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Jurado-Palomo J, Sanz-García A, Martín-Conty JL, Polonio-López B, López-Izquierdo R, Sáez-Belloso S, Del Pozo Vegas C, Martín-Rodríguez F. Prehospital point-of-care medication burden as a predictor of poor related outcomes in unselected acute diseases. Intern Emerg Med 2024:10.1007/s11739-024-03729-x. [PMID: 39090370 DOI: 10.1007/s11739-024-03729-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/26/2024] [Indexed: 08/04/2024]
Abstract
How prehospital medication predicts patient outcomes is unclear. The aim of this work was to unveil the association between medication burden administration in prehospital care and short, mid, and long-term mortality (2, 30, and 365 day) in unselected acute diseases and to assess the potential of the number of medications administered for short, mid, and long-term mortality prediction. A prospective, multicenter, ambulance-based, cohort study was carried out in adults with unselected acute diseases managed by emergency medical services (EMS). The study was carried out in Spain with 44 ambulances and four hospitals. The principal outcome was cumulative mortality at 2, 30, and 365 days. Epidemiological variables, vital signs, and prehospital medications were collected. Patients were classified into four categories: no medication dispensed in prehospital care, one to two medications, three to four medications, and five or more medications. A total of 6401 patients were selected. The 2-day mortality associated with each group was 0.5%, 1.8%, 6.5%, and 18.8%. The 30-day mortality associated with each group was 3.8%, 6.2%, 13.5%, and 31.9%. The 365-day mortality associated with each group was 11%, 15.3%, 25.2%, and 45.7%. The predictive validity of the number of drugs administered, measured by the area under the curve, was 0.808, 0.720, and 0.660 for 2-, 30-, and 365-day mortality, respectively. Our results showed that prehospital drugs could provide relevant information regarding the mortality prediction of patients. The incorporation of this score could improve the management of high-risk patients by the EMS.
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Affiliation(s)
- Jesús Jurado-Palomo
- Grupo de Investigación ITAS, Faculty of Health Sciences, Universidad de Castilla la Mancha, Avda. Real Fábrica de Seda, s/n, 45600, Talavera de la Reina, Spain
- Hospital General Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Ancor Sanz-García
- Grupo de Investigación ITAS, Faculty of Health Sciences, Universidad de Castilla la Mancha, Avda. Real Fábrica de Seda, s/n, 45600, Talavera de la Reina, Spain.
| | - José Luis Martín-Conty
- Grupo de Investigación ITAS, Faculty of Health Sciences, Universidad de Castilla la Mancha, Avda. Real Fábrica de Seda, s/n, 45600, Talavera de la Reina, Spain
| | - Begoña Polonio-López
- Grupo de Investigación ITAS, Faculty of Health Sciences, Universidad de Castilla la Mancha, Avda. Real Fábrica de Seda, s/n, 45600, Talavera de la Reina, Spain
| | - Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | - Silvia Sáez-Belloso
- Prehospital Emergency Medical Services (SACYL), Valladolid, Spain
- Faculty of Nursing, Universidad de Valladolid, Valladolid, Spain
| | - Carlos Del Pozo Vegas
- Faculty of Medicine, University of Valladolid, Valladolid, Spain
- Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, University of Valladolid, Valladolid, Spain
- Prehospital Emergency Medical Services (SACYL), Valladolid, Spain
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Lupton JR, Neth MR, Sahni R, Jui J, Wittwer L, Newgard CD, Daya MR. Survival by time-to-administration of amiodarone, lidocaine, or placebo in shock-refractory out-of-hospital cardiac arrest. Acad Emerg Med 2023; 30:906-917. [PMID: 36869657 DOI: 10.1111/acem.