Prehospital Advanced Life Support Research Articles

Tranexamic acid in the prehospital setting: Israel Defense Forces’ initial experience

BackgroundThe leading cause of preventable death in the military setting is haemorrhage. Accumulating evidence has established the benefit of tranexamic acid (TXA), an antifibrinolytic, for treating traumatic haemorrhage in the hospital setting. The use of TXA in the prehospital setting, however, has not been previously described. The present study details our initial experience with a field protocol that advances TXA administration to (or as close as possible to) the point of injury. MethodsWe present a series of all casualties treated with TXA by Israel Defense Forces’ (IDF) prehospital advanced life support providers between December 2011 and February 2013. Data were abstracted from the IDF Trauma Registry at the Research Section of the Trauma and Combat Medicine Branch, Surgeon General's Headquarters. ResultsForty casualties who received TXA in the prehospital setting were identified. Most casualties were male (n=35; 88%) and young adults (median 28 years). The mechanism of injury was penetrating in 22 cases (55%). TXA was administered earlier than it could have been in the hospital setting without delaying evacuation. There were no reports of adverse outcomes that could be reasonably attributed to TXA. Casualties who received TXA per protocol were sicker than those who received it not per protocol. ConclusionsWe have shown that TXA may be successfully given in the prehospital setting without any apparent delays in evacuation. In light of recent evidence, the ability to give TXA closer to the time of wounding represents an important step towards improving the survival of trauma victims with haemorrhage, even before definitive care is available. While this may be especially relevant in austere combat environments, there is likely benefit in the civilian sector as well. The safety profile of TXA is an important consideration as prehospital personnel tended to overtreat casualties without indications for TXA per protocol. We suggest that TXA be considered a viable option for use by advanced life support providers at or near the point of injury.

Physician-based emergency medical service deployment characteristics in severe traumatic brain injury: A Dutch multicenter study

IntroductionPrehospital guidelines advise advanced life support in all patients with severe traumatic brain injury (TBI). In the Netherlands, it is recommended that prehospital advanced life support is particularly provided by a physician-based helicopter emergency medical service (P-HEMS) in addition to paramedic care (EMS). Previous studies have however shown that a substantial part of severe TBI patients is exclusively treated by an EMS team. In order to better understand this phenomenon, we evaluated P-HEMS deployment characteristics in severe TBI in a multicenter setting. MethodsThe database included patient demographics, prehospital and injury severity parameters and determinants of EMS or EMS/P-HEMS dispatch in 334 patients with severe TBI admitted to level 1 trauma centres in the Netherlands. ResultsP-HEMS was deployed in 62% of patients with severe TBI. Patients treated by the P-HEMS had a higher injury severity score (29 (20–38)) vs. (25 (16–30); P<0.001), more frequently required blood product transfusions (41% vs. 29%; P=0.03) and recurrently suffered from TBI with extracranial injuries (33% vs. 6%; P<0.001) than patients solely treated by an EMS. The prehospital endotracheal intubation rate was higher in the P-HEMS group in isolated TBI (93% vs. 19%; P<0.001) or TBI with extracranial injuries (96% vs. 43%; P<0.001) compared to the EMS group. In the EMS group, more patients were secondary referred to a level 1 trauma centre (32% vs. 4%; P<0.001 vs. P-HEMS). Despite higher injury severity levels in P-HEMS patients, 6-month mortality rates were similar among groups, irrespective of the presence of extracranial injuries in addition to TBI. Deployment of P-HEMS estimated 52% and 72% (P<0.001) in urban and rural regions, respectively, with comparable endotracheal intubation rates among regions. ConclusionsThis study shows that a physician-based HEMS was more frequently deployed in patients with severe TBI in the presence of extracranial injuries, and in rural trauma regions. Treatment of severe TBI patients by a paramedic EMS only was associated with a higher incidence of secondary referrals to a level I trauma centre. Our data support adjustment of local prehospital guidelines for patients with severe TBI to the geographical context.

