Prehospital Resuscitation Research Articles

Pre-Hospital Advanced Life Support Resuscitation Training: A Pilot of An Evidence-Based Curriculum

Introduction There is a broad evidence base to support advanced life support (ALS) education for healthcare professionals being structured, realistic and inclusive of a range of human factors. This paper outlines the results of a pilot ALS resuscitation course tailored for providers working in pre-hospital resource-limited settings. The focus on the pre-hospital ALS environment, team mix, techniques, skills and equipment are important because actions taken by pre-hospital healthcare professionals have a critical impact on the likelihood of patient survival. Methods A pre-hospital ALS course was piloted following research into the need for a course and development of a pre-hospital-specific curriculum, based on Australian Resuscitation Council (ARC) guidelines. There were 13 pilot courses run, involving 66 participants. Participants all worked in the pre-hospital environment and held qualifications ranging from a Certificate IV in Healthcare through to postgraduate paramedicine qualifications. The pre-hospital ALS course consisted of theory and practical elements, pre-reading and a pre- and post-course quiz. Feedback was sought from course participants and an expert panel was consulted on the findings. Results Participants and the Expert Panel indicated that a pre-hospital ALS course should follow current recommendations of the ARC and be delivered to persons with sufficient underpinning knowledge of ALS resuscitation. The course should include pre-reading on ALS protocols and a pre-test followed by one day of face-to-face teaching using equipment reflective of the pre-hospital environment. Scenarios should be relevant to the pre-hospital setting and involve varying numbers of responders. Participants should be assessed on a continual basis during the course. Conclusion To improve participant confidence in the delivery of ALS and maximise the likelihood of patient survival, pre-hospital ALS resuscitation education for pre-hospital providers should follow ARC guidelines, include pre-course reading and practical simulation that reflects participants’ day-to-day employment.

Pre-Hospital Advanced Life Support Resuscitation – a Curriculum for Pre-Hospital Education

Introduction There is a broad evidence base to support advanced life support (ALS) education for healthcare professionals being structured, realistic and inclusive of a range of human factors. This paper outlines a curriculum for ALS resuscitation education for providers working in the pre-hospital or resource-limited settings. The focus on pre-hospital ALS education is important because actions taken by pre-hospital healthcare professionals have a critical impact on the likelihood of patient survival. Methods The pre-hospital ALS curriculum developed in this research was derived from a survey and interviews with pre-hospital healthcare professionals and first responders, and input from resuscitation, medical and education experts. Following completion of the interviews an expert panel of resuscitation experts was consulted. Results Information collected indicated that a pre-hospital ALS course should follow current recommendations of the Australian Resuscitation Council and that the course should be delivered in a mixed mode comprising of online pre-reading and a quiz followed by one day of face-to-face teaching. Equipment should reflect that used in the pre-hospital environment and a pre-hospital ALS course should include scenarios relevant to the pre-hospital setting involving varying numbers of interprofessional healthcare teams as well as first responders and lay persons. Candidates should be assessed on a continual basis and certificates of participation be valid for 2 to 3 years. Conclusion To improve pre-hospital resuscitation education and maximise the likelihood of patient survival, ALS education for pre-hospital providers should follow Australian Resuscitation Council guidelines, include pre-course reading, case studies and practical simulation in situations that are likely to be encountered by pre-hospital professionals.

A mobile device app to reduce prehospital medication errors and time to drug preparation and delivery by emergency medical services during simulated pediatric cardiopulmonary resuscitation: study protocol of a multicenter, prospective, randomized controlled trial

