Critical Resuscitation Research Articles

Negotiating grey areas: an interview-based analysis of paramedic uncertainty and decision-making in cardiac arrest events

BackgroundParamedics are responsible for critical resuscitation decisions when attending Out of Hospital Cardiac Arrests (OHCA). Existing research indicates that a range of clinical and non-clinical factors moderate their decision-making. Within the United Kingdom (UK), there is little evidence on how and why paramedics make their decisions at actual OHCA events.MethodsWe explored the experiences of UK paramedics using individually recalled OHCA events as catalysts for discussion. Pen portraits developed from semi-structured interviews with 31 paramedics across two UK ambulance services were thematically analysed, enabling cross-participant comparisons whilst retaining depth and context.ResultsWe identified four themes: uncertainties encountered in resuscitation guidelines, influences on decision-making, holistic perspectives, and indirect moderators. We found that paramedics experienced uncertainty at all stages of the resuscitation process. Uncertainties arose from indeterminate, ambiguous or complex information and were described as having both clinical and ethical dimensions. Whilst guidelines drove paramedics’ decisions, non-clinical personal, practical and relational factors moderated their assessments of survivability and decision-making, with attitudes to interactions between patient age, frailty and quality of life playing a substantial role. Coping strategies such as uncertainty reduction, assumption-based reasoning and weighing pros and cons were evident from interviews.ConclusionsThe complexity of interactions between clinical and non-clinical factors points to an element of variability in paramedics’ responses to uncertainty. Exploring UK paramedics’ uncertainties and decision-making during specific OHCA events can help acknowledge and address uncertainties in resuscitation guidelines and paramedic training, providing paramedics with the tools to manage uncertainty in a consistent and transparent way.

Virtual Reality CPR Training Improves Knowledge Acquisition of Critical Tasks

Objectives: Team-focused cardiopulmonary resuscitation (TFCPR) is a choreographed approach to CPR in which responders know and practice their role in resuscitation, with prioritization on minimally-interrupted chest compressions and early appropriate defibrillation. To determine the feasibility of virtual reality (VR) for large scale educational deployment at a regional medical campus (RMC), we developed a VR training module and examined its effect on resuscitation knowledge acquisition among clinicians of various learner levels. Methods: Three separate cohorts were included in the investigation: third year medical students at our RMC, emergency medicine (EM) residents, and board-certified EM attending physicians. Participants were administered an iPad-based, de-identified pre-test, which assessed knowledge of 12 critical resuscitative tasks. All learners received a two-minute orientation to the VR headset fit and operation. Learners then completed training on the VR platform using two cardiac arrest clinical scenarios: an arrest with an initial shockable rhythm and another with a non-shockable initial rhythm. After completion of VR training, participants completed a post-test, again assessing knowledge of the 12 critical action resuscitative tasks, as well as a questionnaire determining metrics related to participants’ overall experience with VR training. Results: All participants demonstrated statistically significant increases in post-test scores after VR training with the combined median improvement of 12.5% (CI 12.5–17.0; p <0.0001). Medical students demonstrated the greatest median pre-post score improvement (17%; CI 12.5–25.0; p <0.0001]. Study participants reported the VR training platform to be enjoyable, realistic, immersive, and a good way to learn, with good visual-sensory tolerance and a satisfying training method. Conclusions: At our RMC and single hospital, pre-and post-test analysis, knowledge acquisition of critical resuscitation skills improved after VR TFCPR training for all learners. Additionally, participants demonstrated a high level of satisfaction with VR as a training methodology. VR is a feasible knowledge acquisition adjunct or alternative to traditional cardiac arrest resuscitation training.