Multivariate Analysis of Successful Intravenous Line Placement in the Prehospital Setting

Background. Intravenous (IV) line placement is an important prehospital advanced life support skill, but IV success rates are variable among providers. Little is known about what factors are associated with successful IV placement, limiting the ability to develop benchmarks for skill maintenance, such as requiring a specific number of IV placements per year. Objective. We aimed to identify whether first-pass IV success was associated with the number of attempted or successful previous IV attempts. We hypothesized that IV success is associated with the number of successful IV placements in the preceding year. Methods. We retrospectively studied 800 consecutive charts with an IV attempt from 11 suburban and rural emergency medical services (EMS) agencies over a one-month period. Cases involving pediatric patients (age <18 years) and those with incomplete data were excluded. Success of the first IV attempt was identified. Potential predictor variables were collected and analyzed by univariate logistic regression, including patient age, systolic blood pressure, history of IV drug abuse or renal disease, traumatic event, catheter size, and location of IV attempt, as well as the individual provider's numbers of total and successful IV attempts in the preceding year. Variables significantly associated with IV success at the p < 0.10 level were included in a multivariate regression model using a p-value of 0.05. Results. Of 602 cases meeting the study criteria, 469 (77.9%) had a successful first-pass IV placement. Significantly associated with IV success in the univariate regression were patient age (p = 0.054), trauma (p = 0.074), IV catheter size (p < 0.001), IV location (p = 0.056), and the number of previous successful IV attempts (p = 0.039), whereas the number of total previous IV attempts was not significantly associated (p = 0.871). In the multivariate logistic regression model, only IV catheter size had a significant association (p < 0.001), with a larger-bore IV catheter size associated with higher success. Conclusion. In this retrospective study, larger IV catheter size, but not the prehospital providers’ previous year's experience, was associated with successful IV placement in adult patients. These data fail to support requirements for a minimum number of yearly IV placements by full-time paramedics to improve success rates.

Prehospital care in patients with severe traumatic brain injury: does the level of prehospital care influence mortality?

The controversy between the "scoop and run" versus the "stay and play" approach in severely injured trauma patients has been an ongoing issue for decades. The present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the Netherlands have improved outcome. In this retrospective study, files (n=60) were analyzed from a prospectively collected database including all patients admitted to one of six hospitals in the Limburg region in the Netherlands with a Glasgow Coma Scale (GCS) score ≤8 on admittance over the period from January 2006 to December 2008. All patients had traumatic brain damage proven on computed tomography (CT) or magnetic resonance imaging (MRI). Relevant prehospital and clinical data from the present cohort were compared to data from a similar study (n=30) conducted 20years ago. The primary outcome assessed was mortality. The two study groups had similar characteristics with regard to the GCS score. In the historic cohort, Basic Life Support (BLS) and the "scoop and run" approach in patients with major traumatic brain injury was common, with an average time on scene of 7.5min. Currently, prehospital care is performed mainly on the level of prehospital Advanced Life Support (ALS), with the average time on scene being about four times as long as in the historic cohort. However, the overall mortality rate for the current cohort compared to the historic cohort has not changed. Despite more on-site ALS in severely head injured patients nowadays compared to the historic cohort, there was no reduction in mortality.

Usefulness of Medical Conferences

clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest. JAMA. 1992;268(19):2667-2672. 3. Kellermann AL, Hackman BB, Somes G. Predicting the outcome of unsuccessful prehospital advanced cardiac life support. JAMA. 1993;270(12):1433-1436. 4. Gum PA, Thamilarasan M, Watanabe J, Blackstone EH, Lauer MS. Aspirin use and all-cause mortality among patients being evaluated for known or suspected coronary artery disease: a propensity analysis. JAMA. 2001;286(10):11871194.

Usefulness of Medical Conferences

clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest. JAMA. 1992;268(19):2667-2672. 3. Kellermann AL, Hackman BB, Somes G. Predicting the outcome of unsuccessful prehospital advanced cardiac life support. JAMA. 1993;270(12):1433-1436. 4. Gum PA, Thamilarasan M, Watanabe J, Blackstone EH, Lauer MS. Aspirin use and all-cause mortality among patients being evaluated for known or suspected coronary artery disease: a propensity analysis. JAMA. 2001;286(10):11871194.