BackgroundEmergency drug preparation and administration in children is both complex and time-consuming and places this population at a higher risk than adults for medication errors. Moreover, survival and a favorable neurological outcome from cardiopulmonary resuscitation are inversely correlated to drug preparation time. We developed a mobile device application (the pediatric Accurate Medication IN Emergency Situations (PedAMINES) app) as a step-by-step guide for the preparation to delivery of drugs requiring intravenous injection. In a previous multicenter randomized trial, we reported the ability of this app to significantly reduce in-hospital continuous infusion medication error rates and drug preparation time compared to conventional preparation methods during simulation-based pediatric resuscitations. This trial aims to evaluate the effectiveness of this app during pediatric out-of-hospital cardiopulmonary resuscitation.Methods/designWe will conduct a multicenter, prospective, randomized controlled trial to compare the PedAMINES app with conventional calculation methods for the preparation of direct intravenously administered emergency medications during standardized, simulation-based, pediatric out-of-hospital cardiac arrest scenarios using a high-fidelity manikin. One hundred and twenty paramedics will be randomized (1:1) in several emergency medical services located in different regions of Switzerland. Each paramedic will be asked to prepare, sequentially, four intravenously administered emergency medications using either the app or conventional methods. The primary endpoint is the medication error rates. Enrollment will start in mid-2019 and data analysis in late 2019. We anticipate that the intervention will be completed in early 2020 and study results will be submitted in late 2020 for publication (expected in early 2021).DiscussionThis clinical trial will assess the impact of an evidence-based mobile device app to reduce the rate of medication errors, time to drug preparation and time to drug delivery during prehospital pediatric resuscitation. As research in this area is scarce, the results generated from this study will be of great importance and may be sufficient to change and improve prehospital pediatric emergency care practice.Trial registrationClinicalTrials.gov, ID: NCT03921346. Registered on 18 April 2019.

Abstract 458: Pause Duration During Manual CPR is Associated With Survival and Favorable Neurological Outcome in All-Rhythm OHCA

Introduction: AHA guidelines emphasize the importance of limiting pauses during CPR to less than 10 seconds due to the association of interruptions in chest compressions (CC) with adverse outcomes. Previous literature has associated shorter peri-shock pause times with greater odds of survival and longest pause in CC with lower odds of survival, though these analyses were restricted to patients with initial shockable rhythm. The aim of this analysis is to investigate the association between CC pause duration and patient outcomes in all-rhythm OHCA. Methods: OHCA cases from three EMS Agencies in Arizona between Jan 2016-Dec 2016 (n=229) were analyzed. De-identified prehospital patient data were linked to outcome data as part of the state quality program. Pauses calculated from CPR pad accelerometer data were defined by a minimum duration of 1000 ms. Mean pause duration was calculated by case as the average of all pauses, while longest pause duration was defined as the single longest pause in CC. Descriptive statistics and multivariate logistic regression was performed in STATA 15.1. Primary outcome measures defined were ROSC, survival-to-discharge, and favorable neurological outcome (Cerebral Performance Category 1 or 2). Covariates included in the statistical model include time in CPR, age, witnessed arrest, initial shockable rhythm, bystander CPR, and CPR quality. Results: A total of 37.1% of patients (n=85) achieved prehospital ROSC, 12.7% (n=29) survived, and 10.5% (n=24) had favorable neurological outcome. Average mean and longest pause duration was 8.13 + 0.76 s and 24.93 + 2.84 in survivors with favorable neurological outcome compared to 9.21 + 0.47 s and 35.56 + 3.55 s in non-survivors. Mean pause duration was associated with survival (adjusted OR 0.89, 95% CI 0.80-0.99) and favorable neurological outcome (adjusted OR 0.83, 95% CI 0.72-0.97). Longest pause duration was associated with favorable neurological outcome (adjusted OR 0.97, 95% CI 0.94-1.00). Conclusions: Prolonged pauses in CC during prehospital resuscitation was associated with worse survival and neurological function in OHCA patients with all cardiac rhythms. Pause duration should be kept as brief as possible due to the impact upon outcomes regardless of presenting cardiac rhythm.

Abstract 168: Relation Between the Prehospital Administrated Doses of Epinephrine and the Acquisition of Return of Spontaneous Circulation in Patients With Cardiopulmonary Arrest

