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BACKGROUND: Fever after cardiac arrest may impact outcome. We aimed to assess the incidence of fever in post-cardiac arrest patients, factors predicting fever and its association with functional outcome in patients treated without targeted temperature management (TTM). METHODS: The FINNRESUSCI observational cohort study in 2010-2011 included intensive care unit (ICU)-treated out-of-hospital cardiac arrest (OHCA) patients from all five Finnish university hospitals and 14 of 15 central hospitals. This post hoc analysis included those FINNRESUSCI study patients who were not treated with TH. We defined fever as at least one temperature measurement of ≥37.8°C within 72 h of ICU admission. The primary outcome was favourable functional outcome at 12 months, defined as cerebral performance category (CPC) of 1 or 2. Binary logistic regression models including witnessed arrest, bystander cardiopulmonary resuscitation (CPR), initial rhythm and delay of return of spontaneous circulation were used to compare the functional outcomes of the groups. RESULTS: There were 67,428 temperature measurements from 192 patients, of whom 89 (46%) experienced fever. Twelve-month CPC was missing in 7 patients, and 51 (28%) patients had favourable functional outcome at 12 months. The patients with shockable initial rhythms had a lower incidence of fever within 72 h of ICU admission (28% vs. 72%, p < .01), and the patients who experienced fever had a longer median return of spontaneous circulation (ROSC) delay (20 [IQR 10-30] vs. 14 [IQR 9-22] min, p < .01). Only initial non-shockable rhythm (OR 2.99, 95% CI 1.51-5.94) was associated with increased risk of fever within the first 72 h of ICU admission. Neither time in minutes nor area (minutes × degree celsius over threshold) over 37°C, 37.5°C, 38°C, 38.5°C, 39°C, 39.5°C or 40°C were significantly different in those with favourable functional outcome compared to those with unfavourable functional outcome within the first 24, 48 or 72 h from ICU admission. Fever was not associated with favourable functional outcome at 12 months (OR 0.90, 95% CI 0.44-1.84). CONCLUSIONS: Half of OHCA patients not treated with TTM developed fever. We found no association between fever and outcome.
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Reanimación Cardiopulmonar , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Temperatura Corporal , HospitalizaciónRESUMEN
PURPOSE: In aneurysmal intracerebral hemorrhage (aICH), our review showed the lack of the patient's individual (i) timeline panels and (ii) serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. METHODS: Our retrospective cohort consists of 54 consecutive aICH patients from a defined population who acutely underwent the clipping of a middle cerebral artery bifurcation saccular aneurysm (Mbif sIA) with the aICH evacuation at Kuopio University Hospital (KUH) from 2010 to 2019. We constructed the patient's individual timeline panels since the emergency call and serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. The patients were indicated by numbers (1.-54.) in the pseudonymized panels, tables, results, and discussion. RESULTS: The aICH volumes on KUH admission (median 46 cm3) plotted against the time from the emergency call to the evacuation (median 8 hours) associated significantly with the rebleeds (n=25) and the deaths (n=12). The serial CT/MRI slice panels illustrated the aICHs, intraventricular hemorrhages (aIVHs), residuals after the aICH evacuations, perihematomal edema (PHE), delayed cerebral injury (DCI), and in the 42 survivors, the clinical outcome (mRS) and the brain tissue outcome. CONCLUSIONS: Regarding aICH evacuations, serial brain CT/MRI panels present more information than words, figures, and graphs. Re-bleeds associated with larger aICH volumes and worse outcomes. Swift logistics until the sIA occlusion with aICH evacuation is required, also in duty hours and weekends. Intraoperative CT is needed to illustrate the degree of aICH evacuation. PHE may evoke uncontrollable intracranial pressure (ICP) in spite of the acute aICH volume reduction.