Performance of Pleuropulmonary Ultrasound in the Diagonisis of Acute Respiratory Conditions in Intensive Care Patients: Case of the Sens Hospital Center

Background and Objective: Despite its increasing use, in critical care, the diagnosis accuracy of Lung Ultransound Sonographye (LUS) is a topic that remains highly debated. The objective of our study was to evaluate the performance of LUS compared to chest computer tomography (CT) in the diagnosis of acute respiratory condictions in critical patients at Sens hospital from March 1st to September 31st 2023. Methods: Single-center, cross-sectional study of 54 patients, all adult with acute respiratory symptoms who benefited concurrent LUS and chest CT scan. The LUS was performed according to the BLUE-Protocol by the doctors of the department, within 8 hours before the chest CT scan was performed. The CT scan was interpreted by the hospital's radiologists who were also blinded by the LUS results. The performance of LUS was assessed by calculating sensitivity (se), specificity (sp), positive predictive values (PPV) and negative predictive values (NPV) compared to chest CT. Results: Pneumothorax had a Se=100%, Sp=100, PPV=100%, NPV=100%, Youden=1.00, AUC=1.00; Interstitial syndrome had a Se=100%, Sp=98.1%, PPV=50%, NPV=100%, Youden=0.98%, AUC=0.99 with p=0.14. Alveolar consolidation had Se=100%, Sp=90.5%, PPV=94.3%, NPV=100%, Youden=0.90%, AUC=0.95%. Pleural effusion had Se=100%, Sp=88.9%, PPV=90%, NPV=100%, Youden=0.89%, AUC=0.94%. Pulmonary embolism had a Se=66.7%; Sp=97.9%, PPV=80%, NPV=95.9%, Youden=0.65%, AUC=0.82% with p=0.11. As for COPD/ Asthma decompensation, she had a Se=NA (not applicable), Sp=100%, PPV=NA, NPV=100%, Youden=NA and AUC=100%. Conclusion: The performance of LUS in this study are satisfactory for the diagnosis of alveolar consolidation, pneumothorax, pleural fluid effusion and interstitial syndrome (only as a function of Youden's index). They are less good for the diagnosis of pulmonary embolism. Thus, we propose it as an alternative to CT in patients in critical resuscitation.

Newborn Time - improved newborn care based on video and artificial intelligence - study protocol

BackgroundApproximately 3-8% of all newborns do not breathe spontaneously at birth, and require time critical resuscitation. Resuscitation guidelines are mostly based on best practice, and more research on newborn resucitation is highly sought for.MethodsThe NewbornTime project will develop artificial intelligence (AI) based solutions for activity recognition during newborn resuscitations based on both visible light spectrum videos and infrared spectrum (thermal) videos. In addition, time-of-birth detection will be developed using thermal videos from the delivery rooms. Deep Neural Network models will be developed, focusing on methods for limited supervision and solutions adapting to on-site environments. A timeline description of the video analysis output enables objective analysis of resuscitation events. The project further aims to use machine learning to find patterns in large amount of such timeline data to better understand how newborn resuscitation treatment is given and how it can be improved. The automatic video analysis and timeline generation will be developed for on-site usage, allowing for data-driven simulation and clinical debrief for health-care providers, and paving the way for automated real-time feedback. This brings added value to the medical staff, mothers and newborns, and society at large.DiscussionThe project is a interdisciplinary collaboration, combining AI, image processing, blockchain and cloud technology, with medical expertise, which will lead to increased competences and capacities in these various fields.Trial registrationISRCTNregistry, number ISRCTN12236970

On Occasion of Seventy-five Years of Cardiac Defibrillation in Humans.