Current termination of resuscitation (TOR) guidelines predict neurologically favorable outcome in Japan

BackgroundIt is unclear whether the basic life support (BLS) and advanced life support (ALS) pre-hospital termination of resuscitation (TOR) rules developed in North America can be applied successfully to patients with out-of-hospital cardiac arrest (OHCA) in other countries. ObjectivesTo assess the performance of the BLS and ALS TOR in Japan. MethodsRetrospective nationwide, population-based, observational cohort study of consecutive OHCA patients with emergency responder resuscitation attempts from 1 January 2005 to 31 December 2009 in Japan. The BLS TOR rule has 3 criteria whereas the ALS TOR rule includes 2 additional criteria. We extracted OHCA patients meeting all criteria for each TOR rule, and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying OHCA patients who did not have neurologically favorable one-month survival. ResultsDuring the study-period, 151,152 cases were available to evaluate the BLS TOR rule, and 137,986 cases to evaluate the ALS TOR rule. Of 113,140 patients that satisfied all three criteria for the BLS TOR rule, 193 (0.2%) had a neurologically favorable one-month survival. The specificity of BLS TOR rule was 0.968 (95% CI: 0.963–0.972), and the PPV was 0.998 (95% CI: 0.998–0.999) for predicting lack of neurologically favorable one-month survival. Of 41,030 patients that satisfied all five criteria for the ALS TOR rule, just 37 (0.1%) had a neurologically favorable one-month survival. The specificity of ALS TOR rule was 0.981 (95% CI: 0.973–0.986), and the PPV was 0.999 (95% CI: 0.998–0.999) for predicting lack of neurologically favorable one-month survival. ConclusionsThe prehospital BLS and ALS TOR rules performed well in Japan with high specificity and PPV for predicting lack of neurologically favorable one-month survival in Japan. However, the specificity and PPV were not 1000 and we have to develop more specific TOR rules.

The pending loss of advanced life support paramedics in South Africa

Background In 2008 South Africa (SA) had 1631 registered advanced life support (ALS) paramedics to provide pre-hospital advanced life support care to a population of approximately 50 million. Compared to globally accepted ratios, the number of ALS paramedics in South Africa can be considered as grossly inadequate. This current shortage may be ascribed to migration. However, the extent and nature of this migration, the factors that have contributed to them leaving the country and the existence or effectiveness of implemented strategies that attempt to manage migration of SA ALS paramedic is not known for sure. Methods The study consisted of a two-phase mixed method descriptive survey. A subset of SA ALS paramedics made up the study population. Quantitative data (Phase One) was obtained from a web-based survey distributed to the accessible population (N=97). Thereafter, qualitative data (Phase Two) was gathered through in-depth interviews with selected information rich participants (n=10) also from within the accessible population. Through methodological triangulation, data from Phase One and Phase Two were integrated to obtain an in-depth understanding of South African ALS paramedic migration. In addition, the study investigated whether strategies that attempted to manage migration of SA ALS paramedics existed, and if they did, how effective have they been. Result Fifty-one of 97 (53%) ALS paramedics responded to the questionnaire in Phase One. Of those, 24 (47.1%) were found to be working inside South Africa, while 27 (52.9%) were working outside South Africa. Working conditions, physical security, and economic considerations were ranked as the top three major factors contributing to the decision or intended decision to migrate. Initiatives to manage the shortage of ALS paramedics in the public sector EMS do exist; however, it appears to be inadequate at its current rate of progress. Conclusion This study suggests that ALS paramedics in SA are leaving to find work outside the country because of working conditions, physical security, and economic considerations. The current measures to manage migration appear to be ineffective, indicating that new or additional strategies to manage migration of ALS paramedics in SA may be required.