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Amiodarone and lidocaine have not been shown to have a clear survival benefit compared to placebo for out-of-hospital cardiac arrest (OHCA). However, randomized trials may have been impacted by delayed administration of the study drugs. We sought to evaluate how timing from emergency medical services (EMS) arrival on scene to drug administration affects the efficacy of amiodarone and lidocaine compared to placebo. METHOD This is a secondary analysis of the 10-site, 55-EMS-agency double-blind randomized controlled amiodarone, lidocaine, or placebo in OHCA study. We included patients with initial shockable rhythms who received the study drugs of amiodarone, lidocaine, or placebo before achieving return of spontaneous circulation. We performed logistic regression analyses evaluating survival to hospital discharge and secondary outcomes of survival to admission and functional survival (modified Rankin scale score ≤ 3). We evaluated the samples stratified by early (<8 min) and late administration groups (≥8 min). We compared outcomes for amiodarone and lidocaine compared to placebo and adjust for potential confounders. RESULTS There were 2802 patients meeting inclusion criteria, with 879 (31.4%) in the early (<8 min) and 1923 (68.6%) in the late (≥8 min) groups. In the early group, patients receiving amiodarone, compared to placebo, had significantly higher survival to admission (62.0% vs. 48.5%, p = 0.001; adjusted OR [95% CI] 1.76 [1.24-2.50]), survival to discharge (37.1% vs. 28.0%, p = 0.021; 1.56 [1.07-2.29]), and functional survival (31.6% vs. 23.3%, p = 0.029; 1.55 [1.04-2.32]). There were no significant differences with early lidocaine compared to early placebo (p > 0.05). Patients in the late group who received amiodarone or lidocaine had no significant differences in outcomes at discharge compared to placebo (p > 0.05). CONCLUSIONS The early administration of amiodarone, particularly within 8 min, is associated with greater survival to admission, survival to discharge, and functional survival compared to placebo in patients with an initial shockable rhythm.
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Affiliation(s)
- Joshua R Lupton
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew R Neth
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ritu Sahni
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Lynn Wittwer
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Craig D Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Lupton JR, Jui J, Neth MR, Sahni R, Daya MR, Newgard CD. Development of a clinical decision rule for the early prediction of Shock-Refractory Out-of-Hospital cardiac arrest. Resuscitation 2022; 181:60-67. [PMID: 36280216 DOI: 10.1016/j.resuscitation.2022.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/16/2022] [Accepted: 10/08/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nearly half of ventricular fibrillation or ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA) patients receive three or more shocks, often referred to as refractory VF/VT. Our objective was to derive a clinical decision rule (CDR) for the early stratification of patients into risk categories for refractory VF/VT. METHODS We included adults with non-traumatic OHCA in the Resuscitation Outcomes Consortium Epistry (2011-2015) with ≥ 1 EMS shock. We used Classification and Regression Tree analysis for CDR building using variables known at initial EMS rhythm analysis including age, sex, witness, location, bystander interventions, initial EMS rhythm, obvious non-cardiac etiology, and dispatch to arrival times. The outcome was refractory VF/VT (≥3 shocks). We calculated sensitivity, specificity, area under the receiver operating curve (AUROC), and odds ratios (OR). The rule was validated using the Portland Cardiac Arrest Epidemiologic Registry (2018-2020). RESULTS There were 17,140 eligible patients and 8,146 (47.5%) had refractory VF/VT. The optimal CDR (AUROC = 0.671) defined three groups: high-risk were any patients requiring an EMS shock after a bystander AED shock; moderate-risk were any non-EMS witnessed arrests with shockable initial EMS rhythms; and the remainder were low-risk. Refractory VF/VT increased across the low (30.7%), moderate (58.5%) and high-risk (84.8%) groups. Compared to low-risk, being moderate-risk or higher (OR [95% CI]:3.37 [3.16-3.59]; sensitivity 72.7%; specificity 55.9%) or high-risk (OR:12.63 [9.89-16.13]; sensitivity 5.4%; specificity 99.1%) had higher odds of refractory VF/VT. Results was similar in the validation cohort (n = 765, AUROC = 0.672). CONCLUSIONS Patients at higher risk for refractory VF/VT can be identified early in EMS care.
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Affiliation(s)
- Joshua R Lupton
- Department of Emergency Medicine, Oregon Health and Science University, United States.
