare characteristics, clinical evolution and outcome in adult patients with influenza A (H1N1) acute respiratory distress syndrome (ARDS) treated with or without extracorporeal membrane oxygenation (ECMO).

Methods

A prospective observational study of patients treated in Marseille South Hospital from October 2009 to January 2010 for confirmed influenza A (H1N1)-related ARDS. Clinical features, pulmonary dysfunction and mortality were compared between patients treated with and without ECMO.

Results

Of 18 patients admitted, 6 were treated with veno-venous and 3 with veno-arterial ECMO after median (interquartile, IQR) duration of mechanical ventilation of 10 (6–96) h. Six ECMO were initiated in a referral hospital by a mobile team, a median (IQR) of 3 (2–4) h after phone contact. Before ECMO, patients had severe respiratory failure with median (IQR) PaO₂ to FiO₂ ratio of 52 (50–60) mmHg and PaCO₂ of 85 (69–91) mmHg. Patients treated with or without ECMO had the same hospital mortality rate (56%, 5/9). Duration of ECMO therapy was 9 (4–14) days in survivors and 5 (2–25) days in non-survivors. Early improvement of PaO₂ to FiO₂ ratio was greater in ECMO survivors than non-survivors after ECMO initiation [295 (151–439) versus 131 (106–144) mmHg, p < 0.05]. Haemorrhagic complications occurred in four patients under ECMO, but none required surgical treatment.

Conclusions

ECMO may be an effective salvage treatment for patients with influenza A (H1N1)-related ARDS presenting rapid refractory respiratory failure, particularly when provided by a mobile team allowing early cannulation prior to transfer to a reference centre.     

Factors Influencing the Timeliness of Emergency Medical Service Response to Time Critical Emergencies

Objective: While emergency medical service (EMS) response times (ERT) remain a leading measure of system performance in many developed countries, relatively few studies have explored the factors associated with meeting benchmark performance for potentially time critical incidents. The purpose of this study was to identify system-level and patient-level factors associated with ERT, which are readily available at the time of ambulance dispatch. Methods: Between July 2009 and June 2014, we included data from 1,000,458 EMS responses to time critical “lights and sirens” incidents in Melbourne, Australia. The primary outcome measure was ERT, defined as the time from emergency call to the arrival of the first EMS team on scene. Quantile regression models were used to identify system-level and patient-level factors associated with 10-percentile intervals of ERT. Results: The median ERT was 10.6 minutes (IQR: 8.1–14.0), increasing from 9.6 minutes (IQR: 7.6–12.5) in 2009/10 to 11.0 minutes (IQR: 8.4–14.7) in 2013/14 (p < 0.001). System-level factors independently associated with the 90th percentile ERT were distance to scene, activation time, turnout time, case upgrade, hour of day, day of week, workload in the previous hour, ambulance skill set, priority zero case (e.g., suspected cardiac or respiratory arrest), and average hospital delay time in the previous hour. Patient-level factors such as age, gender, chief medical complaint, and severity of complaint were also significantly associated with ERT. Conclusions: System-level and patient-level factors available at the time of ambulance dispatch are useful predictors of ERT performance, which could be used to improve the timeliness of EMS response.     

Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock

AimWe analyzed the results of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) necessitating extracorporeal membrane oxygenation (ECMO), and investigated for the associated risk factors for poor clinical outcomes.MethodsWe retrospectively reviewed the medical records of 27 patients who required ECMO for AMI associated with CS between April 2006 and July 2010. Mean age was 63.7 ± 11.0 (range: 45–81) years, and there were 16 males (59.3%).ResultsThe mean duration of ECMO support was 30.2 ± 30.1 (range: 1–141) h. Cardiopulmonary resuscitations (CPR) were performed in 21 patients (77.8%) before ECMO initiation. Twenty-two patients (81.5%) were successfully weaned off ECMO, and 16 patients (59.3%) survived to discharge. The 30-day mortality was 37.0% (10/27 patients). Complications developed in 17 patients (63.0%: pneumonia in 10 patients, acute renal failure in 10 patients, massive bleeding in 4 patients, and thromboembolic event in 1 patient). The period between CPR initiation and ECMO commencement was a significant risk factor for ECMO weaning failure. High pre-ECMO serum lactate level was identified as a significant risk factor for poor survival on univariated and multivariated analysis.ConclusionECMO support could improve survival in patients who suffer AMI associated with CS, and early ECMO initiation yields better outcomes (successful ECMO weaning).     

