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Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation 2017; 118:75-81. [DOI: 10.1016/j.resuscitation.2017.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/22/2017] [Accepted: 07/05/2017] [Indexed: 11/24/2022]
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Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation 2017. [PMID: 28629995 DOI: 10.1016/j.resuscitation.2017.06.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Although the intraosseous (IO) route is increasingly used for vascular access in out-of-hospital cardiac arrest (OHCA), little is known about its comparative effectiveness relative to intravenous (IV) access. We evaluated clinical outcomes following OHCA comparing drug administration via IO versus IV routes. METHODS This retrospective cohort study evaluated Emergency Medical Services (EMS)-treated adults with atraumatic OHCA in a large metropolitan EMS system between 9/1/2012-12/31/2014. Access was classified as IO or IV based on the route of first EMS drug administration. Study endpoints were survival to hospital discharge, return of spontaneous circulation (ROSC) and survival to hospital admission. RESULTS Among 2164 adults with OHCA, 1800 met eligibility criteria, 1525 of whom were treated via IV and 275 principally via tibial-IO routes. Compared to IV, IO-treated patients were younger, more often women, had unwitnessed OHCA, a non-cardiac aetiology, and presented with non-shockable rhythms. IO versus IV-treated patients were less likely to survive to hospital discharge (14.9% vs 22.8%, p=0.003), achieve ROSC (43.6% vs 55.5%, p<0.001) or be hospitalized (38.5% vs 50.0% p<0.001). In multivariable adjusted analyses, IO treatment was not associated with survival to discharge (odds ratio (OR) (95% confidence interval) 0.81 (0.55, 1.21), p=0.31), but was associated with a lower likelihood of ROSC (OR=0.67 (0.50, 0.88), p=0.004) and survival to hospitalization (OR=0.68 (0.51, 0.91), p=0.009). CONCLUSION Though not independently associated with survival to discharge, principally tibial IO versus IV treatment was associated with a lower likelihood of ROSC and hospitalization. How routes of vascular access influence clinical outcomes after OHCA merits additional study.
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Affiliation(s)
| | - Benjamin A Stubbs
- Department of Family Medicine, University of Washington, United States
| | - Tom Rea
- Department of Medicine, University of Washington, United States
| | - Peter J Kudenchuk
- Department of Medicine, Division of Cardiology, University of Washington, Box 356422, 1959 NE Pacific Street, Seattle, WA, 98195-6422, United States.
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Weiser C, Schwameis M, Sterz F, Herkner H, Lang IM, Schwarzinger I, Spiel AO. Mortality in patients resuscitated from out-of-hospital cardiac arrest based on automated blood cell count and neutrophil lymphocyte ratio at admission. Resuscitation 2017; 116:49-55. [PMID: 28476480 DOI: 10.1016/j.resuscitation.2017.05.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 04/05/2017] [Accepted: 05/02/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The neutrophil lymphocyte ratio(NLR) is a marker of systemic inflammation. We hypothesized that admission NLR is related to mortality and that epinephrine application during resuscitation influences NLR in patients after successful resuscitation from out of hospital cardiac arrest (OHCA). METHODS This retrospective cohort study is based on a registry including all OHCA patients who had a presumed cardiac cause of cardiac arrest and achieved sustained ROSC prior to admission between 2005 and 2014. Patients were categorized into three groups according to the calculated NLR at admission (NLR <6, ≥6, and 'abnormal differential' indicating no differential blood cell count on patients report due to exceedance of machine predefined parameter limits). The primary outcome measure was long-term mortality after OHCA. Cox proportional hazards models were used for multivariable analysis. RESULTS Out of 2273 OHCA patients during the study period a total of 1188(52%) patients were eligible for analysis, of those 274(23%) were female and mean age was 64 (25-75 IQR:52-72). Compared to a NLR<6 (n=442), adjusted hazard ratio for long-term mortality was significantly higher in patients with a NLR≥6 (n=447; 1.52 (95%CI 1.03-2.24)) and in patients with abnormal differential (n=299; 3.16 (95%CI 2.02-4.97)). Epinephrine application during resuscitation did not explain the effect of NLR on mortality. CONCLUSION In this large retrospective cohort study of altogether >1000 OHCA patients, hospital admission NLR<6 compared to abnormal differential or NLR≥6 was associated with mortality independently from epinephrine application.