Introduction: The efficacy of epinephrine (Ep) administration to cardiopulmonary arrest (CPA) patients is still controversial, and correlation between plasma Ep levels of and prognosis in CPA patients is unclear. Hypothesis: We hypothesized that the more EP is administered, the higher the rate of ROSC becomes in CPA patients. The purpose of this study is to evaluate whether a dose of Ep influenced the prognosis in CPA patients. Methods: This was a prospective, observational clinical study, approved by the ethics committee of Gunma University Hospital (IRB #14-13). CPA patients transferred to our hospital were enrolled prospectively between July 2014 and July 2017. The levels of Ep in the plasma were measured using blood samples immediately obtained at the time of arrival to our hospital. Patients were divided into the four groups based on the prehospital administered dose of EP; patients without prehospital Ep administration (group Z), prehospital administration of 1mg Ep (group O), 2mg Ep (group T) and 4mg Ep (group F). The plasma Ep levels and the conditions of resuscitation were compared among those groups. The IBM SPSS Statistics 25 software was used for statistical analysis. Data are shown as median (Q1, Q3). The Kruskal-Wallis or chi-square tests were used to conduct the comparisons among four groups. P<0.05 denoted statistical significance. Results: We analyzed 150 patients. There were 96 patients in group Z, 38 in group O, 11 in group T and 5 in group F. There was no significant difference in prehospital resuscitation time among 4 groups, and the level of Ep in the plasma obtained immediately after arrival at hospital was the highest in the group F with a significant difference {286.0 (247.2, 424.9) ng/ml in group F, 244.0 (22.1, 620.3) ng/ml in group T, 1.6 (0.5, 4.5) ng/ml in group O and 2.0 (0.4, 4.5) ng/ml in group Z, respectively, p<0.001}. However, the ratio of ROSC acquisition was the lowest in the group F with a significant difference (0 in group F, 18.2% in group T, 15.8% in group O and 35.4% in group Z). Conclusions: Our results suggest that the prehospital administered dose of Ep is not relates with the acquisition of ROSC in patients with CPA.

Should Albumin be Considered for Prehospital Resuscitation in Austere Environments? A Prospective Randomized Survival Study in Rabbits.

The new guidelines for prehospital care of combat casualties in shock recommend administration of whole blood or blood components to increase blood pressure to a permissible hypotensive level (i.e., hypotensive resuscitation [HR]). We investigated if 2 h of HR using limited volumes of whole blood, plasma, or albumin would lead to full recovery and long-term survival of rabbits subjected to severe hemorrhagic shock (HS). Following instrumentation, laparotomy was performed on IV-anesthetized spontaneously breathing New Zealand white rabbits (3.0 kg -3.5 kg). Next, ∼40% of rabbits' blood volume was removed producing HS (mean arterial pressure [MAP]∼20 mm Hg). Fifteen minutes later, rabbits were resuscitated with a limited volume (12.5 mL/kg) of rabbit whole blood (fresh whole blood [FWB]), rabbit fresh frozen plasma (FFP), or 5% human albumin (ALB) to a target pressure (MAP) of 60 mm Hg (n=8/grp) and monitored for 2 h. Liver bleeding time was measured at baseline and 10 min after HR. Subsequently, animals were fully resuscitated (blood + lactated Ringer [LR]), surgically repaired, and recovered for 8 days. An untreated group (n = 6) was also included. Following HS, lactate and base deficit levels were increased to 8.2 ± 1.6 and 12.9 ± 3.1 mM respectively with no difference among groups. A lower volume of FWB volume was required to reach the target MAP (P < 0.05 vs. ALB) but MAP declined during the HR period (P < 0.01 vs. ALB). FWB provided higher hematocrit and platelets but it did not reduce lactate level faster than other fluids. Beside higher fibrinogen, no differences were found in hemostatic or resuscitative effects of FFP versus ALB. Bleeding time was prolonged with ALB and FFP fluids but unchanged with FWB. Untreated rabbits died during shock or shortly after. All treated rabbits except one recovered and lived for 8 days with normal blood tests and similar tissue histology. Two hours of HR using a limited volume of FWB, FFP, or ALB led to full recovery and long-term survival of rabbits subjected to HS. Apart from bleeding time, no clinically significant differences were found among the three fluids. Five percent human albumin solutions are isotonic, iso-oncotic, ready-to-use, stable, and compatible with all blood types and should be considered for prehospital resuscitation where blood products are not available or not accepted.

A Review of Nonfatal Drowning in the Pediatric-Age Group: A 10-Year Experience at a University Hospital in Saudi Arabia.

