Enhancing survival outcomes in developing emergency medical service system: Continuous quality improvement for out-of-hospital cardiac arrest.

Introduction: Emergency Medical Service (EMS) providers are essential for out-of-hospital cardiac arrest (OHCA) survival, however implementing high-performance CPR guidelines in developing EMS settings presents challenges. This study assessed the impact of Continuous Quality Improvement (CQI) initiatives on OHCA outcomes in a hospital-based EMS agency in Bangkok, Thailand. Methods: A before-and-after study design was utilized, utilizing data from a prospective OHCA registry spanning 2019 to 2023. CQI interventions included low-dose high-frequency training in advanced airway management, high-performance CPR, and post-debriefing with video recording (VDO). Data collection encompassed patient characteristics, EMS management, and survival outcomes. Quality CPR metrics were assessed using the mobile defibrillator and CPR code review software. Statistical analyses compared outcomes between the pre-intervention period in 2019 and the post-full CQI implementation period in 2023. Results: Among enrolled OHCA patients, with 88 cases occurring in 2019 and 91 cases in 2023. The bystander CPR rate was similar between both groups (47.73% in 2023 vs 53.85%, p = 0.413). In 2023, there was a significantly higher rate of prehospital intubation (93.40% vs 70.45%, p < 0.001) compared to 2019. Prehospital return of spontaneous circulation (ROSC) improved from 30.68% to 49.45% (p = 0.012), with an adjusted odds ratio (aOR) of 2.16 (95% CI: 1.14-4.07). Survival to discharge increased significantly from 2.27% in 2019 to 7.69% in 2023 (p = 0.27), with an aOR of 3.81 (95% CI: 0.46-31.79). Conclusion: Tailored CQI initiatives in a developing EMS setting were significantly associated with improved prehospital ROSC but showed an insignificant increase in survival to discharge.

Characteristics of non-accidental injuries in children and adolescents in Asia: a cross-national, multicenter cohort study.

Children and adolescents are vulnerable to non-accidental injury. Early identification and prevention rely on detailed epidemiological studies, which are limited in Asia. This retrospective study used the registry data of Pan-Asian Trauma Outcome Study (PATOS) from October 1, 2015 to December, 31, 2020. Pediatric patients (aged < 20 years) with non-accidental injuries were enrolled, which were divided by age into preschool (0-6 years), child (7-12 years), and adolescent (13-19 years) groups. Baseline characteristics, injury epidemiology, and excess mortality ratio-adjusted injury severity score (EMR-ISS) were collected. Major trauma was defined as an EMR-ISS score > 24. The study enrolled 451 patients with non-accidental injuries, accounting for 2.81% of pediatric trauma events presented to an emergency department in the PATOS registry. The overall mortality rate was 0.9%, similar to those in Western countries. Mortality rate was high in preschool children (8.7%, p = 0.017) than in other age groups. The sex-specific incidence was higher in boys (3.10% vs. 2.13%, p = 0.001). In adolescents, more events occurred on the street (25.9%), whereas home remained the most common locale in girls of all ages. In the multivariable regression analysis, abdominal and multiple injuries were risk factors for major trauma.

The Incidence of Diaphragmatic Dysfunction in Patients Presenting With Dyspnea in the Emergency Department.

OBJECTIVES: Diaphragmatic dysfunction has been reported as a cause of dyspnea, and its diagnosis can be made using ultrasound. Diaphragmatic ultrasound is mainly used to predict respiratory failure in chronic conditions. The use of diaphragmatic ultrasound has also risen in acute settings, such as emergency departments (EDs). However, the number of studies on its use still needs to be increased. The present study aimed to find the incidence of diaphragmatic dysfunction in the ED. METHODS: This prospective cohort study was conducted in an ED. We enrolled patients aged greater than 18 years who presented with dyspnea. Diaphragmatic excursion and diaphragmatic thickness techniques were performed. The primary outcome was the incidence of diaphragmatic dysfunction. The secondary outcomes were the associations between diaphragmatic dysfunction and the composition of respiratory therapies within 24 hours, intubation within 24 hours, and 7-day mortality. RESULTS: A total of 237 patients were analyzed. The incidences of diaphragmatic dysfunction assessed by diaphragmatic excursion and diaphragm thickness were 22.4 and 32.1%, respectively. Patients with sepsis and cancer had the highest incidences. Diaphragmatic dysfunction assessed by both techniques was not associated with the composition of respiratory support therapies within 24 hours, intubation within 24 hours, or 7-day mortality. CONCLUSIONS: The incidence of diaphragmatic dysfunction in dyspneic patients in the ED ranged from 22.4 to 32.1%, depending on the ultrasound technique. Diaphragmatic dysfunction was not associated with the composition of respiratory support therapies, intubation, or mortality.

Epidemiology and Prehospital Care of Pediatric Unintentional Injuries Among Countries with Different Economic Status in Asia: A Cross-National, Multi-Center Observational Study.