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Aneurisma , Arteria Cerebral Media , Humanos , Encéfalo , Hemorragia Cerebral/diagnóstico por imagen , Hemorragia Cerebral/etiología , Hemorragia Cerebral/cirugía , Progresión de la Enfermedad , Hematoma , Imagen por Resonancia Magnética , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Our review of acute brain insult articles indicated that the patients' individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented. METHODS: We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.-45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ([Formula: see text]; 56%) or 3 years ([Formula: see text]; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors). RESULTS: The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome. CONCLUSIONS: The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.
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Craniectomía Descompresiva , Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/cirugía , Proyectos Piloto , Estudios Retrospectivos , Hemorragia Cerebral , Encéfalo , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Predictors of subsequent events after Emergency Medical Services (EMS) non-conveyance decisions are still unclear, though patient safety is the priority in prehospital emergency care. The aim of this study was to find out whether machine learning can be used in this context and to identify the predictors of subsequent events based on narrative texts of electronic patient care records (ePCR). METHODS: This was a prospective cohort study of EMS patients in Finland. The data was collected from three different regions between June 1 and November 30, 2018. Machine learning, in form of text classification, and manual evaluation were used to predict subsequent events from the clinical notes after a non-conveyance mission. RESULTS: FastText-model (AUC 0.654) performed best in prediction of subsequent events after EMS non-conveyance missions (n = 11,846). The model and manual analyses showed that many of the subsequent events were planned before, EMS guided the patients to visit primary health care facilities or ED next or following days after non-conveyance. The most frequent signs and symptoms as subsequent event predictors were musculoskeletal-, infection-related and non-specific complaints. 1 in 5 the EMS documentation was inadequate and many of these led to a subsequent event. CONCLUSION: Machine learning can be used to predict subsequent events after EMS non-conveyance missions. From the patient safety perspective, it is notable that subsequent event does not necessarily mean that patient safety is compromised. There were a number of subsequent visits to primary health care or EDs, which were planned before by EMS. This demonstrates the appropriate use of limited resources to avoid unnecessary conveyance to the ED. However, further studies are needed without planned subsequent events to find out the harmful subsequent events, where EMS non-conveyance puts patient safety at risk.
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Servicios Médicos de Urgencia , Documentación , Humanos , Aprendizaje Automático , Seguridad del Paciente , Estudios ProspectivosRESUMEN
INTRODUCTION: Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies. METHODS: The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method. RESULTS: A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine. CONCLUSIONS: Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.
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Reanimación Cardiopulmonar , Paro Cardíaco , Hipotermia Inducida , Finlandia , Paro Cardíaco/terapia , HumanosRESUMEN
BACKGROUND: The safety of the Emergency Medical Service's (EMS's) non-conveyance decision was evaluated by EMS re-contacts, primary health care or emergency department (ED) visits, and hospitalization within 48 h. The secondary outcome was 28-day mortality. METHODS: This cohort study used prospectively collected data on non-conveyed EMS patients from three different regions in Finland between June 1 and November 30, 2018. The Adjusted International Classification of Primary Care (ICPC2) as the reason for care was compared to hospital discharge diagnoses (ICD10). Multivariable logistic regressions were used to determine factors that were independently associated with adverse outcomes. Results are presented with adjusted odds ratios (aORs) together with 95% confidence intervals (CIs). Data regarding deceased patients were reviewed by the study group. RESULTS: Of the non-conveyed EMS patients (n = 11,861), 6.3% re-contacted the EMS, 8.3% attended a primary health care facility, 4.2% went to the ED, 1.6% were hospitalized, and 0.1% died 0-24 h after the EMS mission. The 0-24 h adverse event rate was higher than 24-48 h. After non-conveyance, 32 (0.3%) patients were admitted to an intensive care unit within 24 h. Primary non-urgent EMS mission (aOR 1.49; 95% CI 1.25 to 1.77), EMS arrival at night (aOR 1.82; 95% CI 1.58 to 2.09), ALS unit type vs BLS (aOR 1.43; 95% CI 1.16 to 1.77), rural area (aOR 1.74; 95% CI 1.51 to 1.99), and older patient age (aOR 1.41; 95% CI 1.20 to 1.66) were associated with subsequent primary health care visits (0-24 h). CONCLUSIONS: Four in five non-conveyed patients did not have any re-contact in follow-up period. EMS non-conveyance seems to be a relatively safe method of focusing ED resources and avoiding ED crowding.