The aim of this study was to evaluate the nonfatal drowning experience, risk factors, intrahospital assessment and postincidental outcomes for children admitted to King Fahd Hospital of the University, AlKhobar, Saudi Arabia, over a 10-year period. Children up to the age of 14 years who were admitted with the diagnosis of nonfatal drowning from July 2005 to June 2015 were included. Data regarding demographics, timing, season and location of drowning, presence of an assigned lifeguard, duration of submersion and transport to hospital, cardiopulmonary resuscitation, initial Glasgow Coma Scale, temperature, pH, blood sugar level, total hospital stay, and discharge status were extrapolated, and their effects on the patient's outcome analyzed. Patients' outcomes were classified into either full recovery, moderate to severe neurological damage, or brain death. Fifty-one subjects were included in the study; 66.7% were males, 57% were younger than 6 years, and 80% were Saudi citizens. Of the total cases, 94% recovered fully, and 6% were diagnosed as having brain death or discharged from the intensive care unit with severe neurological injury. Submersion time of more than 5 minutes, Glasgow Coma Scale of 4 or less, pH of less than 7.1, temperature of 35°C or less, and blood sugar of 180 mg/dL or greater were found to correlate with bad outcomes with great statistical significance. The findings of this study were in line with results of most of the international and local studies on the subject. Significant defects have been concluded in prehospital medical care and cardiopulmonary resuscitation. Adequate swimming safety regulations, assignments of lifeguards, and parental education should be taken into consideration by media and involved authorities.

Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes.

Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient. Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.

Ultrasonographic inferior vena cava diameter response to trauma resuscitation after 1 hour predicts 24-hour fluid requirement.

Identification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR). An NTI-funded, American Association for the Surgery of Trauma Multi-Institutional Trials Committee prospective, cohort trial was conducted at four Level I Trauma Centers. Major trauma patients were screened for an IVCD of 12 mm or less or IVCCI of 50% or less on initial focused assessment sonographic evaluations for trauma. A second IVCD was obtained 40 minutes to 60 minutes later, after standard-of-care fluid resuscitation. Patients whose second measured IVCD was less than 10 mm were deemed nonrepleted (NONREPLETED), those 10 mm or greater were repleted (REPLETED). Prehospital and initial resuscitation fluids and 24FR were recorded. Demographics, Injury Severity Score, arterial blood gasses, length of stay, interventions, and complications were recorded. Means were compared by ANOVA and categorical variables were compared via χ. Receiver operating characteristic curves analysis was used to compare the measures as 24FR predictors. There were 4,798 patients screened, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled. There were 86 REPLETED and 58 NONREPLETED. Demographics, initial hemodynamics, or laboratory measures were not significantly different. NONREPLETED had smaller IVCD (6.0 ± 3.7 mm vs. 14.2 ± 4.3 mm, p < 0.001) and higher IVCCI (41.7% ± 30.0% vs. 13.2% ± 12.7%, p < 0.001) but no significant difference in IJVD or IJVCCI. REPLETED had greater 24FR than NONREPLETED (2503 ± 1751 mL vs. 1,243 ± 1,130 mL, p = 0.003). Receiver operating characteristic analysis indicates IVCDMIN predicted 24FR (area under the curve [AUC], 0.74; 95% confidence interval [CI], 0.64-0.84; p < 0.001) as did IVCCI (AUC, 0.75; 95% CI, 0.65-0.85; p < 0.001) but not IJVDMIN (AUC, 0.48; 95% CI, 0.24-0.60; p = 0.747) or IJVCI (AUC, 0.54; 95% CI, 0.42-0.67; p = 0.591). Ultrasound assessed IVCDMIN and IVCCI response initial resuscitation predicts 24-hour fluid resuscitation requirements. Diagnostic tests or criteria, level II.

Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma “Go-Team”

ObjectiveThe R Adams Cowley Shock Trauma Center (STC) is Maryland's primary adult resource center for trauma care. The Shock Trauma “Go-Team” is a specialized component of Maryland's emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team. MethodsA retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018. Go-Team call logs/records were identified from multiple sources. Medical records were reviewed for patient demographics, mechanisms of injury, and treatments in the field. There was a total of 61 activations, with 22 deployments to the scene of injury. ResultsThe majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required. ConclusionThe STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system.

Effect of tranexamic acid administration on acute traumatic coagulopathy in rats with polytrauma and hemorrhage.

