Flying squad response to out-of-hospital cardiac arrest--a decade of experience.

The Flying Squad (MEDIC I) based at the Royal Infirmary, Edinburgh, commenced operation in 1980. The MEDIC I response to out of hospital non-traumatic cardiac arrest over the past decade is reported. On-scene resuscitation was attempted in 384 patients. A total of 149 (39%) patients were successfully resuscitated and transferred to hospital. Thirty-six (9.4%) patients survived to discharge from hospital. Patients receiving basic life support prior to the arrival of MEDIC I and in ventricular fibrillation had a survival rate of 14.5% (25/174). During 1988-89, 21 patients were initially attended by ambulance crews equipped with semi-automatic external defibrillators and eight (38%) of these patients survived. The response of a hospital-based flying squad to support trained ambulance crews, especially when equipped with a defibrillator may provide an economically and operationally feasible alternative to training all first responders in the full range of paramedic skills.     

Prehospital cardiac care Cuban style

The Cuban national Integrated Medical Emergeny System or "Sistema Integrado de Urgencias Medicas" (SIUM) was formed in 1997. In 1998, the SIUM began an active out-of-hospital thrombolysis program using Heberkinasa, the only streptokinase obtained through recombinant DNA techniques, produced by the Cuban Center for Genetic Engineering and Biotechnology. An active community training program has also been implemented, standardizing training for the almost 20,000 members of the national emergency medical services.     

Budd-Chiari syndrome: long-term survival and factors affecting mortality

Eighteen patients with Budd-Chiari syndrome were studied over a 20 year period to determine the pattern of initial mortality and long-term survival. There were eight early deaths, two due to malignancy, two following surgery, three due to hepatic failure or portal hypertension and one due to septicaemia. The initial high mortality diminished after the first three years and actuarial analysis of survival showed that nearly 50 per cent were alive after five years. The presence of bleeding oesophageal varices indicated poor prognosis. Patients with functioning intrahepatic collaterals seemed to have a longer survival. Many of the surviving patients are leading normal lives with well-controlled symptoms. The prognosis of patients with chronic Budd-Chiari syndrome who survive the initial years of the illness may be better than previously believed.     

Repeated magnetic resonance imaging and cerebral performance after cardiac arrest--a pilot study

Aim of the study

Prognostication may be difficult in comatose cardiac arrest survivors. Magnetic resonance imaging (MRI) is potentially useful in the prediction of neurological outcome, and it may detect acute ischemia at an early stage. In a pilot setting we determined the prevalence and development of cerebral ischemia using serial MRI examinations and neurological assessment.

Methods

Ten witnessed out-of-hospital cardiac arrest patients were included. MRI was carried out approximately 2 h after admission to the hospital, repeated after 24 h of therapeutic hypothermia and 96 h after the arrest. The images were assessed for development of acute ischemic lesions. Neurophysiological and cognitive tests as well as a self-reported quality-of-life questionnaire, Short Form-36 (SF-36), were administered minimum 12 months after discharge.

Results

None of the patients had acute cerebral ischemia on MRI at admission. Three patients developed ischemic lesions after therapeutic hypothermia. There was a change in the apparent diffusion coefficient, which significantly correlated with the temperature (p < 0.001). The neurophysiological tests appeared normal. The patients scored significantly better on SF 36 than the controls as regards both bodily pain (p = 0.023) and mental health (p = 0.016).

Conclusions

MRI performed in an early phase after cardiac arrest has limitations, as MRI performed after 24 and 96 h revealed ischemic lesions not detectable on admission. ADC was related to the core temperature, and not to the volume distributed intravenously. Follow-up neurophysiologic tests and self-reported quality of life were good.     

Prehospital resuscitation and sudden cardiac death

Rates of survival horn pre-hospital cardiac arrest are often used to judge the quality of emergency medical systems. Despite many advances in technology and pharmacotherapy over the last two decades, overall survival rates in most systems remain disappointing. Objective analysis of different systems of care and associated outcomes has been hampered by a lack of uniform data reporting. Attempts to improve survival must focus on the key to resuscitation from sudden cardiac death, that is rapid response defibrillation.     