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Affiliation(s)
- Christoph Weiser
- Departments of Emergency Medicine, Medical University of Vienna, Austria.
| | - Michael Schwameis
- Departments of Emergency Medicine, Medical University of Vienna, Austria
| | - Fritz Sterz
- Departments of Emergency Medicine, Medical University of Vienna, Austria
| | - Harald Herkner
- Departments of Emergency Medicine, Medical University of Vienna, Austria
| | - Irene M Lang
- Departments of Cardiology, Medical University of Vienna, Austria
| | - Ilse Schwarzinger
- Departments of Laboratory Medicine, Medical University of Vienna, Austria
| | - Alexander O Spiel
- Departments of Emergency Medicine, Medical University of Vienna, Austria
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54
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Intensive care medicine research agenda on cardiac arrest. Intensive Care Med 2017; 43:1282-1293. [PMID: 28285322 DOI: 10.1007/s00134-017-4739-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/23/2017] [Indexed: 12/21/2022]
Abstract
Over the last 15 years, treatment of comatose post-cardiac arrest patients has evolved to include therapeutic strategies such as urgent coronary angiography with percutaneous coronary intervention (PCI), targeted temperature management (TTM)-requiring mechanical ventilation and sedation-and more sophisticated and cautious prognostication. In 2015, collaboration between the European Resuscitation Council (ERC) and the European Society for Intensive Care Medicine (ESICM) resulted in the first European guidelines on post-resuscitation care. This review addresses the major recent advances in the treatment of cardiac arrest, recent trials that have challenged current practice and the remaining areas of uncertainty.
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55
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Determinants of unfavorable prognosis for out-of-hospital sudden cardiac arrest in Bielsko-Biala district. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 13:217-223. [PMID: 27785135 PMCID: PMC5071583 DOI: 10.5114/kitp.2016.62195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The prognosis in out-of-hospital sudden cardiac arrest (OHCA) remains unfavorable and depends on a number of demographic and clinical variables, the reversibility of its causes and its mechanisms. AIM To investigate the risk factors of prehospital death in patients with OHCA in Bielsko County. MATERIAL AND METHODS The study analyzed all dispatch cards of the National Emergency Medical Services (EMS) teams in Bielsko-Biala for the year 2013 (n = 23 400). Only the cards related to sudden cardiac arrest in adults were ultimately included in the study (n = 272; 190 men, 82 women; median age: 71 years). RESULTS Sixty-seven victims (45 men, 22 women) were pronounced dead upon the arrival of the EMS team, and cardiopulmonary resuscitation (CPR) was not undertaken. In the remaining group of 205 subjects, CPR was commenced but was ineffective in 141 patients (97 male, 44 female). Although univariate analysis indicated 6 predictors of prehospital death, including OHCA without the presence of witnesses (odds ratio (OR) = 4.2), OHCA occurring in a public place (OR = 3.1), no bystander CPR (OR = 9.7), no bystander cardiac massage (OR = 13.1), initial diagnosis of non-shockable cardiac rhythm (OR = 7.0), and the amount of drugs used for CPR (OR = 0.4), logistic regression confirmed that only the lack of bystander cardiac massage (OR = 6.5) and non-shockable rhythm (OR = 4.6) were independent determinants of prehospital death (area under ROC curve = 0.801). CONCLUSIONS Non-shockable rhythm of cardiac arrest and lack of bystander cardiac massage are independent determinants of prehospital death in Bielsko-Biala inhabitants suffering from OHCA.