Trauma and hemorrhagic shock can lead to acute traumatic coagulopathy (ATC) that is not fully reversed by prehospital resuscitation as simulated with a limited volume of fresh whole blood (FWB) in a rat model. Tranexamic Acid (TXA) is used as an anti-fibrinolytic agent to reduce surgical bleeding if administered prior to or during surgery, and to improve survival in trauma if given early after trauma. It is not clear from the existing clinical literature whether TXA has the same mechanism of action in both settings. This study sought to explore the molecular mechanisms of TXA activity in trauma and determine whether administration of TXA as a supplement to FWB resuscitation could attenuate the established ATC in a rat model simulating prehospital resuscitation of polytrauma and hemorrhagic shock. In a parallel in-vitro study, the effects on clotting assays of adding plasmin at varying doses along with either simultaneous addition of TXA or pre-incubation with TXA were measured, and the results suggested that maximum anti-fibrinolytic effect of TXA on plasmin-induced fibrinolysis required pre-incubation of TXA and plasmin prior to clot initiation. In the rat model, ATC was induced by polytrauma followed by 40% hemorrhage. One hour after trauma, the rats were resuscitated with FWB collected from donor rats. Vehicle or TXA (10mg/kg) was given as bolus either before trauma (TXA-BT), or 45min after trauma prior to resuscitation (TXA-AT). The TXA-BT group was included to contrast the coagulation effects of TXA when used as it is in elective surgery vs. what is actually feasible in real trauma patients (TXA-AT group). A single dose of TXA prior to trauma significantly delayed the onset of ATC from 30min to 120min after trauma as measured by a rise in prothrombin time (PT). The plasma d-dimer as well as plasminogen/fibrinogen ratio in traumatized liver of TXA-BT were significantly lower as compared to vehicle and TXA-AT. Wet/dry weight ratio and leukocytes infiltration of lungs were significantly decreased only if TXA was administrated later, prior to resuscitation (TXA-AT). In conclusion: Limited prehospital trauma resuscitation that includes FWB and TXA may not correct established systemic ATC, but rather may improve overall outcomes of resuscitation by attenuation of acute lung injury. By contrast, TXA given prior to trauma reduced levels of fibrinolysis at the site of tissue injury and circulatory d-dimer, and delayed development of coagulopathy independent of reduction of fibrinogen levels following trauma. These findings highlight the importance of early administration of TXA in trauma, and suggest that further optimization of dosing protocols in trauma to exploit TXA’s various sites and modes of action may further improve patient outcomes.

P1725Current spectrum and 1-year mortality of cardiogenic shock in Europe. Results of the CULPRIT-SHOCK randomized clinical trial and registry

Abstract Background An early invasive strategy with coronary revascularization has been shown to improve prognosis in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Little is known about the current spectrum, treatment and 1-year mortality in patients with CS undergoing early angiography in Europe. Methods We evaluated baseline characteristics, treatments and 1-year outcome in a large number of patients with CS included into the prospective CULPRIT-SHOCK randomized trial and the accompanying registry. Between April 2013 and April 2017, a total of 1075 patients with cardiogenic shock were screened at 83 European centers, of whom 706 (65.6%) were included in the randomized trial RCTand 369 into the registry. Results The median age was 67 years and 25% were female. In total, 55% of patients had pre-hospital resuscitation, 6% underwent fibrinolysis before angiography, 65% presented with ST-elevation myocardial infarction, 15% with left bundle branch block, and 20% with non-ST-elevation myocardial infarction. The majority of patients (80%) needed mechanical ventilation. Catecholamines were used in 90% and mechanical support in 29.5% of the patients (IABP 38.5%, ECMO 22%, Impella 33%, other 7%). Total 30-day and 1-year mortality was 46% and 52%, respectively. Mechanical complications were observed in 2.1% of patients, the latter had a 30-day and 1-year mortality of 62% and 67%, respectively. The mortality related to the extent of coronary artery disease is shown in the table. 1-vessel (14%) 2-vessel (31%) 3-vessel (55%) Left main (15%) 30-day mortality 36% 44% 51% 53% 1-year mortality 39% 50% 57% 64% Conclusions This first report including data of the prospective CULPRIT-SHOCK randomized trial as well as the accompanying registry demonstrates the high-risk clinical characteristics of patients with AMI complicated by CS undergoing contemporary treatment. Despite an early invasive strategy mortality in patients with AMI complicated by CS in Europe is still high and is related to the extent of coronary artery disease.