Adult clonidine overdose: prolonged bradycardia and central nervous system depression,but not severe toxicity

Context: There are limited reports of adult clonidine overdose. We aimed to describe the clinical effects and treatment of clonidine overdose in adults.

Methods: This was a retrospective review of a prospective cohort of poisoned patients who took clonidine overdoses (>200?μg). Demographic information, clinical effects, treatment, complications (central nervous system and cardiovascular effects) and length of stay (LOS) were extracted from a clinical database or medical records.

Results: From 133 admissions for clonidine poisoning (1988–2015), no medical record was available in 14 and 11 took staggered ingestions. Of 108 acute clonidine overdoses (median age 27 years; 14–65 years; 68 females), 40 were clonidine alone ingestions and 68 were clonidine with co-ingestants. Median dose taken was 2100?μg (interquartile range [IQR]: 400–15,000?μg). Median LOS was 21h (IQR: 14–35?h) and there were no deaths. Glasgow coma score [GCS] <15 occurred in 73/108 (68%), and more patients taking co-ingestants (8/68; 12%) had coma (GCS <9) compared to clonidine alone (2/40; 5%). Miosis occurred in 31/108 (29%) cases. Median minimum HR was 48?bpm (IQR: 40–57?bpm), similar between clonidine alone and co-ingestant overdoses. There was a significant association between dose and minimum HR for clonidine alone overdoses (p?=?0.02). 82/108 (76%) had bradycardia, median onset 2.5?h post-ingestion (IQR: 1.7–5.5?h) and median duration 20?h (2.5–83?h), similar for clonidine alone and co-ingestant overdoses. There were no arrhythmias. Three patients ingesting 8000–12,000?μg developed early hypertension. Median minimum systolic BP was 96?mmHg (IQR: 90–105?mmHg) and hypotension occurred in 26/108 (24%). 12/108 patients were intubated, but only 2 were clonidine alone cases. Treatments included activated charcoal (24), atropine (8) and naloxone (23). The median total naloxone dose was 2?mg (IQR: 1.2–2.4?mg), but only one patient given naloxone was documented to respond with partial improvement in GCS.

Discussion: Clonidine causes persistent but not life-threatening clinical effects. Most patients develop mild central nervous system depression and bradycardia. Naloxone was not associated with improved outcomes.     

Extracorporeal CPR for massive pulmonary embolism in a “hybrid 2136 emergency department”

AimPatients with massive pulmonary embolism (PE) have poor outcomes and their management remains challenging. An interventional radiology (IVR)-computed tomography (CT) system available in our emergency room (ER) allows immediate access to CT and extracorporeal membrane oxygenation (ECMO) with safe cannulation under fluoroscopy. We aimed to determine if initial treatment in this “hybrid ER” is helpful in patients with PE requiring extracorporeal cardiopulmonary resuscitation (ECPR).MethodsThe records of patients transferred to our hybrid ER between September 2014 and December 2017 who required ECPR for PE were reviewed.ResultsNine consecutive patients (median age 50 [range 30–76] years) with PE requiring ECPR were identified in our hybrid ER. Five (55.6%) had at least one risk factor for PE. Six (66.7%) experienced an out-of-hospital cardiac arrest and 3 (33.3%) had a cardiac arrest in the hybrid ER. Right ventricular overload was detected on electrocardiography and bedside transthoracic echocardiography in all cases. The median pH, lactate, PaCO₂, and HCO₃ values on arterial blood gas analysis in the hybrid ER were 7.01 (6.68–7.26), 14 (8–22) mmol l⁻¹, 44.7 (23.8–60.5) mmHg, and 10.4 (6.7–14.1), respectively. Four patients (44.4%) received monteplase for thrombolysis. No patient underwent surgical embolectomy. The median duration of ECMO was 69 (38–126) h. There were two ECMO-related bleeding complications. Eight patients (88.9%) survived and one died of post-resuscitation encephalopathy after weaning from ECMO.ConclusionA hybrid ER may be useful for initial management of massive PE requiring ECPR and may help to improve outcomes.     