Prehospital care and outcome of pediatric out-of-hospital cardiac arrest

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS. PREHOSPITAL EMERGENCY CARE 2002;6:283-290     

Emergency department factors associated with survival after sudden cardiac arrest

Background

Sudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of emergency department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome.

Objective

We sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission.

Methods

We identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1–1.5, p = 0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1–1.6, p = 0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4–1.8, p < 0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6–0.9, p = 0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6–1.1, p = 0.116).

Conclusions

An estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA.     

Two-way analysis for detecting factors affecting ventilator-associated pneumonia

The “clinically required ventilation period” for assessing ventilator-associated pneumonia (VAP) has not been studied because this period could not be clinically predicted. We addressed this problem using both rate analysis and failure-time analysis. A total of 325 patients who had received mechanical ventilatory support in the intensive care unit of a university hospital were reviewed. The total ventilation period and the ventilation period before VAP were compared using logistic regression and the Cox proportional hazard model for univariate and multivariate analyses. The Frechet distribution model was also used. Fifty patients were excluded for having pneumonia before intubation or for being admitted to a department in which no VAP occurred; 12 patients had VAP. Discrepancies in both methods caused by time-dependent bias were observed in patients emergently admitted (odds ratio, 1.435; hazard ratio, 0.3928). This reduced hazard ratio remained with the multivariate Frechet distribution model. Longer operation time significantly increased the VAP rate in the logistic model only. Low body mass index increased the rate of VAP in both models, especially in female patients (hazard ratio, 0.1707; 95% confidence interval, 0.02105–0.6728). The results of rate analysis and failure-time analysis were similar for most factors but differed somewhat for several factors, such as emergency admission. Unknown factors might be obscured by this type of difference, and this two-way method might be able to reveal artificial effects.     

A Utstein-style analysis of prognostic factors related to survival in out-of-hospital cardiac arrests in Akita-City, Japan

To analyze the epidemiology of out-of-hospital cardiac arrests and to elucidate modifiable factors affecting survival, we conducted a prospective cohort study in a middle-sized urban city served by a single emergency medical service (EMS) system in which emergency medical technicians use an automated external defibrillator. Data were collected from out-of-hospital cardiac arrests occurring between 1 January, 1994 and 31 December, 1998 by applying the Utstein style. The main outcome measure was survival at 1 year after hospital discharge. The overall incidence of out-of-hospital cardiac arrest was 71.7/100 000 inhabitants/year. Resuscitations were attempted in 762 of 1118 patients with confirmed cardiac arrest. Of the 762 patients, 37 (4.86%) survived. The cause of cardiac arrest was presumed to be cardiac in 340 (44.6%). Of the 340 cardiac arrests, 180 (52.9%) were witnessed by bystanders. Ventricular fibrillation (VF) was recorded as an initial rhythm in 56 (31.1%) of the 180 patients, and cardiopulmonary resuscitation (CPR) was performed by bystanders in 89 (49.4%). The survival rate was 39.2% (22/56) when cardiac arrest was bystander-witnessed and of cardiac origin with VF as an initial rhythm. VF as an initial rhythm, age of the patients and intervals of call-to-first CPR attempt and collapse-to-arrival at patient's side were major factors relating to survival in the witnessed cardiac arrests of cardiac origin. The age, and gender of the patients, place of collapse and intervals of collapse-to-first CPR and collapse-to-arrival at patient's side were representative factors affecting the incidence of VF as an initial rhythm. The survival rate in Akita-City from bystander-witnessed cardiac arrests of cardiac origin with VF as an initial rhythm was comparable to those in other regions with advanced EMS systems. However, the incidence of VF as an initial rhythm is extremely low. Reduction of intervals of call (collapse)-to-first CPR attempt and collapse-to-arrival at patient's side or authorization of use of automated external defibrillator in basic life support may increase the incidence of VF as an initial rhythm and improve the survival from witnessed cardiac arrests with cardiac origin.     

自然分娩影响因素的定性分析

目的了解目前影响产妇选择自然分娩的因素。方法采用小组访谈法进行资料收集,访谈对象包括10名医疗机构管理人员。结果影响自然分娩服务的因素包括：政策层面、人力资源以及社会因素。结论为了促进自然分娩,需要进一步针对政策、助产人力资源及教育、孕妇认知及社会舆论导向层面的因素进行相应的研究和干预。     

Surviving traumatic cardiac arrest: Identification of factors associated with survival

IntroductionThe endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED).MethodsThe National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed.ResultsA total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99).ConclusionOver a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.     