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Matthew R Neth
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Ritu Sahni
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Craig D Newgard
- Department of Emergency Medicine, Oregon Health and Science University, United States
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Sensor technologies to detect out-of-hospital cardiac arrest: A systematic review of diagnostic test performance. Resusc Plus 2022; 11:100277. [PMID: 35935174 PMCID: PMC9352446 DOI: 10.1016/j.resplu.2022.100277] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022] Open
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Ornato JP, Dunbar EG, Harbour W, Ludin T, Peberdy MA. Importance of Analyzing Intervals to Emergency Medical Service Treatments. PREHOSP EMERG CARE 2022; 27:927-933. [PMID: 35894873 DOI: 10.1080/10903127.2022.2107124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 07/07/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Although most US emergency medical services (EMS) systems collect time-to-treatment data in their electronic prehospital patient care reports (PCRs), analysis of these data seldom appears in publications. We believe EMS agencies should routinely analyze the initial time-to-treatment data for various potentially life-threatening conditions. This not only assures that protocol-required treatments have been provided but can discover avoidable delays and drive protocol/treatment priority change. Our study purpose was to analyze the interval from 9-1-1 call receipt until the first administration of naloxone to adult opioid overdose victims to demonstrate the quality assurance importance of analyzing time-to-treatment data. METHODS Retrospective analysis of intervals from 9-1-1 call receipt to initial naloxone treatment in adult opioid overdose victims. We excluded victims <18 years of age and cases where a bystander, police, or a health care worker gave naloxone before EMS arrival. We compared data collected before and during the COVID-19 pandemic to determine its effect on the analysis. RESULTS The mean patient age of 582 opioid overdose victims was 40.7 years [95% CI 39.6, 41.8] with 405 males (69.6%). EMS units' scene arrival was 6.7 minutes from the 9-1-1 call receipt. It took 1.8 minutes to reach the victim, and 8.6 additional minutes to administer the first naloxone regardless of administration route (70.4% intravenous, 26.1% intranasal, 2.7% intraosseous, 0.7% intramuscular). EMS personnel administered the first naloxone 17.1 minutes after the 9-1-1 call receipt, with 50.3% of the delay occurring after patient contact. There was no statistically significant difference in the times-to-treatment before vs. during the pandemic. CONCLUSION The prepandemic interval from 9-1-1 call receipt until initial EMS administration of naloxone was substantial and did not change significantly during COVID-19. Our findings exemplify why EMS agencies should analyze initial time-to-treatment data, especially for life-threatening conditions, beyond assuring that protocol-required treatments have been provided. Based on our analysis, fire department crews now carry intranasal naloxone, and intranasal naloxone is given to "impaired" opioid overdose victims the first-arriving fire department or EMS personnel. We continue to collect data on intervals-to-treatment prospectively and monitor our critical process/treatment intervals using the plan-do-study-act model to improve our process/carry out change, and publish our results in a future publication.