Heart attack, or cardiac arrest, became a leading cause of death after the turn of the century. Defibrillation is one of the most important medical advances of the twentieth century. Defibrillation is a critical step in the treatment of cardiac arrest as it can be the only way to restore a normal heart rhythm and save the life of the individual. However, it is important to note that defibrillation is only effective if it is performed quickly and in conjunction with other life-saving measures such as cardiopulmonary resuscitation (CPR). The history of cardiac defibrillation therapy is long and fascinating, spanning several centuries, many countries and continents. The aim of this article was to provide historical information about technical and scientific advances in cardiac devices and the development of today defibrillators. Review of the available literature, historical data, personal contacts, others and personal experience in this field. In 1947, Beck published the first paper describing open chest defibrillation of the human heart. Ten years later, Kouwenhoven demonstrated that the heart could be defibrillated through a closed chest. The first external defibrillator weighed 120 kg and delivered 500 v of alternating current (AC) potential. The mere size of the defibrillator restricted its use to surgical suites or other areas hospital locations. In many cases, cardiac arrhythmias recurred. This was thought to be related to the amount of energy used to defibrillate the heart which it was believed caused myocardial damage. These factors limited the practical application of defibrillators. By 1956, a unit was built that could be wheeled into the emergency room, plugged into a wall outlet, and deliver 1000 volts. By 1962, Lown realized that AC current resulted in a high frequency of cardiac arrhythmias and cardiac damage. A direct current (DC) defibrillator, consisting of a battery, a capacitor to store energy, and a transformer was developed. The therapy spread from operating rooms to coronary care units and emergency departments and in the late 1960s left the hospital and started appearing on mobile intensive care units. The first portable EMS defibrillators (used by paramedics) emerged in the early 1970s. In 1980 the automatic implantable cardioverter-defibrillator was invented. Automated external defibrillators began appearing in the late 1980s allowing the therapy to be delivered by EMTs and lay people. The 'father' of the modern automated external defibrillator (AED), Professor James Francis (1916-2004) was a physician and cardiologist from Northern Ireland who transformed emergency medicine and paramedic services with the invention of the portable defibrillator. Defibrillators are critical resuscitation devices. The use of reliable defibrillators has led to more effective treatments and improved patient safety through better control and management of complications during Cardiopulmonary Resuscitation (CPR). The 75th anniversary of the world's first successful human cardiac defibrillation represents the landmark event that defined the future of cardiovascular medicine and ushered in a new era of advanced cardiac life support.

Case Report – Successful Thrombectomy After Critical Resuscitation Following a Cardiac Arrest

Sparse evidence exists to support a delayed attempt at thrombectomy after a periprocedural cardiac arrest or acute medical decompensation. This case highlights the presentation of a 23‐year‐old woman with dilated cardiomyopathy, who initially presented with a left middle cerebral artery stroke syndrome, but who had a cardiac arrest in the angiogram suite prior to the procedure starting. After aggressive resuscitation in the critical care unit, repeat imaging showed a persistent perfusion deficit in the left middle cerebral artery territory and she successfully underwent a thrombectomy. The case highlights that critical care efforts, even after a severe initial presentation, and significant resuscitative efforts in the intensive care unit setting, can still lead to a successful thrombectomy, and that eligibility for thrombectomy can be reassessed as the patient stabilizes.

Albumin versus balanced crystalloid for resuscitation in the treatment of sepsis: A protocol for a randomised controlled feasibility study, "ABC-Sepsis".

BackgroundPatients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window.MethodsABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours.ObjectivesPrimary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs.DiscussionThis trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.

An Improved Integral Inequality for Delay-Dependent Gain-Scheduled LPV Control

The present work examines the delay-dependent gain-scheduling feedback control with guaranteed closed-loop stability and induced L2 norm performance for continuous-time linear parameter-varying (LPV) systems with arbitrary time-varying delay. An extension of Lyapunov stability utilizing Krasovskii functionals is considered to derive stability analysis and synthesis conditions for delay-dependent dynamic output feedback LPV control design. The main challenges associated with this approach are selecting appropriate Lyapunov-Krasovskii functionals (LKFs) and finding efficient integral inequalities to bound the derivative of the LKF. Accordingly, a novel modified parameter-dependent LKF candidate along with an affine version of Jensen’s inequality bounding technique are employed leading to the derivation of less conservative sufficient conditions expressed in terms of convex linear matrix inequalities (LMIs). The proposed methodology is compared with past work in the literature in terms of conservatism reduction and performance improvement through a numerical example. Finally, the application of the proposed output-feedback LPV control design is evaluated on the automated mean arterial blood pressure (MAP) regulation in critical patient resuscitation via vasoactive drug infusion. Closed-loop simulation results are presented to illustrate the potential of the introduced LPV gain-scheduling design to provide MAP set-point tracking in the presence of disturbances and varying input delays.