Abstract 239: Does the Performance of Emergency Medical Dispatch (EMD) Affect Survival from Out-of-Hospital Cardiac Arrests (OHCAs)? An Analysis of the Taipei Utstein Arrest Registry

Introduction Dispatch-instructed bystander cardiopulmonary resuscitation (DI-CPR) was recommended by current resuscitation guidelines. The pivotal step of DI-CPR was the accurate recognition of OHCAs by interview of caller. However, previous studies showed the compliance of dispatchers in posing priority questions to identification of OHCAs is unsatisfactory. This study aimed to estimate the incremental effect on recovery of spontaneous circulation (ROSC) of OHCAs if the dispatcher could have more OHCAs recognized through a better adhesion to dispatch protocol. Methods Emergency medical service system of Taipei City is the first one in Taiwan to implement service of prehospital advanced life support (ALS) and to develop the database of Utstein registry to track the OHCAs. We analyzed the Taipei Utstein database to evaluate the association between bystander CPR and ROSC of OHCAs stratified by EMD performance including recognition of OHCA and instruction of CPR. Because the recognition of OHCAs was not requested in registry, we used the results of dispatched tier as surrogates. The dispatcher would send an ALS team to the scene if they succeed to alert the OHCAs by call, while only a BLS team would be dispatched if they failed to. Results From 2008 to 2009, there were total 3573 adult non-traumatic OHCAs registered with attempted resuscitation. Among them, bystander CPR rate and overall ROSC rate were 15.4% and 22.2% respectively. Bystander CPR was significantly associated with better ROSC even after adjustment for other variables. The bystander CPR rate was up to 25.5% in OHCAs recognized by EMD but was only 10.0% in those who did not. The association between ROSC and the performance of dispatchers were tabulated beneath. Conclusion Bystander CPR was one of the most important factors to survival of OHCAs in Taipei. Performance of EMD had the potential to benefit the ROSC rate of OHCA patients as long as the dispatcher could recognize more OHCAs cases.

AP090 Cerebral flow improvement during CPR with LUCAS measured by Doppler

Great quality chest compressions are the most important maneouvers together with prompt defibrillation to guarantee critical flow to heart and brain in a sudden cardiac arrest treatment. Cerebral flow can be measured by trans-cranial doppler; normal rates for a healthy person are 60–80 cm/s. LUCAS® devices performs 5 cm depth chest compressions at a rate of 100 per minute, becoming immune to tiredness. Aim: To compare the middle cerebral artery flow measured by doppler, with or without LUCAS® chest compressor during cardio-pulmonary resuscitation. Methods: Prospective study from January 2011 to June 2011, where one prehospital advanced life support unit (ALSU) from the city of Barcelona was provided with the Toshiba Viamo portable ultrasound scanner and one physician was trained in cerebrovascular ultrasound during 1 month previously to the beggining of the study. Cerebral middle artery flow at 5–6 cm was mesured in all the sudden cardiac arrest (SCA) assisted by this trained unit in the study period, previously and after the LUCAS® device was placed. Results: 6 patients with SCA were assisted, 3 of them males (66±10.53 years old) and 3 females (48.33±22.67 years old). 1 patient with a SCA caused by a STEMI recovered spontaneous circulation (ROSC) before the ultrasound scan could be performed and his flow after ROSC was 96 cm/s. 2 young females suffered SCA as a consequence of a spontaneous subarachnoid haemorrhage (SSH) and no flow was observed with manual chest compressions nor with LUCAS®, but one of them ROSC. In the other 3 patients the median flow was 31.6±8.32 cm/s in the manual group in front of 50.6±27.12 cm/s in LUCAS® group. Conclusions: Patients with SCA due to SSH seem not to receive cerebral flow during resuscitation with manual chest compressions nor with LUCAS®. LUCAS seems to improve cerebral flow compared with manual CPR during the resuscitation of patients with a non-SSH SCA.

In reply: Is out-of-hospital intubation by paramedics valid enough to be continued?