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Servicios Médicos de Urgencia , Seguridad del Paciente , Estudios de Cohortes , Aglomeración , Servicio de Urgencia en Hospital , Hospitalización , Humanos , Oportunidad RelativaRESUMEN
BACKGROUND: Few publications have addressed prehospital use of ketamine in analgesic doses. We aimed to assess the effect and safety profile of ketamine compared with other analgesic drugs (or no drug) in adult prehospital patients with acute pain. METHODS: A systematic review of clinical trials assessing prehospital administration of ketamine in analgesic doses compared with other analgesic drugs or no analgesic treatment in adults. We searched PubMed, EMBASE, Cochrane Library and Epistemonikos from inception until 15 February 2020, including relevant articles in English and Nordic languages. We used the Cochrane and Grading of Recommendations Assessment, Development and Evaluation methodologies and exclusively assessed patient-centred outcomes. Two independent authors screened trials for eligibility, extracted data and assessed risk of bias. RESULTS: We included eight studies (2760 patients). Ketamine was compared with various opioids given alone, and intranasal ketamine given with nitrous oxide was compared with nitrous oxide given alone. Four randomised controlled trials (RCTs) and one cluster randomised trial included 699 patients. One prospective cohort included 27 patients and two retrospective cohorts included 2034 patients. Five of the eight studies had high risks of bias. Pain score with ketamine is probably lower than after opioids as demonstrated in a cluster-RCT (308 patients) and a retrospective cohort (158 patients) study, Δvisual analogue scale -0.4 (-0.8 to 0.0) and Δnumeric pain rating scale -3.0 (-3.86 to -2.14), respectively. Ketamine probably leads to less nausea and vomiting (risk ratio (RR) 0.24 (0.11 to 0.52)) but more agitation (RR 7.81 (1.85 to 33)) than opioids. CONCLUSIONS: This systematic literature review finds that ketamine probably reduces pain more than opioids and with less nausea and vomiting but higher risk of agitation. Risk of bias in included studies is high. OTHER: Scandinavian society of anaesthesiology and intensive care medicine funded meetings and software. The Norwegian Air Ambulance Foundation funded publication. Otherwise this research received no grant from any agency in the public, commercial or not-for-profit sectors. PROSPERO REGISTRATION NUMBER: CRD42018114399.
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Dolor Agudo , Servicios Médicos de Urgencia , Ketamina , Dolor Agudo/tratamiento farmacológico , Adulto , Analgésicos , Analgésicos Opioides/efectos adversos , Humanos , Ketamina/efectos adversos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Stroke causes death, disability and increases the use of healthcare resources worldwide. The outcome of intravenous thrombolysis and mechanical endovascular thrombectomy highly depends on the delay from symptom onset to initiation of definitive treatment. The purpose of this study was to compare the various patient transportation strategies to minimize pre-hospital delays. METHODS: Emergency medical services (EMS) mission locations and ambulance response times in Finland with urgent stroke-suspected dispatch codes were collected from Emergency Response Centre (ERC) records between 1 January 2016 and 31 December 2016. Four transport scenarios were simulated for each mission, comparing ground and helicopter transportation to hospital with different treatment capabilities. RESULTS: In 2016, a total of 20,513 urgent stroke-suspected missions occurred in Finland. Of these, we were able to locate and calculate a route to scenario-based hospitals in 98.7% (20,240) of the missions. For ground transport, the estimated median pre-hospital time to a thrombolysis-capable and thrombectomy-capable hospital were 54.5 min (95% confidence interval (CI), 31.7-111.4) and 94.4 min (95% CI, 33.3-195.8), respectively. Should patients be transported on the ground to thrombectomy-capable hospitals only, the pre-hospital time would increase in 11,003 (54.4%) of missions, most of which were in rural areas. With the fastest possible transportation method, the estimated mean transport time to a thrombectomy-capable hospital was 80.84 min (median, 80.80 min; 95% CI, 33.3-143.1). Helicopter transportation was the fastest method in 68.8% (13,921) of missions, and the time saved was greater than 30 min in 27.1% (5475) of missions. In rural areas, helicopter transportation was the fastest option in nearly all missions if dispatched simultaneously with ground ambulance. CONCLUSION: Helicopter transportation may significantly decrease pre-hospital delays for stroke patients, especially in rural areas, but the selection of an optimal transportation method or chain of methods should be determined case-by-case.