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Affiliation(s)
- Joseph P Ornato
- Department of Emergency Medicine, Virginia Commonwealth University Health, Richmond, Virginia
- Richmond Ambulance Authority, Richmond, Virginia
- Internal Medicine (Cardiology), Richmond, Virginia
| | - Emily G Dunbar
- Richmond Ambulance Authority, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | | | - Tom Ludin
- Richmond Ambulance Authority, Richmond, Virginia
| | - Mary Ann Peberdy
- Department of Emergency Medicine, Virginia Commonwealth University Health, Richmond, Virginia
- Internal Medicine (Cardiology), Richmond, Virginia
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Apiratwarakul K, Tiamkao S, Cheung LW, Celebi I, Suzuki T, Ienghong K. Application of Automated External Defibrillators in Motorcycle Ambulances in Thailand’s Emergency Medical Services. Open Access Emerg Med 2022; 14:141-146. [PMID: 35437357 PMCID: PMC9013265 DOI: 10.2147/oaem.s361335] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022] Open
Abstract
Background Access time to emergency patients is a critical factor that affects the outcomes of life-or-death situations, especially in the cases of out-of-hospital cardiac arrests (OHCA). This study focused on developing a new model of emergency medical services (EMS) using a motorcycle-based ambulance (motorlance) with an automated external defibrillator (AED). There are currently no studies regarding access time for this vehicle. This study aimed at utilization of an AED in conjunction with motorlance and comparing the response time between a traditional ambulance and a motorlance. Methods This was a prospective study conducted in the EMS department of Srinagarind Hospital, located in Khon Kaen, Thailand, over a five-month period, from September 2021 to January 2022. Data were recorded employing a national standard of operations record form used for Thailand EMS departments nationwide. Results The 891 cases were divided into two groups which were motorlance and ambulance. The activation times for motorlance and ambulance were 0.44 minutes and 1.42 minutes, respectively (p < 0.001) and the response time in the motorlance group was 7.20 minutes compared with 9.25 minutes in the ambulance group. In OHCA, the motorlance with AED arrived at patients location and assisted to continue resuscitation at the hospital 88.9% of the time. Conclusion AED used in conjunction with motorcycle ambulances had shorter periods of both activation time and response time compared to ambulances. The use of AEDs clearly increases the number of continuous resuscitations in out-of-hospital cardiac arrest patients.
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Affiliation(s)
- Korakot Apiratwarakul
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Somsak Tiamkao
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Lap Woon Cheung
- Department of Accident and Emergency, Princess Margaret Hospital, Kowloon, Hong Kong
- Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ismet Celebi
- Department of Paramedic, Gazi University, Ankara, Turkey
| | - Takaaki Suzuki
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Kamonwon Ienghong
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Correspondence: Kamonwon Ienghong, Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand, Tel +66 043 366 869, Email
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Lupton JR, Neth MR, Sahni R, Wittwer L, Le N, Jui J, Newgard CD, Daya MR. The Association Between the Number of Prehospital Providers On-Scene and Out-of-Hospital Cardiac Arrest Outcomes. PREHOSP EMERG CARE 2021; 26:782-791. [PMID: 34669565 DOI: 10.1080/10903127.2021.1995799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: The ideal number of emergency medical services (EMS) providers needed on-scene during an out-of-hospital cardiac arrest (OHCA) resuscitation is unknown. Our objective was to evaluate the association between the number of providers on-scene and OHCA outcomes. Methods: This was a secondary analysis of adults (≥18 years old) with non-traumatic OHCA from a 10-site North American prospective cardiac arrest registry (Resuscitation Outcomes Consortium) including a 2005-2011 cohort and a 2011-2015 cohort. The primary outcome was survival to hospital discharge. We calculated the median number of EMS providers on-scene during the first 10 minutes of the resuscitation and used multivariable logistic regression adjusting for age, sex, witness status, bystander CPR, arrest location, initial rhythm, and dispatch to EMS arrival time. Results: There were 30,613 and 41,946 patients with necessary variables in the 2005-2011 and 2011-2015 cohorts, respectively. Survival to hospital discharge (95% CI) was higher with 9 or more providers on-scene (17.2% [15.8-18.5] and 14.0% [12.6-15.4]) compared to 7-8 (14.1% [13.4-14.8] and 10.5% [9.9-11.1]), 5-6 (10.0% [9.5-10.5] and 8.5% [8.1-8.9]), 3-4 (10.5% [9.3-11.6] and 9.3% [8.5-10.1]), and 1-2 (8.6% [7.2-10.0] and 8.0% [7.1-9.0]) providers for the 2005-2011 and 2011-2015 cohorts, respectively. In multivariable logistic regressions, compared to 5-6 providers, there were no significant differences in survival to hospital discharge for 1-2 or 3-4 providers, while having 7-8 (adjusted odds ratios (aORs) 1.53 [1.39-1.67] and 1.31 [1.20-1.44]) and 9 or more (aORs 1.76 [1.56-1.98] and 1.63 [1.41-1.89]) providers were associated with improved survival in both the 2005-2011 and 2011-2015 cohorts, respectively. Conclusions: The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers.
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