To the Editor:As Dr. Morita and his colleagues describe in their Letterto the Editor, many recent studies have shown that out-of-hospital intubation is associated with decreased survival[1–3]. However, there are differences in the medicalbackground of the endotracheal intubation (ETI) performedin these studies and our study.The incidence of ETI attempted by paramedics in thereported studies was extremely high ([80%) in the USA[1–3], with ETI attempted in patients with a difficult air-way or with a Cormack grade of C2[2]. In the regioncovered by our study, ETI is not permitted as a routineprocedure for patients with out-of-hospital cardiac arrest(OHCA). In addition, ETI attempts are terminated whenthe Cormack grade of patient is C2.The etiology of cardiac arrest may have differedbetween the patients in our study and those of the otherstudies. In none of the three studies [1–3] did the patientsshow an etiology of cardiac arrest. Approximately 60–70%of cardiac arrest is related to coronary heart disease in theUSA [4]. In our study, we showed that implementation ofETI may worsen the outcomes in OHCA patients with acardiac etiology, but they may improve the outcomes inOHCA patients without a noncardiac etiology.Finally, ETI was repeatedly attempted by paramedics inthe USA [2]. In our region, only two attempts are made.The interruption of chest compression accompanying theETI was set at\30 s prior to November 2006 and at\10 sthereafter.The Ontario pre-hospital advanced life support(OPALS) respiratory distress study showed that the intro-duction of an EMS advanced-life-support program signif-icantly reduced the mortality of patients with shortness ofbreath [5]. Japanese paramedics are allowed to performETI immediately after they witness a cardiac arrest. Webelieve that effectiveness of ETI should be prospectivelyevaluated in OHCAs that occur following the arrival of theparamedic.In our study, we excluded 124 patients in whomadvanced airway management (AAM) was discontinued orfailed. Of these 124 patients, 52 were managed by non-certified paramedics and did not include cases of attemptedETI. In the remaining 72 patients, certified paramedicsattempted either ETI or another AAM procedure, or both.Therefore, the 124 patients varied widely in terms of AAMprocedure and were justifiably excluded from the analysis.The AAM procedure was more frequently attempted bycertified paramedics. However, we showed that manage-ment by paramedics qualified for ETI was not independentfactor associated with sustained return of spontaneouscirculation.More than 50 or 60 intubations may be necessary toachieve a 90% success rate when the ETI is attemptedwithout considering the Cormack. According to a pre-liminary analysis in our region, after paramedics have had15 consecutive cases with Cormack grade of 1, the successrate in the following ten cases exceeds 95%. The trainingprograms are considered to be appropriate for the patientswith a Cormack grade of 1.The harm caused by ETI should be minimized by edu-cation and continuous quality assurance. In our region, arecertification program for certified paramedics has been

The Association Between Obesity and Difficult Prehospital Tracheal Intubation

Nonphysician advanced life support (ALS) providers often perform tracheal intubation (TI) for cardiac arrest or other life-threatening indications in the prehospital setting, where airway assessment and airway management tools are limited. However, the frequency of difficult TI in obese patients in this setting is unclear. In this study we determined factors associated with TI success, and determined TI difficulty as a function of body mass index (BMI) in a system of ALS providers experienced in TI, to guide future prehospital education efforts. A retrospective review was performed of all patients ≥15 years of age who underwent prehospital TI by paramedics in the Seattle Medic One system over a 4-year period, and were transported to the regional level 1 trauma center (Harborview Medical Center). Data were abstracted from a prospectively collected prehospital airway management database and from the hospital medical records, including demographic information, number of TI attempts, TI success or failure, and body weight/height (BMI). Descriptive statistics and multivariable logistic regression were calculated, with the primary end point being difficult TI (defined as ≥4 TI attempts or the need to use an alternative airway management technique). Of 80,501 patient contacts in whom 4114 TIs were attempted during the 4-year study period, 823 met study entry criteria (including a calculable BMI). The overall TI success rate in the study population was 98.5% (811 out of 823), with 6.8% (56 out of 823) meeting the predetermined definition for difficult TI. There was no significant association between difficult TI and patient age, gender, use of succinylcholine, or medical diagnosis (trauma vs. nontrauma). In comparison with the lean patient subgroup (BMI <30 kg/m(2)), patients with class III obesity (BMI >40 kg/m(2)) had a significant association with difficult TI (odds ratio 3.68; confidence interval [CI] 1.27-10.59), whereas those with class I/II obesity (BMI ≥30 kg/m(2) and <40 kg/m(2)) did not (odds ratio 0.98; CI 0.46 -2.07). Among prehospital ALS providers with previously documented and published successful TI performance, increased difficulty with TI was observed in patients with extreme obesity, but not in patients with lesser degrees of obesity. Because extreme obesity is an easily identifiable patient characteristic, didactic and clinical (e.g., operating room) airway management education for such providers should emphasize airway management challenges and strategies associated with obesity, including specific equipment, patient positioning, and practice recommendations that may facilitate both TI and alternative airway management techniques in this population.