An Intelligent Augmented Reality Training Framework for Neonatal Endotracheal Intubation.

Neonatal Endotracheal Intubation (ETI) is a critical resuscitation skill that requires tremendous practice of trainees before clinical exposure. However, current manikin-based training regimen is ineffective in providing satisfactory real-time procedural guidance for accurate assessment due to the lack of see-through visualization within the manikin. The training efficiency is further reduced by the limited availability of expert instructors, which inevitably results in a long learning curve for trainees. To this end, we propose an intelligent Augmented Reality (AR) training framework that provides trainees with a complete visualization of the ETI procedure for real-time guidance and assessment. Specifically, the proposed framework is capable of capturing the motions of the laryngoscope and the manikin and offer 3D see-through visualization rendered to the head-mounted display (HMD). Furthermore, an attention-based Convolutional Neural Network (CNN) model is developed to automatically assess the ETI performance from the captured motions as well as identify regions of motions that significantly contribute to the performance evaluation. Lastly, augmented user-friendly feedback is delivered with interpretable results with the ETI scoring rubric through the color-coded motion trajectory that classifies highlighted regions that need more practice. The classification accuracy of our machine learning model is 84.6%.

Neonatal delivery room CPR: An analysis of the Get with the Guidelines®—Resuscitation Registry

BackgroundCardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm. MethodsRetrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines—Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors. ResultsThere were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis. ConclusionIn this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

Impact of Personal Protective Equipment on the Performance of Emergency Pediatric Tasks.

Personal protective equipment (PPE) is worn by health care providers (HCPs) to protect against hazardous exposures. Studies of HCPs performing critical resuscitation tasks in PPE have yielded mixed results and have not evaluated performance in care of children. We evaluated the impacts of PPE on timeliness or success of emergency procedures performed by pediatric HCPs. This prospective study was conducted at 2 tertiary children's hospitals. For session 1, HCPs (medical doctors and registered nurses) wore normal attire; for session 2, they wore full-shroud PPE garb with 2 glove types: Ebola level or chemical. During each session, they performed clinical tasks on a patient simulator: intubation, bag-valve mask ventilation, venous catheter (IV) placement, push-pull fluid bolus, and defibrillation. Differences in completion time per task were compared. There were no significant differences in medical doctor completion time across sessions. For registered nurses, there was a significant difference between baseline and PPE sessions for both defibrillation and IV placement tasks. Registered nurses were faster to defibrillate in Ebola PPE and slower when wearing chemical PPE (median difference, -3.5 vs 2 seconds, respectively; P < 0.01). Registered nurse IV placement took longer in Ebola and chemical PPE (5.5 vs 42 seconds, respectively; P < 0.01). After the PPE session, participants were significantly less likely to indicate that full-body PPE interfered with procedures, was claustrophobic, or slowed them down. Personal protective equipment did not affect procedure timeliness or success on a simulated child, with the exception of IV placement. Further study is needed to investigate PPE's impact on procedures performed in a clinical care context.

Optimizing whole blood storage: hemostatic function of 35-day stored product in CPD, CP2D, and CPDA-1 anticoagulants.