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Ambulancias Aéreas/estadística & datos numéricos , Simulación por Computador , Hospitales/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Accidente Cerebrovascular/diagnóstico , Tiempo de Tratamiento , Transporte de Pacientes/métodos , Servicios Médicos de Urgencia/métodos , Femenino , Finlandia/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Accidente Cerebrovascular/epidemiologíaRESUMEN
BACKGROUND: Emergency Medical Services (EMS) and Emergency Departments (ED) have seen increasing attendance rates in the last decades. Currently, EMS are increasingly assessing and treating patients without the need to convey patients to health care facility. The aim of this study was to describe and compare the patient case-mix between conveyed and non-conveyed patients and to analyze factors related to non-conveyance decision making. METHODS: This was a prospective study design of EMS patients in Finland, and data was collected between 1st June and 30th November 2018. Adjusted ICPC2-classification was used as the reason for care. NEWS2-points were collected and analyzed both statistically and with a semi-supervised information extraction method. EMS patients' geographic location and distance to health care facilities were analyzed by urban-rural classification. RESULTS: Of the EMS patients (40,263), 59.8% were over 65 years of age and 46.0% of the patients had zero NEWS2 points. The most common ICPC2 code was weakness/tiredness, general (A04), as seen in 13.5% of all patients. When comparing patients between the non-conveyance and conveyance group, a total of 35,454 EMS patients met the inclusion criteria and 14,874 patients (42.0%) were not conveyed to health care facilities. According the multivariable logistic regression model, the non-conveyance decision was more likely made by ALS units, when the EMS arrival time was in the evening or night and when the distance to the health care facility was 21-40 km. Furthermore, younger patients, female gender, whether the patient had used alcohol and a rural area were also related to the non-conveyance decision. If the patient's NEWS2 score increased by one or two points, the likelihood of conveyance increased. When there was less than 1 h to complete a shift, this did not associate with either non-conveyance or conveyance decisions. CONCLUSIONS: The role of EMS might be changing. This warrants to redesign the chain-of-survival in EMS to include not only high-risk patient groups but also non-critical and general acute patients with non-specific reasons for care. Assessment and on-scene treatment without conveyance can be called the "stretched arm of the emergency department", but should be planned carefully to ensure patient safety.
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Toma de Decisiones , Servicios Médicos de Urgencia/métodos , Población Rural , Anciano , Anciano de 80 o más Años , Femenino , Finlandia , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente , Estudios ProspectivosRESUMEN
BACKGROUND: Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting. METHODS: A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments. RESULTS: Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine. CONCLUSIONS: Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.