Do-not-attempt resuscitation independently predict in-hospital mortality in septic patients

IntroductionSepsis patients require timely and appropriate treatment in an intensive care setting. However, “do-not-attempt resuscitation” (DNAR) status may affect physicians' priorities and treatment preferences. The aim of this study was to evaluate whether DNAR status affects the outcomes of septic patients.MethodsThis was a retrospective cohort study included septic patients admitted to the emergency department intensive care unit (ED-ICU) in a university-based teaching hospital during April–November 2015. Septic patients admitted to the ED-ICU were included.ResultsOf the 132 eligible patients, 49.2% (65/132) had DNAR status (median age 80 years old, IQR, 73–86). The overall in-hospital mortality rate was 28.8% (38/132). Non-survivors had a higher percentage of receiving inotropes/vasopressors (52.6% vs 34.0%, p = 0.048), higher median Charlson comorbidity index scores [8.5 (IQR, 7–11.75) vs 8 (IQR, 6–9), p = 0.012], higher APACHE II score [25 (IQR, 20–30.25) vs 20 (IQR, 17–25), p = 0.002], and higher SOFA score [7 (IQR, 6–11) vs 6 (IQR,4–8), p = 0.012]. There was no significant difference in intubation among the two groups. In a multivariate logistic regression analysis, DNAR status was an independent predictor of in-hospital mortality (odds ratio = 6.22, 95% confidence interval (CI) = (2.71–17.88), p < 0.001). The area under the ROC curve for the logistic regression model was 0.84 [95% CI = (0.77–0.92), p < 0.001]. In subgroup analysis, DNAR status remained an independent predictor of mortality among age ≥65 years and ≥80 years.ConclusionAfter adjusting for comorbidities, treatments, and illness severity, DNAR status was associated with in-hospital mortality of septic patients. Further studies should evaluate physicians' attitudes toward septic patients with DNAR status.     

“Rolling Refreshers”: A novel approach to maintain CPR psychomotor skill competence

ObjectivesHigh quality CPR skill retention is poor. We hypothesized that “just-in-time” and “just-in-place” training programs would be effective and well-accepted to maintain CPR skills among PICU staff.Methods“Rolling Refreshers”, a portable manikin/defibrillator system with chest compression sensor providing automated corrective feedback to optimize CPR skills, were conducted daily in the PICU with multidisciplinary healthcare providers. Providers practiced CPR until skill success was attained, prospectively defined as <3 corrective prompts within 30 s targeting chest compression (CC) rate 90–120/min, CC depth >38 mm during continuous CPR. Providers completing ≥2 refreshers/month (Frequent Refreshers [FR]) were compared to providers completing <2 refreshers/month (Infrequent Refreshers [IR]) for time to achieve CPR skill success. Univariate analysis performed using non-parametric methods. Following actual cardiac arrests, CPR providers were surveyed for subjective feedback on training approach efficacy (5-point Likert scale; 1 = poor to 5 = excellent).ResultsOver 15 weeks, 420 PICU staff were “refreshed”: 340 nurses, 34 physicians, 46 respiratory therapists. A consecutive sample of 20 PICU staff was assessed before subsequent refresher sessions (FREQ n = 10, INFREQ n = 10). Time to achieve CPR skill success was significantly less in FREQ (median 21 s, IQR: 15.75–30 s) than in INFREQ (median 67 s, IQR: 41.5–84 s; p < 0.001). Following actual resuscitations, CPR providers (n = 9) rated “Rolling Refresher” training as effective (mean = 4.2; Likert scale 1–5; standard deviation 0.67).ConclusionsA novel “Rolling Refresher” CPR skill training approach using “just-in-time” and “just-in-place” simulation is effective and well received by PICU staff. More frequent refreshers resulted in significantly shorter times to achieve proficient CPR skills.     

Use of ISTH bleeding assessment tool to predict inherited platelet dysfunction in resource constrained settings

Background: The International Society of Thrombosis &; Hemostasis (ISTH) bleeding assessment tool (ISTH-BAT) is used to record bleeding symptoms in patients with possible bleeding disorders.

Aim: To investigate the utility of the ISTH-BAT in predicting platelet dysfunction in individuals with suspected inherited platelet function disorders.

Method: Individuals with clinical evidence of bleeding and suspected inherited platelet function disorder and healthy volunteers were included in the study. The ISTH-BAT questionnaire was applied prior to light transmission aggregometry (LTA).

Results: A total of 261 participants were included (100 healthy volunteers, and 161 with suspected inherited platelet function disorders). The ISTH-BAT score in participants with suspected inherited platelet function disorders (median 2; interquartile range [IQR] 5–1) was significantly higher than in healthy volunteers (median 0; IQR 2–0). There was also a significant difference between participants with suspected inherited platelet function disorders with a platelet defect detected by LTA (median 4; IQR 8–3) and those with normal platelet function (median 2; IQR 3–1) (p?p?=?p?=?< 0.001]).

Conclusion: The ISTH-BAT is a useful tool for documenting bleeding symptoms and the score obtained is also predictive of the presence of a platelet defect on LTA in patients with suspected inherited platelet dysfunction.     