Chest compression release velocity factors during out-of-hospital cardiac resuscitation

BackgroundHigher chest compression release velocity (CCRV) has been associated with better outcomes after out-of-hospital cardiac arrest (OHCA), and patient factors have been associated with variations in chest wall compliance and compressibility. We evaluated whether patient sex, age, weight, and time in resuscitation were associated with CCRV during pre-hospital resuscitation from OHCA. MethodsObservational study of prospectively collected OHCA quality improvement data in two suburban EMS agencies in Arizona between 10/1/2008 and 12/31/2016. Subject-level mean CCRV during the first 10 min of compressions was correlated with categorical variables by the Wilcoxon rank-sum test and with continuous variables by the Spearman’s rank correlation coefficient. Generalized estimating equation and linear mixed-effect models were used to study the trend of CCRV over time. ResultsDuring the study period, 2535 adult OHCA cases were treated. After exclusion criteria, 1140 cases remained for analysis. Median duration of recorded compressions was 8.70 min during the first 10 min of CPR. An overall decline in CCRV was observed even after adjusting for compression depth. The subject-level mean CCRV was higher for minutes 0–5 than for minutes 5–10 (mean 347.9 mm/s vs. 339.0 mm/s, 95% CI of the difference −12.4 to −5.4, p < 0.0001). Males exhibited a greater mean CCRV compared to females [344.4 mm/s (IQR 307.3–384.6) vs. 331.5 mm/s (IQR 285.3–385.5), p = 0.013]. Mean CCRV was negatively correlated with age and positively correlated with patient weight. ConclusionCCRV declines significantly over the course of resuscitation. Patient characteristics including male sex, younger age, and increased weight were associated with a higher CCRV.

Epidemiology, etiology, and outcomes of out-of-hospital cardiac arrest in young patients in lebanon.

The burden of out-of-hospital cardiac arrest (OHCA) on different population segments in developing countries is not well studied. Previous studies from Lebanon report poor survival to hospital discharge (4.8%-5.5%). This study describes characteristics and outcomes of young OHCA victims in Beirut, Lebanon METHODS: This retrospective observational study included young patients (<35 years of age) with OHCA admitted to the emergency department (ED) of a tertiary care center in Lebanon over a 10-year period. Fifty-four patients with OHCA were identified. Most were males (74.1%, n=40) and the mean age was 17.9±10.9 years. The most common arrest location was home (44.4%, n=24). The majority were witnessed (78.8%, n=41) with 15.4% (n=8) witnessed by emergency medical services (EMS). Prehospital cardiopulmonary resuscitation was done for 22 patients (41.5%) mostly by EMS (n=19, 86.4%), 9.1% (n=2) by a bystander, and 4.5% (n=1) by a family member. Prehospital automated external defibrillator use was documented in 13% (n=7) of cases. Most patients (n=48, 88.9%) were resuscitated in the ED where the most common rhythm was asystole (55.6%, n=30). Half of the patients (50%, n=27) survived to hospital admission. Overall survival to hospital discharge was 16.7% (n=9). Good neurologic outcome (cerebral performance category 1 or 2) was documented in seven patients (9.3%). Survival rate of young OHCA victims in Lebanon (16.7%) is higher than previously reported rates of OHCA in the overall population. Targeted community activities and medical oversight of EMS activities are needed to link EMS activities to clinical outcomes.

The use of body-worn cameras in pre-hospital resuscitation.

Introduction:Body-worn cameras (BWCs) are commonplace in many workplaces, but rare in the real-time audit of clinical performance in the pre-hospital setting. There are currently no data supporting the use of BWCs as an acceptable tool in clinical audit. Out-of-hospital cardiac arrest (OHCA) is a good candidate for audit – time critical, high stakes and not well observed. While the use of cameras to record such clinical data is demonstrably useful, it could be perceived by front line ambulance staff as intrusive and have a deleterious impact on clinical care. Investigating these potential barriers is important in ensuring that our effort to enhance the early phase of pre-hospital care through video audit does not have negative unintended consequences.Methods:Since 2012, the Resuscitation Research Group has used BWCs to provide a unique insight into how care is delivered by paramedics attending OHCAs. Paramedics attending arrests as part of the Resuscitation Rapid Response Unit (3RU) second-tier response wear a BWC, and collect real-time footage of these challenging, emotive clinical encounters. This footage has provided a unique medium for the audit of both individual technical task and team-oriented non-technical skills performance. We present the results of a survey in which paramedics share their views on the use of BWCs within their service.Results:A convenience sample of 83 questionnaires was collected. In relation to the primary outcome of the study, 81% (n = 53) of paramedics who responded to the statement, ‘the use of BWCs is a positive step for the service’, agreed or remained neutral, while only 19% (n = 12) disagreed.Conclusion:BWCs, and the supporting infrastructure and feedback processes, are an effective, acceptable and beneficial tool in the audit and analysis of team performance in pre-hospital resuscitation.