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Dolor Agudo/tratamiento farmacológico , Servicios Médicos de Urgencia/métodos , Nervio Femoral/efectos de los fármacos , Bloqueo Nervioso/métodos , Manejo del Dolor/métodos , HumanosRESUMEN
BACKGROUND: Circulating SN (secretoneurin) concentrations are increased in patients with myocardial dysfunction and predict poor outcome. Because SN inhibits CaMKIIδ (Ca2+/calmodulin-dependent protein kinase IIδ) activity, we hypothesized that upregulation of SN in patients protects against cardiomyocyte mechanisms of arrhythmia. METHODS: Circulating levels of SN and other biomarkers were assessed in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT; n=8) and in resuscitated patients after ventricular arrhythmia-induced cardiac arrest (n=155). In vivo effects of SN were investigated in CPVT mice (RyR2 [ryanodine receptor 2]-R2474S) using adeno-associated virus-9-induced overexpression. Interactions between SN and CaMKIIδ were mapped using pull-down experiments, mutagenesis, ELISA, and structural homology modeling. Ex vivo actions were tested in Langendorff hearts and effects on Ca2+ homeostasis examined by fluorescence (fluo-4) and patch-clamp recordings in isolated cardiomyocytes. RESULTS: SN levels were elevated in patients with CPVT and following ventricular arrhythmia-induced cardiac arrest. In contrast to NT-proBNP (N-terminal pro-B-type natriuretic peptide) and hs-TnT (high-sensitivity troponin T), circulating SN levels declined after resuscitation, as the risk of a new arrhythmia waned. Myocardial pro-SN expression was also increased in CPVT mice, and further adeno-associated virus-9-induced overexpression of SN attenuated arrhythmic induction during stress testing with isoproterenol. Mechanistic studies mapped SN binding to the substrate binding site in the catalytic region of CaMKIIδ. Accordingly, SN attenuated isoproterenol induced autophosphorylation of Thr287-CaMKIIδ in Langendorff hearts and inhibited CaMKIIδ-dependent RyR phosphorylation. In line with CaMKIIδ and RyR inhibition, SN treatment decreased Ca2+ spark frequency and dimensions in cardiomyocytes during isoproterenol challenge, and reduced the incidence of Ca2+ waves, delayed afterdepolarizations, and spontaneous action potentials. SN treatment also lowered the incidence of early afterdepolarizations during isoproterenol; an effect paralleled by reduced magnitude of L-type Ca2+ current. CONCLUSIONS: SN production is upregulated in conditions with cardiomyocyte Ca2+ dysregulation and offers compensatory protection against cardiomyocyte mechanisms of arrhythmia, which may underlie its putative use as a biomarker in at-risk patients.
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Paro Cardíaco/metabolismo , Neuropéptidos/metabolismo , Secretogranina II/metabolismo , Taquicardia Ventricular/metabolismo , Animales , Biomarcadores/metabolismo , Calcio/metabolismo , Señalización del Calcio , Proteína Quinasa Tipo 2 Dependiente de Calcio Calmodulina/metabolismo , Paro Cardíaco/fisiopatología , Humanos , Ratones , Miocitos Cardíacos/metabolismo , Péptido Natriurético Encefálico/metabolismo , Técnicas de Placa-Clamp , Fragmentos de Péptidos/metabolismo , Fosforilación , Canal Liberador de Calcio Receptor de Rianodina/metabolismo , Taquicardia Ventricular/fisiopatología , Troponina T/metabolismo , Regulación hacia ArribaRESUMEN
BACKGROUND: In Finland, hospital districts (HD) are required by law to determine the level and availability of Emergency Medical Services (EMS) for each 1-km2 sized area (cell) within their administrative area. The cells are currently categorised into five risk categories based on the predicted number of missions. Methodological defects and insufficient instructions have led to incomparability between EMS services. The aim of this study was to describe a new, nationwide method for categorising the cells, analyse EMS response time data and describe possible differences in mission profiles between the new risk category areas. METHODS: National databases of EMS missions, population and buildings were combined with an existing nationwide 1-km2 hexagon-shaped cell grid. The cells were categorised into four groups, based on the Finnish Environment Institute's (FEI) national definition of urban and rural areas, population and historical EMS mission density within each cell. The EMS mission profiles of the cell categories were compared using risk ratios with confidence intervals in 12 mission groups. RESULTS: In total, 87.3% of the population lives and 87.5% of missions took place in core or other urban areas, which covered only 4.7% of the HDs' surface area. Trauma mission incidence per 1000 inhabitants was higher in core urban areas (42.2) than in other urban (24.2) or dispersed settlement areas (24.6). The results were similar for non-trauma missions (134.8, 93.2 and 92.2, respectively). Each cell category had a characteristic mission profile. High-energy trauma missions and cardiac problems were more common in rural and uninhabited cells, while violence, intoxication and non-specific problems dominated in urban areas. CONCLUSION: The proposed area categories and grid-based data collection appear to be a useful method for evaluating EMS demand and availability in different parts of the country for statistical purposes. Due to a similar rural/urban area definition, the method might also be usable for comparison between the Nordic countries.