Transitioning from whole blood (WB) to components developed from efforts to maximize donor yield. Components are advantageous for specific derangements, but treating hemorrhage with components requires significantly more volume to provide similar effects to WB. Because storage lesion and waste remain problematic, this study examined hemostatic function of refrigerated WB stored for 35 days in anticoagulants citrate-phosphate-dextrose-adenosine (CPDA-1), citrate-phosphate-dextrose (CPD), or citrate-phosphate-double dextrose (CP2D). Refrigerated WB units from healthy donors were sampled over 35 days. Global hemostatic parameters were measured by thromboelastometry, thrombogram, platelet aggregometry, and platelet adhesion to collagen under shear conditions. The effects of transfusion filtration and mixing 35-day stored product with fresh WB were evaluated. Countable platelets declined as aggregation clusters appeared in microscopy. While gross platelet agonist-induced aggregation declined over time, normalization revealed aggregation responses in remaining platelets. Peak thrombin generation increased over time. Clot strength diminished over storage in tissue factor-activated samples (normalized by filtration of aggregates). Functional fibrinogen responses remained consistent throughout. Filtration was necessary to maintain consistent platelet adhesion to collagen beyond collection day. Few differences were observed between anticoagulants, and stored/fresh mixing studies normalized coagulation parameters. WB is easier to collect, store, and transfuse. WB provides platelets, an oft-neglected, critical resuscitation component, but their individual numbers decline as aggregates appear, resulting in diminished coagulation response. WB has better performance in these assays when examined at earlier time points, but expirations designated to specific anticoagulants appear arbitrary for hemostatic functionality, as little changes beyond 21 days regardless of anticoagulant.

Simulation as a Training Method for the Professionalization of Teams

Simulation as an educational method can be applied to the training of processes, technical and non-technical skills. This article focuses on the role of simulation in crisis resource management and non-technical skills. A realistic work environment requires well-trained staff regarding simulation technology and communication. A training (unit) is divided into three sections. During the briefing the team is introduced to the scenario. Afterwards, the patient is treated by an interdisciplinary team. Communication under the pressure of action, even if one does not agree with the approach of the colleagues, should be practiced. After the scenario a structured debriefing is conducted. The trainer supervises the reflection of the teams' actions. Various methods such as "guided team self-correction", "advocacy-inquiry" and the "TeamGAINS"-approach are available for this decisive phase of the training. A safe environment is guaranteed, video recordings will never leave the training. Active experimentation, concrete experiences and accurate reflection are the key factors of success for the method simulation. Positive effects on critical incidents, resuscitation outcome and improvement of team climate can be observed after simulation training.

Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial.

BackgroundThe American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses.ObjectiveThe study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards.MethodsWe conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines.ResultsTwenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses.ConclusionsAR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

Staphylococcus aureus carriage at admission predicts early-onset pneumonia after burn trauma

Background and objectives Early-onset pneumonia (EOP) is frequent after burn trauma, increasing morbidity in the critical resuscitation phase, which may preclude early aggressive management of burn wounds. Currently, however, preemptive treatment is not recommended. The aim of this study was to identify predictive factors for EOP that may justify early empirical antibiotic treatment. Methods Data for all burn patients requiring ≥ 4 h mechanical ventilation (MV) who were admitted to our service between January 2001 and October 2012 were extracted from the hospital's computerized information system. We reviewed EOP episodes (occurring within 7 days after admission) among patients who underwent endotracheal aspiration (ETA) within 5 days after admission. Univariate and multivariate analyses were performed to identify independent factors associated with EOP. Logistic regression was used to identify factors predicting EOP development. Results During the study period, 396 burn patients were admitted. ETA was performed within 5 days in 204/290 patients receiving ≥ 4 h MV. One hundred and eight patients developed EOP and 176 microorganisms were identified. The three most prevalent microorganisms isolated were S. aureus ( n = 47, 26.7%), Haemophilus influenzae ( n = 37, 21.0%), and Streptococcus pneumoniae ( n = 23, 13.1%). All but one ( n = 46, 97.9%) case of S. aureus EOP were caused by methicillin-sensitive S. aureus . Among the 33 patients showing S. aureus positivity on ETA samples, 16 (48.5%) developed S. aureus EOP. Among the 156, S. aureus non-carriers, 16 (10.2%) developed EOP . S. aureus carriage independently predicted EOP ( P S. aureus carriage as a unique criterion for the initiation of early empirical treatment would have resulted in 17 unnecessary antibiotic treatments in this cohort. Discussion and conclusions We identified S. aureus carriage as an independent and strong predictor of EOP. As rapid point-of-care testing for S. aureus is readily available, we recommend testing of all patients at admission for burn trauma and the consideration of early preemptive treatment in all positive patients. Further studies are needed to evaluate this new strategy.