Prehospital resuscitation in adult patients following injury: A Western Trauma Association critical decisions algorithm.

Prehospital resuscitation in adult patients following injury: A Western Trauma Association critical decisions algorithm.

Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock

Current therapies for traumatic blood loss focus on hemorrhage control and blood volume replacement. Severe hemorrhagic shock, however, is associated with a state of arginine vasopressin (AVP) deficiency, and supplementation of this hormone may decrease the need for blood products in resuscitation. To determine whether low-dose supplementation of AVP in patients with trauma (hereinafter referred to as trauma patients) and with hemorrhagic shock decreases their need for transfused blood products during resuscitation. This randomized, double-blind placebo-controlled clinical trial included adult trauma patients (aged 18-65 years) who received at least 6 U of any blood product within 12 hours of injury at a single urban level 1 trauma center from May 1, 2013, through May 31, 2017. Exclusion criteria consisted of prehospital cardiopulmonary resuscitation, emergency department thoracotomy, corticosteroid use, chronic renal insufficiency, coronary artery disease, traumatic brain injury requiring any neurosurgical intervention, pregnancy, prisoner status, or AVP administration before enrollment. Data were analyzed from May 1, 2013, through May 31, 2017, using intention to treat and per protocol. After administration of an AVP bolus (4 U) or placebo, participants received AVP (≤0.04 U/min) or placebo for 48 hours to maintain a mean arterial blood pressure of at least 65 mm Hg. The primary outcome was total volume of blood product transfused. Secondary end points included total volume of crystalloid transfused, vasopressor requirements, secondary complications, and 30-day mortality. One hundred patients underwent randomization (49 to the AVP group and 51 to the placebo group). Patients were primarily young (median age, 27 years [interquartile range {IQR}, 22-25 years]) and male (n = 93) with penetrating trauma (n = 79). Cohort characteristics before randomization were well balanced. At 48 hours, patients who received AVP required significantly less blood products (median, 1.4 [IQR, 0.5-2.6] vs 2.9 [IQR, 1.1-4.8] L; P = .01) but did not differ in requirements for crystalloids (median, 9.9 [IQR, 7.9-13.0] vs 11.0 [8.9-15.0] L; P = .22) or vasopressors (median, 400 [IQR, 0-5900] vs 1400 [IQR, 200-7600] equivalent units; P = .22). Although the groups had similar rates of mortality (6 of 49 [12%] vs 6 of 51 [12%]; P = .94) and total complications (24 of 44 [55%] vs 30 of 47 [64%]; P = .37), the AVP group had less deep venous thrombosis (5 of 44 [11%] vs 16 of 47 [34%]; P = .02). Low-dose AVP during the resuscitation of trauma patients in hemorrhagic shock decreases blood product requirements. Additional research is necessary to determine whether including AVP improves morbidity or mortality. ClinicalTrials.gov identifier: NCT01611935.

Prehospital cardiopulmonary resuscitation duration and neurological outcome after out-of-hospital cardiac arrest among children by location of arrest: a Nationwide cohort study

BackgroundLittle is known about the associations between the duration of prehospital cardiopulmonary resuscitation (CPR) by emergency medical services (EMS) and outcomes among paediatric patients with out-of-hospital cardiac arrests (OHCAs). We investigated these associations and the optimal prehospital EMS CPR duration by the location of arrests.MethodsWe included paediatric patients aged 0–17 years with OHCAs before EMS arrival who were transported to medical institutions after resuscitation by bystanders or EMS personnel. We excluded paediatric OHCA patients for whom CPR was not performed, who had cardiac arrest after EMS arrival, whose EMS CPR duration were < 0 min or ≥120 min and who had cardiac arrest in healthcare facilities. Prehospital EMS CPR duration was defined as the time from CPR initiation by EMS personnel to the time of prehospital return of spontaneous circulation or to the time of hospital arrival. The primary outcome was 1-month survival with a favourable neurological outcome (cerebral performance category scale 1 or 2). Statistical analysis was performed with Mann-Whitney U tests for numerical variables and chi-squared test for categorical variables. Univariable and multivariable logistic regression analyses were applied to assess the association between prehospital EMS CPR duration and a favourable neurological outcome, and crude and adjusted odds ratios and their 95% confidence intervals were calculated.ResultsThe proportion of patients with a favourable neurological outcome was lower in residential locations than in public locations (2.3% [66/2865] vs 10.8% [113/1048]; P < .001). In both univariable and multivariable logistic regression analyses, the proportion of patients with a favourable neurological outcome decreased as prehospital EMS CPR duration increased, regardless of the location of arrests (P for trend <.001). However, some patients achieved a favourable neurological outcome after a prolonged prehospital EMS CPR duration (> 30 min) in both groups (1.4% [6/417] in residential locations and 0.6% [1/170] in public locations).ConclusionsA longer prehospital EMS CPR duration is independently associated with a lower proportion of patients with a favourable neurological outcome. The association between prehospital EMS CPR duration and neurological outcome differed significantly by location of arrests.