Self-reported cocaine use is not associated with elevations in high-sensitivity troponin I

Objective: High-sensitivity troponin (hsTn) assays detect 10 times lower concentrations of cardiac troponin than conventional assays. We examined the effects of self-reported cocaine use to determine whether those with acute cocaine use being evaluated for ACS are more likely to have elevated hsTnI than those nonusers being evaluated for ACS.

Methods: We conducted a sub-analysis of a prospective cohort of ED patients evaluated for acute coronary syndrome. Recent cocaine use was determined by structured patient interviews. High-sensitivity troponin (Abbott) and conventional troponin I (Abbott, cTnI) were measured on samples drawn at presentation. Urine toxicology screen for cocaine metabolite was obtained at the discretion of treating clinicians.

Results: Of 1862 patients enrolled, 444 reported prior cocaine use and 99 reported cocaine use within the preceding month. Median hsTn in patients with last cocaine use within 24?h, 2–7 days, 1 week–1 month, >1 month, and no prior cocaine use were: 9 (IQR: 3–17) ng/L, 6 (IQR: 3–24.3) ng/L, 6 (IQR: 3–89.5) ng/L, 3 (IQR: 3–18.5) ng/L and 3 (IQR: 3–17) ng/L, respectively. Urine toxicology assays (UTox) for cocaine were performed in 640 (34.4%) patients. The median hsTn for those who were UTox+, UTox???and those without a UTox were: 9?ng/L (IQR: 3–48.5), 9?ng/L (IQR: 3–40) and 3?ng/L (IQR: 3–12), respectively. There were no differences in the prevalence of new troponin elevations (hsTn >99th percentile but cTnI <99th percentile) in those with recent cocaine use compared to those without recent cocaine use.

Conclusions: In this first investigation of hsTn in patients with self-reported recent cocaine use, we have determined that hsTn does not lead to an increase in the prevalence of troponin elevation in cocaine users.     

Characteristics and outcomes of patients treated with airway pressure release ventilation for acute respiratory distress syndrome: A retrospective observational study

BackgroundThe optimal mode of ventilation in acute respiratory distress syndrome (ARDS) remains uncertain. Airway pressure release ventilation (APRV) is a recognized treatment for mechanically-ventilated patients with severe hypoxaemia. However, contemporary data on its role as a rescue modality in ARDS is lacking. The goal of this study was to describe the clinical and physiological effects of APRV in patients with established ARDS.MethodsThis retrospective observational study was performed in a 23-bed adult intensive care unit in a tertiary extracorporeal membrane oxygenation (ECMO) referral centre. Patients with ARDS based on Berlin criteria were included through a prospectively-collected APRV database. Patients receiving APRV for less than six hours were excluded.ResultsFifty patients fulfilled the eligibility criteria. Prior to APRV initiation, median Murray Lung Injury Score was 3.5 (interquartile range (IQR) 2.5–3.9) and PaO₂/FiO₂ was 99 mmHg (IQR 73–137). PaO₂/FiO₂ significantly improved within twenty-four hours post-APRV initiation (ANOVA F(1, 27) = 24.34, P < .005). Two patients (4%) required intercostal catheter insertion for barotrauma. Only one patient (2%) required ECMO after APRV initiation, despite a majority (68%) fulfilling previously established criteria for ECMO at baseline. Hospital mortality rate was 38%.ConclusionsIn patients with ARDS-related refractory hypoxaemia treated with APRV, an early and sustained improvement in oxygenation, low incidence of clinically significant barotrauma and progression to ECMO was observed. The safety and efficacy of APRV requires further consideration.     

Bispectral Index Monitoring in Helicopter Emergency Medical Services Patients

Background. Many critically ill patients are given sedatives andparalytics to facilitate aeromedical transport. Bispectral index (BIS) monitoring is a computer-derived electroencephalography (EEG) analog currently used to monitor the level of awareness of sedated patients. It gives a score of 1–100, with 1 representing no brain function and100 representing a completely alert patient. Objective. To evaluate whether critically ill patients are adequately sedated during aeromedical transport. Methods. This was a prospective, observational study of a convenience sample of critically ill patients transported by helicopter. All intubated patients who received sedatives and/or paralytics to facilitate transport were eligible for enrollment by the attending clinician. Prior to liftoff, a BIS sensor was applied to the patient's forehead. Minimum, maximum, andmean BIS index scores were recorded every minute during transport. Results. Forty-seven patients (57% male) were enrolled, with a median age of 60 years (interquartile range [IQR] 18–81, range 14 to 86 years). The median duration of monitoring was 15.0– minutes (IQR 6.0–26.0, range 2 to 33). The median BIS score was 54.6 (IQR 38.6–67.3, range 28 to 89.5). Only two patients (4.3%, 95% confidence interval [CI] 0.5% to 14.8%) had at least one BIS score greater than 85, the accepted threshold for recall. Conclusion. These results suggest that patients are adequately sedated during air medical transport.     