Staphylococcus aureus carriage at admission predicts early-onset pneumonia after burn trauma.

Early-onset pneumonia (EOP) is frequent after burn trauma, increasing morbidity in the critical resuscitation phase, which may preclude early aggressive management of burn wounds. Currently, however, preemptive treatment is not recommended. The aim of this study was to identify predictive factors for EOP that may justify early empirical antibiotic treatment. Data for all burn patients requiring ≥4h mechanical ventilation (MV) who were admitted between January 2001 and October 2012 were extracted from the hospital's computerized information system. We reviewed EOP episodes (≤7days) among patients who underwent endotracheal aspiration (ETA) within 5days after admission. Univariate and multivariate analyses were performed to identify independent factors associated with EOP. Logistic regression was used to identify factors predicting EOP development. During the study period, 396 burn patients were admitted. ETA was performed within 5days in 204/290 patients receiving ≥4h MV. One hundred and eight patients developed EOP; 47 cases were caused by Staphylococcus aureus, 37 by Haemophilus influenzae, and 23 by Streptococcus pneumoniae. Among the 33 patients showing S. aureus positivity on ETA samples, 16 (48.5%) developed S. aureus EOP. Among the 156 S. aureus non-carriers, 16 (10.2%) developed EOP. Staphylococcus aureus carriage independently predicted EOP (p < 0.0001). We identified S. aureus carriage as an independent and strong predictor of EOP. As rapid point-of-care testing for S. aureus is readily available, we recommend testing of all patients at admission for burn trauma and the consideration of early preemptive treatment in all positive patients. Further studies are needed to evaluate this new strategy.

Rapid identification of pesticides in human oral fluid for emergency management by thermal desorption electrospray ionization/mass spectrometry

The World Health Organization acknowledges that pesticide self-poisoning is among the most frequently used methods of suicide worldwide. It is therefore of the highest importance to promptly identify the type of pesticides ingested by self-poisoning patients because different pesticides cause intoxication through different mechanisms, requiring different therapeutic strategies, precautions against contraindicating actions, directions of clinical course monitoring and predictions of prognosis. In this perspective Special Feature, Pr. Bai-Hsiun Chen (Laboratory Medicine and Pediatrics, College of Medicine, Kaohsiung Medical University, Taiwan) and colleagues propose a point-of-care analytical method for rapid identification of five residual pesticides in oral fluid using thermal desorption-electrospray ionization/mass spectrometry (TD-ESI/MS). This non-invasive approach can expedite emergency care and may provide important toxicological information for decision-making during critical resuscitation.

Rapid identification of pesticides in human oral fluid for emergency management by thermal desorption electrospray ionization/mass spectrometry.

Self-poisoning with pesticides accounts for approximately one-third of all suicides worldwide. To expedite rescue in the emergency department, it is essential to develop a point-of-care analytical method for rapid identification of ingested pesticides. In this study, five of the most common pesticides ingested by self-poisoning patients in Taiwan were analyzed from oral fluid samples. Pesticide-oral fluid mixtures were applied on a cotton swab and then transferred into methanol. A metallic probe was used to sample the methanol solution for subsequent thermal desorption-electrospray ionization mass spectrometry analysis. Altogether, pesticide sampling, transfer, desorption, ionization, and detection took less than 1 min. The reproducibility of this method (n = 6) was shown in the observed low-relative standard deviation (<7%) in the detection of pesticide in oral fluid. The detection limits of the pesticides in oral fluid obtained from four human subjects by thermal desorption-electrospray ionization mass spectrometry were between 1-10 ppb with relative standard deviation 10.7%. Moreover, in this study, linear responses of five pesticides in oral fluid with concentrations between 1 ppb-1 ppm (R2 between 0.9938 and 0.9988) were observed. As the whole analytical process is extremely short, this technique allows for early non-invasive point-of-care identification of pesticides in the oral fluid of self-poisoning patients in the emergency room, providing important toxicological information for decision-making during critical resuscitation.