两种方法治疗不同直径直肠癌肝转移的效果和影响生存率的因素分析

目的 探讨超声引导下射频消融术和腹腔镜治疗不同直径直肠癌肝转移的效果和影响生存率的相关因素。方法 回顾性分析2017年1月-2019年12月该院收治的87例行原发癌切除的发生直肠癌肝转移的患者的临床资料,按照不同治疗方法分为两组,观察组（n=45）采用超声引导下射频消融术治疗,对照组（n=42）采用腹腔镜手术切除治疗。比较两组患者疗效、肝功能指标变化情况和患者死亡情况,并对死亡与存活患者进行单因素和多因素分析,研究影响其生存的相关因素。结果 观察组病灶灭活率为81.82%,明显高于对照组的52.38%(P <0.05),观察组大、中、小病灶灭活程度均高于对照组（P <0.05）;两组患者术后血清白蛋白（ALB）、谷丙转氨酶（GPT）、碱性磷酸酶（ALP）和谷草转氨酶（GOT）等肝功能指标水平均高于术前,术后观察组ALB、GPT和GOT水平均低于对照组（P <0.05）;观察组总有效率为86.67%,高于对照组的69.05%(P <0.05);观察组术后2年内死亡率为15.56%,低于对照组的26.19%(P <0.05),两组患者不同直径病灶死亡率比较,差...     

The impact of a pre-hospital critical care team on survival from out-of-hospital cardiac arrest

AimTo assess the impact of a pre-hospital critical care team (CCT) on survival from out-of-hospital cardiac arrest (OHCA).MethodsWe undertook a retrospective observational study, comparing OHCA patients attended by advanced life support (ALS) paramedics with OHCA patients attended by ALS paramedics and a CCT between April 2011 and April 2013 in a single ambulance service in Southwest England. We used multiple logistic regression to control for an anticipated imbalance of prognostic factors between the groups. The primary outcome was survival to hospital discharge. All data were collected independently of the research.Results1851 cases of OHCA were included in the analysis, of which 1686 received ALS paramedic treatment and 165 were attended by both ALS paramedics and a CCT. Unadjusted rates of survival to hospital discharge were significantly higher in the CCT group, compared to the ALS paramedic group (15.8% and 6.5%, respectively, p < 0.001). After adjustment using multiple logistic regression, the effect of CCT treatment was no longer statistically significant (OR 1.54, 95% CI 0.89–2.67, p = 0.13). Subgroup analysis of OHCA with first monitored rhythm of ventricular fibrillation or pulseless ventricular tachycardia showed similar results.ConclusionPre-hospital critical care for OHCA was not associated with significantly improved rates of survival to hospital discharge. These results are in keeping with previously published studies. Further research with a larger sample size is required to determine whether CCTs can improve outcome in OHCA.     

Prehospital correlates of sleep in patients hospitalized with cardiac disease

The purpose of this study was to examine relationships among selected endogenous factors and sleep patterns during hospitalization in patients with cardiac disease. Participants included 33 male and female patients with myocardial infarction and unstable angina. Wrist actigraph recordings and a computerized sleep algorithm demonstrated that the participants slept for a mean of 424.55 min (SD = 114.52), had a mean sleep efficiency of 77.30% (SD = 15.80), and experienced from 5 to 32 awakenings each night (M = 13.94, SD = 6.29). The mean duration of nighttime awakenings was 9.24 min (SD = 5.60). Self-reports of sleep efficiency, sleep supplementation, and sleep disturbance, using the Verran and Snyder-Halpern (1990) sleep scale, were better than normative data reported for hospitalized patients. The combination of age, gender, New York Heart Association Functional Classification scores (NYHA Criteria Committee, 1964), and prehospitalization sleep loss explained 29% of the variance in objectively measured sleep efficiency and 46% of the variance in duration of nighttime awakenings. These findings suggest the importance of prehospitalization variables as predictors of sleep patterns in hospitalized cardiac patients and provide baseline data for future study. © 1998 John Wiley & Sons, Inc. Res Nurs Health 21: 27–37, 1998