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Servicios Médicos de Urgencia/organización & administración , Programas Médicos Regionales/organización & administración , Finlandia , HumanosRESUMEN
OBJECTIVE: Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences. This type of database presently exists for major incident reporting at www.majorincidentreporting.net. This study aimed to develop a HEMS-specific major incident template. METHODS: This Delphi study included 17 prehospital critical care physicians with current or previous HEMS experience. All participants interacted through e-mail. We asked these experts to define data variables and rank which were most important to report during an immediate prehospital medical response to a major incident. Five rounds were conducted. RESULTS: In the first round, the experts suggested 98 variables. After 5 rounds, 21 variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. CONCLUSION: Based on opinions from European experts, we established a consensus-based template for reporting on HEMS responses to major incidents. This template will facilitate uniformity in the collection, analysis, and exchange of experience.
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Ambulancias Aéreas , Consenso , Informe de Investigación/normas , Bases de Datos Factuales , Técnica Delphi , Servicios Médicos de Urgencia , Europa (Continente) , Humanos , MédicosRESUMEN
THE AIM OF THE STUDY: There are limited data on blood pressure targets and vasopressor use following cardiac arrest. We hypothesized that hypotension and high vasopressor load are associated with poor neurological outcome following out-of-hospital cardiac arrest (OHCA). METHODS: We included 412 patients with OHCA included in FINNRESUSCI study conducted between 2010 and 2011. Hemodynamic data and vasopressor doses were collected electronically in one, two or five minute intervals. We evaluated thresholds for time-weighted (TW) mean arterial pressure (MAP) and outcome by receiver operating characteristic (ROC) curve analysis, and used multivariable analysis adjusting for co-morbidities, factors at resuscitation, an illness severity score, TW MAP and total vasopressor load (VL) to test associations with one-year neurologic outcome, dichotomized into either good (1-2) or poor (3-5) according to the cerebral performance category scale. RESULTS: Of 412 patients, 169 patients had good and 243 patients had poor one-year outcomes. The lowest MAP during the first six hours was 58 (inter-quartile range [IQR] 56-61) mmHg in those with a poor outcome and 61 (59-63) mmHg in those with a good outcome (p<0.01), and lowest MAP was independently associated with poor outcome (OR 1.02 per mmHg, 95% CI 1.00-1.04, p=0.03). During the first 48h the median (IQR) of the TW mean MAP was 80 (78-82) mmHg in patients with poor, and 82 (81-83) mmHg in those with good outcomes (p=0.03) but in multivariable analysis TWA MAP was not associated with outcome. Vasopressor load did not predict one-year neurologic outcome. CONCLUSIONS: Hypotension occurring during the first six hours after cardiac arrest is an independent predictor of poor one-year neurologic outcome. High vasopressor load was not associated with poor outcome and further randomized trials are needed to define optimal MAP targets in OHCA patients.