Understanding traumatic shock: out-of-hospital hypotension with and without other physiologic compromise.

Among trauma patients with out-of-hospital hypotension, we evaluated the predictive value of systolic blood pressure (SBP) with and without other physiologic compromise for identifying trauma patients requiring early critical resources. This was a secondary analysis of a prospective cohort of injured patients 13 years or older with out-of-hospital hypotension (SBP ≤ 90 mm Hg) who were transported by 114 emergency medical service agencies to 56 Level I and II trauma centers in 11 regions of the United States and Canada from January 1, 2010, through June 30, 2011. The primary outcome was early critical resource use, defined as blood transfusion of 6 U or greater, major nonorthopedic surgery, interventional radiology, or death within 24 hours. Of 3,337 injured patients with out-of-hospital hypotension, 1,094 (33%) required early critical resources and 1,334 (40%) had serious injury (Injury Severity Score [ISS] ≥ 16). Patients with isolated hypotension required less early critical resources (14% vs. 52%), had less serious injury (20% vs. 61%), and had lower mortality (24 hours, 1% vs. 26%; in-hospital, 3% vs. 34%). The standardized probability of requiring early critical resources was lowest among patients with blunt injury and isolated moderate hypotension (0.12; 95% confidence interval, 0.09-0.15) and steadily increased with additional physiologic compromise, more severe hypotension, and penetrating injury (0.94; 95% confidence interval, 0.90-0.98). A minority of trauma patients with isolated out-of-hospital hypotension require early critical resuscitation resources. However, hypotension accompanied by additional physiologic compromise or penetrating injury markedly increases the probability of requiring time-sensitive interventions. Prognostic study, level II.

“Allow natural death” versus “Do not resuscitate”: What do patients with advanced cancer choose?

89 Background: Many patients with advanced cancer at our hospital request full resuscitative efforts at the end of life. In the first in a series of quality improvement projects to improve end-of-life (EOL) care, we assessed the knowledge and attitudes of patients towards it to determine if “Allow Natural Death” (AND) orders were more acceptable than “Do Not Resuscitate” (DNR) orders. Methods: Adult patients with advanced cancer being treated at a single community hospital were invited to participate. The first 100 consenting patients were surveyed regarding their diagnosis, prognosis, and attitudes about critical care and resuscitation. They were then presented with hypothetical scenarios in which a decision on their code status had to be made if they had 1 year, 6 months or 1 month left to live. Fifty patients were given a choice between being “full code“ and “DNR”, and 50 could choose between ”full code" and “AND”. Results: Participants were equally likely to choose either of the “no code” options in all hypothetical scenarios (p &gt; 0.54). The choice was not affected by age, sex, race, type of cancer, education, or income level. Patients who said they would want life-prolonging measures such as CPR, tracheostomies, and feeding tube placement in case of a permanent vegetative state were significantly less likely to choose “AND” than “full code” (p=0.001–0.002). A similar proportion of patients who had a living will chose “AND” and “DNR” orders instead of “full code” in all the scenarios (47–74% and 63–71%). In contrast, among patients who did not have a living will 52% chose “DNR”, while 19% opted for “AND”. More than a third (39 of 93) patients were not aware their illness was terminal. Conclusions: We hypothesized that “AND” orders may be more acceptable to patients with advanced cancer, but the wording of the “no code” order does not seem to be related to the patients’ code status decisions. The “Do not resuscitate” phrasing may be more acceptable to patients who view life-prolonging measures favorably.