Commentary: Making a Difference in Emergency Medical Services

Commentary: Making a Difference in Emergency Medical Services

Nosocomial and community-acquired infection rates of patients treated by prehospital advanced life support compared with other admitted patients

Objectives Nosocomial infections are a large burden to both patients and health care organizations, causing hospitals to take measures in an attempt to reduce microorganism transmission. Patients treated by emergency medical services are one population that has not been studied regarding infection rates. This study examines admitted patients treated by advanced life support (ALS) and their likelihood of having community-acquired and nosocomial infections. Methods A retrospective cohort study was conducted of 154 318 admitted patients between 2003 and 2007. Subjects identified as having either community-acquired or nosocomial infections were grouped based on infection type and ALS treatment. The proportion of infected patients among total hospital admissions in each of these groups was calculated and compared using odds ratios (ORs). Results A total of 5418 patients had at least 1 infection while admitted (3653 nosocomial, 1765 community). The probability of an ALS patient getting a nosocomial infection was 3.20% versus 2.28% for non-ALS patients (OR, 1.42; 95% confidence interval [CI], 1.28-1.57). There was no significant difference in community-acquired infections between ALS and non–ALS-treated groups (1.22% vs 1.14%; OR, 1.08; 95% CI, 0.92-1.26). Conclusions Despite having similar rates of community-acquired infections, patients admitted after ALS treatment had significantly greater risk for nosocomial infections. Because causality is not established, it remains unknown whether paramedic interventions contributed to the increased rate. Quite possibly, these patients are more susceptible to virulent organisms; however, prospective research is needed to identify causal relationships. Thus, treatment by ALS can be used as an identifier of patients at an increased risk of acquiring nosocomial infections.

Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses

Introduction This study proposes that intranasal (IN) naloxone administration is preferable to intravenous (IV) naloxone by emergency medical services for opioid overdoses. Our study attempts to establish that IN naloxone is as effective as IV naloxone but without the risk of needle exposure. We also attempt to validate the use of the Glasgow Coma Scale (GCS) in opioid intoxication. Methods A retrospective chart review of prehospital advanced life support patients was performed on confirmed opioid overdose patients. Initial and final unassisted respiratory rates (RR) and GCS, recorded by paramedics, were used as indicators of naloxone effectiveness. The median changes in RR and GCS were determined. Results Three hundred forty-four patients who received naloxone by paramedics from January 1, 2005, until December 31, 2007, were evaluated. Of confirmed opioid overdoses, change in RR was 6 for the IV group and 4 for the IN group ( P = .08). Change in GCS was 4 for the IV group and 3 for the IN group ( P = .19). Correlations between RR and GCS for initial, final, and change were significant at the 0.01 level ( ρ = 0.577, 0.462, 0.568, respectively). Conclusion Intranasal naloxone is statistically as effective as IV naloxone at reversing the effects of opioid overdose. The IV and IN groups had similar average increases in RR and GCS. Based on our results, IN naloxone is a viable alternative to IV naloxone while posing less risk of needle stick injury. Additionally, we demonstrated that GCS is correlated with RR in opioid intoxication.