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Presión Arterial/efectos de los fármacos , Reanimación Cardiopulmonar/métodos , Epinefrina/administración & dosificación , Paro Cardíaco Extrahospitalario/terapia , Vasoconstrictores/administración & dosificación , APACHE , Anciano , Reanimación Cardiopulmonar/efectos adversos , Circulación Cerebrovascular , Femenino , Humanos , Hipotensión/etiología , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/complicaciones , Paro Cardíaco Extrahospitalario/fisiopatología , Estudios Prospectivos , Curva ROC , Factores de TiempoRESUMEN
AIM: To assess whether the established cardiovascular biomarker N-terminal pro-B-type natriuretic peptide (NT-proBNP) provides prognostic information in patients with out-of-hospital cardiac arrest due to ventricular tachycardia or fibrillation (OHCA-VT/VF). METHODS: We measured NT-proBNP levels in 155 patients with OHCA-VT/VF enrolled into a prospective multicenter observational study in 21 ICUs in Finland. Blood samples were drawn <6h of OHCA-VT/VF and later after 24h, 48h, and 96h. The end-points were mortality and neurological outcome classified according to Cerebral Performance Category (CPC) after one year. NT-proBNP levels were compared to high-sensitivity troponin T (hs-TnT) levels and established risk scores. RESULTS: NT-proBNP levels were higher in non-survivors compared to survivors on study inclusion (median 1003 [quartile (Q) 1-3 502-2457] vs. 527 [179-1284]ng/L, p=0.001) and after 24h (1913 [1012-4573] vs. 1080 [519-2210]ng/L, p<0.001). NT-proBNP levels increased from baseline to 96h after ICU admission (p<0.001). NT-proBNP levels were significantly correlated to hs-TnT levels after 24h (rho=0.27, p=0.001), but not to hs-TnT levels on study inclusion (rho=0.05, p=0.67). NT-proBNP levels at all time points were associated with clinical outcome, but only NT-proBNP levels after 24h predicted mortality and poor neurological outcome, defined as CPC 3-5, in models that adjusted for SAPS II and SOFA scores. hs-TnT levels did not add prognostic information to NT-proBNP measurements alone. CONCLUSION: NT-proBNP levels at 24h improved risk assessment for poor outcome after one year on top of established risk indices, while hs-TnT measurements did not further add to risk prediction.
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Péptido Natriurético Encefálico/sangre , Paro Cardíaco Extrahospitalario/mortalidad , Fragmentos de Péptidos/sangre , Valor Predictivo de las Pruebas , Anciano , Biomarcadores/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Paro Cardíaco Extrahospitalario/fisiopatología , Estudios Prospectivos , Medición de Riesgo , Puntuación Fisiológica Simplificada Aguda , Estadísticas no Paramétricas , Troponina T/sangreRESUMEN
BACKGROUND: Though airway management methods during out-of-hospital cardiac arrest (OHCA) remain controversial, no studies on the topic from Finland have examined adherence to OHCA recommendations in real life. In response, the aim of this study was to document the interventions, success rates, and adverse events in airway management processes in OHCA, as well as to analyse survival at hospital discharge and at follow-up a year later. METHODS: During a 6-month study period in 2010, data regarding all patients with OHCA and attempted resuscitation in southern and eastern Finland were prospectively collected. Emergency medical services (EMS) documented the airway techniques used and all adverse events related to the process. Study endpoints included the frequency of different techniques used, their success rates, methods used to verify the correct placement of the endotracheal tube, overall adverse events, and survival at hospital discharge and at follow-up a year later. RESULTS: A total of 614 patients were included in the study. The incidence of EMS-attempted resuscitation was determined to be 51/100,000 inhabitants per year. The final airway technique was endotracheal intubation (ETI) in 413 patients (67.3%) and supraglottic airway device (SAD) in 188 patients (30.2%). The overall success rate of ETI was 92.5%, whereas that of SAD was 85.0%. Adverse events were reported in 167 of the patients (27.2%). Having a prehospital EMS physician on the scene (p < .001, OR 5.05, 95% CI 2.94-8.68), having a primary shockable rhythm (p < .001, OR 5.23, 95% CI 3.05-8.98), and being male (p = .049, OR 1.80, 95% CI 1.00-3.22) were predictors for survival at hospital discharge. CONCLUSIONS: This study showed acceptable ETI and SAD success rates among Finnish patients with OHCA. Adverse events related to airway management were observed in more than 25% of patients, and overall survival was 17.8% at hospital discharge and 14.0% after 1 year.