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Perkins GD, Quinn T, Deakin CD, Nolan JP, Lall R, Slowther AM, Cooke M, Lamb SE, Petrou S, Achana F, Finn J, Jacobs IG, Carson A, Smyth M, Han K, Byers S, Rees N, Whitfield R, Moore F, Fothergill R, Stallard N, Long J, Hennings S, Horton J, Kaye C, Gates S. Pre-hospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug administration In Cardiac arrest (PARAMEDIC-2): Trial protocol. Resuscitation 2016; 108:75-81. [PMID: 27650864 PMCID: PMC5081174 DOI: 10.1016/j.resuscitation.2016.08.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 07/13/2016] [Accepted: 08/26/2016] [Indexed: 12/15/2022]
Abstract
Despite its use since the 1960s, the safety or effectiveness of adrenaline as a treatment for cardiac arrest has never been comprehensively evaluated in a clinical trial. Although most studies have found that adrenaline increases the chance of return of spontaneous circulation for short periods, many studies found harmful effects on the brain and raise concern that adrenaline may reduce overall survival and/or good neurological outcome. The PARAMEDIC-2 trial seeks to determine if adrenaline is safe and effective in out-of-hospital cardiac arrest. This is a pragmatic, individually randomised, double blind, controlled trial with a parallel economic evaluation. Participants will be eligible if they are in cardiac arrest in the out-of-hospital environment and advanced life support is initiated. Exclusions are cardiac arrest as a result of anaphylaxis or life threatening asthma, and patient known or appearing to be under 16 or pregnant. 8000 participants treated by 5 UK ambulance services will be randomised between December 2014 and August 2017 to adrenaline (intervention) or placebo (control) through opening pre-randomised drug packs. Clinical outcomes are survival to 30 days (primary outcome), hospital discharge, 3, 6 and 12 months, health related quality of life, and neurological and cognitive outcomes (secondary outcomes). Trial registration (ISRCTN73485024).
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Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK; Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK.
| | - Tom Quinn
- Faculty of Health, Social Care and Education, Kingston University London and St. George's, University of London, London SW17 0RE, UK
| | - Charles D Deakin
- Respiratory BRU, University Hospital Southampton SO16 6YD, UK; South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
| | - Jerry P Nolan
- School of Clinical Sciences, University of Bristol, Bristol BS8 1TH, UK; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath BA1 3NG, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | | | - Matthew Cooke
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK; Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - Sarah E Lamb
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 9DU, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Felix Achana
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Judith Finn
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Australia; St John Ambulance Western Australia, Belmont, Australia
| | - Ian G Jacobs
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Australia; St John Ambulance Western Australia, Belmont, Australia
| | - Andrew Carson
- West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill DY5 1LX, UK
| | - Mike Smyth
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK; West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill DY5 1LX, UK
| | - Kyee Han
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne NE15 8NY, UK
| | - Sonia Byers
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne NE15 8NY, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Denbighshire, Wales LL17 0RS, UK
| | - Richard Whitfield
- Welsh Ambulance Services NHS Trust, Denbighshire, Wales LL17 0RS, UK
| | - Fionna Moore
- London Ambulance Service NHS Trust, 8-20 Pocock Street, London SE1 0BW, UK
| | - Rachael Fothergill
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK; London Ambulance Service NHS Trust, 8-20 Pocock Street, London SE1 0BW, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - John Long
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Susie Hennings
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Jessica Horton
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Charlotte Kaye
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Simon Gates
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
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Paal P, Gordon L, Strapazzon G, Brodmann Maeder M, Putzer G, Walpoth B, Wanscher M, Brown D, Holzer M, Broessner G, Brugger H. Accidental hypothermia-an update : The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med 2016; 24:111. [PMID: 27633781 PMCID: PMC5025630 DOI: 10.1186/s13049-016-0303-7] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/07/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest. METHODS The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review. RESULTS The hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 °C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care. CONCLUSIONS Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, Barts Health NHS Trust, Queen Mary University of London, KGV Building, Office 10, 1st floor, West Smithfield, London, EC1A 7BE UK
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
| | - Les Gordon
- Department of Anaesthesia, University hospitals, Morecambe Bay Trust, Lancaster, UK
- Langdale Ambleside Mountain Rescue Team, Ambleside, UK
| | - Giacomo Strapazzon
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
| | - Monika Brodmann Maeder
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
| | - Beat Walpoth
- Department of Surgery, Cardiovascular Research, Service of Cardiovascular Surgery, University Hospital Geneva, Geneva, Switzerland
| | - Michael Wanscher
- Department of Cardiothoracic Anaesthesia and Intensive Care 4142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Doug Brown
- International Commission of Mountain Emergency Medicine (ICAR MEDCOM), Kloten, Switzerland
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Gregor Broessner
- Department of Neurology, Neurologic Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Hermann Brugger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck University Hospital, Anichstr. 35, 6020 Innsbruck, Austria
- Institute of Mountain Emergency Medicine, EURAC research, Drususallee 1, Bozen/Bolzano, Italy
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