Collaborative effects of bystander-initiated cardiopulmonary resuscitation and prehospital advanced cardiac life support by physicians on survival of out-of-hospital cardiac arrest: a nationwide population-based observational study

IntroductionThere are inconsistent data about the effectiveness of prehospital physician-staffed advanced cardiac life support (ACLS) on the outcomes of out-of-hospital cardiac arrest (OHCA). Furthermore, the relative importance of bystander-initiated cardiopulmonary resuscitation (BCPR) and ACLS and the effectiveness of their combination have not been clearly demonstrated.MethodsUsing a prospective, nationwide, population-based registry of all OHCA patients in Japan, we enrolled 95,072 patients whose arrests were witnessed by bystanders and 23,127 patients witnessed by emergency medical service providers between 2005 and 2007. We divided the bystander-witnessed arrest patients into Group A (ACLS by emergency life-saving technicians without BCPR), Group B (ACLS by emergency life-saving technicians with BCPR), Group C (ACLS by physicians without BCPR) and Group D (ACLS by physicians with BCPR). The outcome data included 1-month survival and neurological outcomes determined by the cerebral performance category.ResultsAmong the 95,072 bystander-witnessed arrest patients, 7,722 (8.1%) were alive at 1 month, including 2,754 (2.9%) with good performance and 3,171 (3.3%) with vegetative status or worse. BCPR occurred in 42% of bystander-witnessed arrests. In comparison with Group A, the rates of good-performance survival were significantly higher in Group B (odds ratio (OR), 2.23; 95% confidence interval, 2.05 to 2.42; P < 0.01) and Group D (OR, 2.80; 95% confidence interval, 2.28 to 3.43; P < 0.01), while no significant difference was seen for Group C (OR, 1.18; 95% confidence interval, 0.86 to 1.61; P = 0.32). The occurrence of vegetative status or worse at 1 month was highest in Group C (OR, 1.92; 95% confidence interval, 1.55 to 2.37; P < 0.01).ConclusionsIn this registry-based study, BCPR significantly improved the survival of OHCA with good cerebral outcome. The groups with BCPR and ACLS by physicians had the best outcomes. However, receiving ACLS by physicians without preceding BCPR significantly increased the number of patients with neurologically unfavorable outcomes.

Risk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approach

IntroductionEndotracheal intubation (ETI) has been considered an essential part of pre-hospital advanced life support. Pre-hospital ETI, however, is a complex intervention also for airway specialist like anaesthesiologists working as pre-hospital emergency physicians. We therefore wanted to investigate the quality of pre-hospital airway management by anaesthesiologists in severely traumatised patients and identify possible areas for improvement.MethodWe performed a risk assessment according to the predictive Bayesian approach, in a typical anaesthesiologist-manned Norwegian helicopter emergency medical service (HEMS). The main focus of the risk assessment was the event where a patient arrives in the emergency department without ETI despite a pre-hospital indication for it.ResultsIn the risk assessment, we assigned a high probability (29%) for the event assessed, that a patient arrives without ETI despite a pre-hospital indication. However, several uncertainty factors in the risk assessment were identified related to data quality, indications for use of ETI, patient outcome and need for special training of ETI providers.ConclusionOur risk assessment indicated a high probability for trauma patients with an indication for pre-hospital ETI not receiving it in the studied HEMS. The uncertainty factors identified in the assessment should be further investigated to better understand the problem assessed and consequences for the patients. Better quality of pre-hospital airway management data could contribute to a reduction of these uncertainties.

Clinical Decision Rules for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest

Background: Out-of-hospital cardiac arrest (OHCA) has a low probability of survival to hospital discharge. Four clinical decision rules (CDRs) have been validated to identify patients with no probability of survival. Three of these rules focus on exclusive prehospital basic life support care for OHCA, and two of these rules focus on prehospital advanced life support care for OHCA. Clinical Question: Can a CDR for the termination of resuscitation identify a patient with no probability of survival in the setting of OHCA? Evidence Review: Six validation studies were selected from a PubMed search. A structured review of each of the studies is presented. Results: In OHCA receiving basic life support care, the BLS-TOR (basic life support termination of resuscitation) rule has a positive predictive value for death of 99.5% (95% confidence interval 98.9–99.8%), and decreases the transportation of all patients by 62.6%. This rule has been appropriately validated for widespread use. In OHCA receiving advanced life support care, no current rule has been appropriately validated for widespread use. Conclusions: The BLS-TOR rule is a simple rule that identifies patients who will not survive OHCA. Further research is required to identify similarly robust CDRs for patients receiving advanced life support care in the setting of OHCA.