Asunto(s)
Manejo de la Vía Aérea/métodos , Protocolos Clínicos , Paro Cardíaco Extrahospitalario , Evaluación de Resultado en la Atención de Salud , Anciano , Servicios Médicos de Urgencia , Finlandia , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de RegistrosRESUMEN
BACKGROUND: A systemic inflammatory response is observed after cardiopulmonary resuscitation. We investigated two novel inflammatory markers, pentraxin 3 (PTX3) and soluble suppression of tumorigenicity 2 (sST2), in comparison with the classic high-sensitivity C-reactive protein (hsCRP), for prediction of early multiple organ dysfunction syndrome (MODS), early death, and long-term outcome after out-of-hospital cardiac arrest. METHODS: PTX3, sST2, and hsCRP were assayed at ICU admission and 48 h later in 278 patients. MODS was defined as the 24 h non-neurological Sequential Organ Failure Assessment (SOFA) score ≥ 12. Intensive care unit (ICU) death and 12-month Cerebral Performance Category (CPC) were evaluated. RESULTS: In total, 82% of patients survived to ICU discharge and 48% had favorable neurological outcome at 1 year (CPC 1 or 2). At ICU admission, median plasma levels of hsCRP (2.8 mg/L) were normal, while levels of PTX3 (19.1 ng/mL) and sST2 (117 ng/mL) were markedly elevated. PTX3 and sST2 were higher in patients who developed MODS (p<0.0001). Admission levels of PTX3 and sST2 were also higher in patients who died in ICU and in those with an unfavorable 12-month neurological outcome (p<0.01). Admission levels of PTX3 and sST2 were independently associated with subsequent MODS [OR: 1.717 (1.221-2.414) and 1.340, (1.001-1.792), respectively] and with ICU death [OR: 1.536 (1.078-2.187) and 1.452 (1.064-1.981), respectively]. At 48 h, only sST2 and hsCRP were independently associated with ICU death. CONCLUSIONS: Higher plasma levels of PTX3 and sST2, but not of hsCRP, at ICU admission were associated with higher risk of MODS and early death.
Asunto(s)
Proteína C-Reactiva/análisis , Paro Cardíaco/sangre , Paro Cardíaco/mortalidad , Inflamación/sangre , Insuficiencia Multiorgánica/sangre , Insuficiencia Multiorgánica/mortalidad , Receptores de Somatostatina/sangre , Componente Amiloide P Sérico/análisis , Anciano , Biomarcadores/sangre , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Airway management to ensure sufficient gas exchange is of major importance in emergency care. The accepted basic technique is to maintain an open airway and perform artificial ventilation in emergency situations is bag-valve mask (BVM) ventilation with manual airway management without airway adjuncts or with an oropharyngeal tube (OPA) only. Endotracheal intubation (ETI) is often referred to as the golden standard of airway management, but is associated with low success rates and significant insertion-related complications when performed by non-anaesthetists. Supraglottic devices (SADs) are one alternative to ETI in these situations, but there is limited evidence regarding the use of SAD in non-cardiac arrest situations. LMA Supreme (LMA-S) is a new SAD which theoretically has an advantage concerning the risk of aspiration due to an oesophageal inlet gastric tube port. METHODS: Forty paramedics were recruited to participate in the study. Adult (>18 years) patients, unconscious due to medical or traumatic cause with a GCS score corresponding to 3-5 and needed airway management were included in the study. Our aim was to study the feasibility of LMA-S as a primary airway method in unconscious patients by advanced life support (ALS) trained paramedics in prehospital care. RESULTS: Three regional Emergency Medical Service (EMS) services participated and 21 patients were treated during the survey. The LMA-S was placed correctly on the first attempt in all instances 21/21 (100%), with a median time to first ventilation of 9.8 s. Paramedics evaluated the insertion to be easy in every case 21/21 (100%). Because of air leak later in the patient care, the LMA-S was exchanged to an LT-D in two cases and to ETI in three cases (23.81%) by the paramedics. Regurgitation occurred after insertion two times out of 21 (9.52%) and in one of these cases (4.76%), paramedics reported regurgitation inside the LMA-S. CONCLUSION: We conclude that the LMA-S seems to be relatively easy and quick to insert in unconscious patients by paramedics. However, we found out that there were ventilation related problems with the LMA-S. Further studies are warranted.