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19

IntroductionLonger prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients.MethodsThis retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes.ResultsThere were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01].ConclusionThe median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.     

Development of the Video Assessment of Propensity to Use Emergency Restraints Scale (VAPERS): Results of the VAPERS Study Group

Background: Emergency physicians (EPs) may disagree on when or whether patients need restraints. There is no good objective measure of the likelihood of EPs to restrain patients. Objectives: To 1) develop a scale to determine the likelihood that an EP would restrain a patient, 2) develop subscale scoring, and 3) determine a shortened version that correlates highly with the full scale. Methods: This was a prospective cross sectional study. The Video Assessment of Propensity to use Emergency Restraints Scale (VAPERS), consisting of 17 scenarios utilizing actors, was videotaped to produce a research video assessment tool. The VAPERS was designed by development experts to reflect the spectrum of patients who are considered for restraint in an emergency department. The VAPERS was piloted among a 22‐member pilot panel of EPs (faculty and residents). The pilot panel was asked to determine the degree to which each video patient possessed the following patient characteristics: medical instability, trauma, belligerence, agitation, and altered mental status. Each “degree of characteristic” was measured on a separate 100‐mm visual analog scale. Participants were then asked whether or not they would restrain each patient and whether the patient exhibited the potential to harm him‐ or herself or others. VAPERS subscales were developed for the likelihood to restrain patients with each of the patient characteristics. Spearman correlations were used for all comparisons. Linear regression was used to determine which patient characteristics were most related to likelihood to restrain and to develop a reduced scale to predict the overall likelihood to restrain. Results: The overall VAPERS score ranged from 0 to 100, with a median of 50 (interquartile range [IQR], 24–88). The visual analog scale results of how likely each video patient possessed specific characteristics were as follows: medical instability ranged from 0 to 100 (median, 32; IQR, 12–64), trauma ranged from 0 to 69 (median, 0; IQR, 0–31), belligerence ranged from 20 to 93 (median, 28; IQR, 14–63), agitation ranged from 3 to 84 (median, 52; IQR, 23–72), and altered mental status ranged from 1 to 93 (median, 29; IQR, 16–69). Linear regression indicated that two characteristic variables (danger to self and degree of agitation) in the video scenarios were highly correlated (0.87) with overall likelihood to restrain. Based on the results, the authors developed a shortened video assessment tool consisting of five of the original videos that were highly correlated (R= 0.94) with the full VAPERS scale on overall likelihood to restrain. Conclusions: The VAPERS scale covers a wide range of important variables in emergency situations. It successfully measured likelihood to restrain in this pilot study for overall situations, and for subgroups, based on patient characteristics. A shortened five‐video VAPERS also successfully measured the overall likelihood to restrain.     

Air Transport of Patients with Unstable Aortic Aneurysms Directly into Operating Rooms

Objective. The purpose of this study was to describe an air transport service's protocol for direct transport of patients with abdominal aortic aneurysm leak (AAAL) into receiving hospital operating rooms (ORs). Methods. This retrospective consecutive-case analysis examined AAAL patients undergoing nurse-paramedic Boston MedFlight (BMF) transport during 1999–2004, who were taken directly into ORs at four academic centers. BMF uses a rotating roster system to assign receiving hospitals when referring physicians have no preidentified receiving facility, but this practice may prolong patient transport or be associated with less diagnostic certainty, andthus more delay, at receiving hospitals. Thus, the study compared “Roster” versus “Non-roster” patients' time andoutcome end points. Continuous nonparametric data (e.g., time intervals) were described with median andinterquartile range (IQR). Chi-square andKruskal-Wallis tests were used for univariate comparisons; regression analysis assessed dependent variables while adjusting for covariates (e.g., transport mileage). Results. There were 29 direct-to-OR transports, with median distance of 30 miles. All patients had AAAL diagnosis confirmed; 51.7% survived. System performance for end points was similar as assessed between Roster versus Non-roster patients. Conclusions. Interfacility direct-to-OR transport of AAAL patients is feasible. Use of a roster system allows for timely transport facilitation for patients needing specialized care; roster patients achieve similar end points as did patients who had already-identified receiving hospitals upon air medical transport request.