Public Access Defibrillation

Sudden cardiac arrest (SCA) is recognized as a serious public health problem, accounting for 250 000 to 300 000 deaths per year; it is now the third-leading cause of death behind cancer and nonsudden cardiovascular deaths.1,2 Immediate, well-performed cardiopulmonary resuscitation (CPR) and early defibrillation are the only out-of-hospital interventions that improve outcomes.3 The chain of survival relies on lay responders and emergency medical services (EMS) to initiate the potentially life-saving procedures of CPR and defibrillation. Articles see pp 510 and 518 In 1994, the American Heart Association (AHA) convened the first conference on public access defibrillation (PAD) to introduce the strategy of placing easy-to-use defibrillators in public places to decrease the death rate from SCA.4 Specific recommendations encouraged the stakeholders (the AHA, the US Food and Drug Administration, the National Institutes of Health, industry, and communities) to facilitate PAD by developing user-friendly, less-expensive automated external defibrillators (AEDs); testing the concept within large clinical trials; and organizing communities to promote and support effective PAD programs. Widespread CPR and AED training of the public was emphasized. In the ensuing 15 years, many of these recommendations have been heeded, and PAD programs are now commonplace. The National Institutes of Health–sponsored PAD trial demonstrated that survival doubled when events occurred in communities equipped and trained with CPR and AEDs compared with CPR alone.5 Within the Resuscitations Outcomes Consortium (ROC), out-of-hospital cardiac arrest victims had a markedly increased chance of survival if the first shock was delivered by a bystander using an AED rather than by EMS.6 PAD programs in airports, airlines, and casinos have also validated the effectiveness of the concept. Out-of hospital cardiac arrest is treatable, and outcomes can be improved with currently available approaches. Multiple locations have been recognized as having a higher incidence of cardiac arrest …

Effect of Transport Interval on Out-of-Hospital Cardiac Arrest Survival in the OPALS Study: Implications for Triaging Patients to Specialized Cardiac Arrest Centers

To identify any association between out-of-hospital transport interval and survival to hospital discharge in victims of out-of-hospital cardiac arrest. Data from the Ontario Prehospital Advanced Life Support Study (January 1, 1991, to December 31, 2002), an Utstein-compliant registry of out-of-hospital cardiac arrest patients from 21 communities, were analyzed. Logistic regression identified factors that were independently associated with survival in consecutive adult, nontraumatic, out-of-hospital cardiac arrest patients and in the subgroup with return of spontaneous circulation. A total of 18,987 patients met criteria and 15,559 (81.9%) had complete data for analysis (study group). Return of spontaneous circulation was achieved in 2,299 patients (14.8%), and 689 (4.4%) survived to hospital discharge. Median transport interval was 4.0 minutes (25th quartile 3.0 minutes; 75th quartile 6.2 minutes) for survivors and 4.2 minutes (25th quartile 3.0, 75th quartile 6.2) for nonsurvivors. Logistic regression revealed multiple factors that were independently associated with survival: witnessed arrest (odds ratio 2.61; 95% confidence interval [CI] 2.05 to 3.34), bystander cardiopulmonary resuscitation (odds ratio 2.22; 95% CI 1.82 to 2.70), initial rhythm of ventricular fibrillation/tachycardia (odds ratio 2.22; 95% CI 1.97 to 2.50), and shorter emergency medical services (EMS) response interval (odds ratio 1.26; 95% CI 1.20 to 1.33). There was no association between transport interval and survival in either the study group (odds ratio 1.01; 95% CI 0.99 to 1.05) or the return of spontaneous circulation subgroup (odds ratio 1.04; 95% CI 0.99, 1.08). In a large out-of-hospital cardiac arrest study from demographically diverse EMS systems, longer transport interval was not associated with decreased survival. Given the growing evidence showing major influence from specialized postarrest care, these findings support conducting clinical trials that assess the effectiveness and safety of bypassing local hospitals to take patients to regional cardiac arrest centers.