The Israel Defense Forces experience with freeze-dried plasma for the resuscitation of traumatized pediatric patients.

With the growing recognition of the disadvantages of crystalloid- and colloid-based resuscitation and the advantages of using blood products as the preferred resuscitation fluid, the Israel Defense Forces Medical Corps (IDF-MC) adopted plasma as the primary volume resuscitation regimen in 2013. While data are accumulating for prehospital plasma transfusion, little to no data exist regarding using plasma as a prehospital resuscitation fluid for traumatized pediatric patients. All patients treated by the IDF-MC personnel are recorded in the IDF Trauma Registry, a unique prehospital trauma registry. All patients treated by the IDF advanced life support providers with FDP at the point of injury between April 2013 and June 2018 who were younger than 18 years at the time of injury were included. Six hundred seventy-nine children were treated by IDF medical providers, of whom 33 (5%) were identified in the IDF Trauma Registry as having received FDP at the point of injury. Most patients (80%) were treated for penetrating injuries. Most patients received one plasma unit. Fifty-four percent of the patients were also treated by Tranexamic Acid (TXA) and 48% were transfused with crystalloids. In 33% of patients, additional life-saving interventions were performed. While the ideal resuscitation fluid for the pediatric population remains to be determined, it seems reasonable to pursue a similar approach to that of applied that for adults. In the IDF-MC, the resuscitation fluid of choice for trauma patients in hemorrhagic shock is freeze-dried plasma transfused at the point of injury. The current study demonstrates the feasibility of FDP administration in the prehospital scenario for injured children and further supports the growing confidence in the use of FDP for the treatment of pediatric trauma patients. Retrospective descriptive study, level IV.

Correlation between field triage criteria and the injury severity score of trauma patients in a French inclusive regional trauma system

BackgroundIn France, the pre-hospital field triage of trauma patients is currently based on the Vittel criteria algorithm. This algorithm was originally created in 2002 before the stratification of trauma centers and, at the national level, has not been revised since. This could be responsible for the overtriage of trauma patients in Level I Trauma Centers. The principal aim of this study was to evaluate the correlation between each Vittel field triage criterion and trauma patients’ Injury Severity Score.MethodsOur Level I Trauma Center receives an average of 300 trauma patients per year. Demographic and physiological data, along with the entire trauma patient management process and Vittel field triage criteria, are recorded in a local trauma registry. The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are calculated after a complete assessment of the trauma victim during their in-hospital management. Results were concerned with the presence of an ISS of greater than 15, which defined a major trauma patient; mortality within 30 days; and admission to the intensive care unit. This study is a registry analysis from January 2013 to September 2017.ResultsOf the 1373 patients in the registry, 1151 were included in the analysis with a mean age of 43 years (± 19) and a median ISS of 13 (IQR = 5–22), where 887 (77%) were male. Nine of the 24 Vittel criteria were associated with an ISS > 15. In a multivariate analysis, no criterion related to kinetic elements was significantly correlated with an ISS > 15, mortality within 30 days, or admission to intensive care. Three algorithm categories were predictive of a major trauma patient (ISS > 15): physiological variables, pre-hospital resuscitation, and physical injuries, while kinetic elements were not.ConclusionsCriteria related to physiological variables, pre-hospital resuscitation, and physical injuries are the most relevant to predicting the severity of a trauma patient’s condition. A revision of the VCA could potentially have beneficial effects on the over and undertriage phenomena, which constitute ongoing medical and financial concerns.