OBJECTIVE: Injury is a major cause of morbidity and mortality in children. However, the epidemiology and prehospital care for pediatric unintentional injuries in Asia are still unclear. METHODS: A total of 9,737 pediatric patients aged <18 years with unintentional injuries cared for at participating centers of the Pan-Asian Trauma Outcome Study (PATOS) from October 2015 to December 2020 were reviewed retrospectively. Patients were divided into two groups: those <8 and those ≥8 years of age. Variables such as patient demographics, injury epidemiology, Injury Severity Score (ISS), and prehospital care were collected. Injury severity and administered prehospital care stratified by gross national income were also analyzed. RESULTS: Pediatric unintentional injuries accounted for 9.4% of EMS-transported trauma cases in the participating Asian centers, and the mortality rate was 0.88%. The leading cause of injury was traffic injuries in older children aged ≥8 years (56.5%), while falls at home were common among young children aged <8 years (43.9%). Compared with younger children, older children with similar ISS tended to receive more prehospital interventions. Uneven disease severity was found in that older children in lower-middle and upper-middle-income countries had higher ISS compared with those in high-income countries. The performance of prehospital interventions also differed among countries with different gross national incomes. Immobilizations were the most performed prehospital intervention followed by oxygen administration, airway management, and pain control; only one patient received prehospital thoracentesis. Procedures were performed more frequently in high-income countries than in upper-middle-income and lower-middle-income countries. CONCLUSIONS: The major cause of injury was road traffic injuries in older children, while falls at home were common among young children. Prehospital care in pediatric unintentional injuries in Asian countries was not standardized and might be insufficient, and the economic status of countries may affect the implementation of prehospital care.

Comparing performance measures and clinical outcomes between mobile stroke units and usual care in underserved areas.

BACKGROUND: The efficacy of mobile stroke units (MSUs) in improving acute ischemic stroke (AIS) care in developing countries is unknown. We compared performance measures and stroke outcomes in AIS patients between MSU and usual care: emergency medical services (EMS) and walk-in. METHODS: We enrolled patients > 18 years of age with an AIS within 4.5 h after onset. Demographic data, types, and time of reperfusion therapies and clinical outcomes were recorded. A favorable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 3 months. RESULTS: A total of 978 AIS patients (MSU = 243, EMS = 214, walk-in = 521) were enrolled between June 1, 2018, and April 30, 2021. The mean age (± SD) was 66 (± 14) years, and 510 (52.1%) were male. AIS time metrics were the shortest in the MSU with a mean (± SD) door to needle (DN) time of 20 (± 7), 29 (± 13), and 35 (± 16) min (p < 0.001) and door to puncture (DP) time of 73 ± 19, 86 ± 33, and 101 ± 42 min (p < 0.001) in MSU, EMS, and walk-in, respectively. Participants in the MSU (56.8%) received higher rate of reperfusion therapie(s) when compared to the EMS (51.4%) and walk-in (31.5%) (p < 0.001). After adjustment for any potential confounders and using the EMS as a reference, the MSU has the highest likelihood of achieving a favorable outcome (adjusted OR 2.15; 95% CI 1.39-3.32). CONCLUSIONS: In underserved populations, MSUs significantly reduced DN time, increased the likelihood of receiving reperfusion treatment, and achieved independency at 3 months when compared to usual care.

Impact of the COVID-19 outbreak on out-of-hospital cardiac arrest management and outcomes in a low-resource emergency medical service system: a perspective from Thailand.

BACKGROUND: The impact of the coronavirus disease 2019 (COVID-19) outbreak on out-of-hospital cardiac arrest (OHCA) has been of interest worldwide. However, evidence from low-resource emergency medical service systems is limited. This study investigated the effects of the COVID-19 outbreak on the prehospital management and outcomes of OHCA in Thailand. METHODS: This multicentered, retrospective, observational study compared the management and outcomes of OHCA for 2 periods: pre-COVID-19 (January-September 2019) and during the outbreak (January-September 2020). Study data were obtained from the Thai OHCA Network Registry. The primary outcome was survival rate to hospital discharge. Data of other OHCA outcomes and prehospital care during the two periods were also compared. RESULTS: The study enrolled 691 patients: 341 (49.3%) in the pre-COVID-19 period and 350 (50.7%) in the COVID-19 period. There was a significant decrease in the survival rate to discharge during the COVID-19 outbreak (7.7% vs 2.2%; adjusted odds ratio [aOR], 0.34; 95% confidence interval [CI], 0.15-0.95). However, there were no significant differences between the 2 groups in terms of their rates of sustained return of spontaneous circulation (33.0% vs 31.3%; aOR, 1.01; 95% CI, 0.68-1.49) or their survival to intensive care unit/ward admission (27.8% vs 19.8%; aOR, 0.78; 95% CI, 0.49-1.15). The first-responder response interval was significantly longer during the COVID-19 outbreak (median [interquartile range] 5.3 [3.2-9.3] min vs 10 [6-14] min; P < 0.001). There were also significant decreases in prehospital intubation (66.7% vs 48.2%; P < 0.001) and prehospital drug administration (79.5% vs 70.6%; P = 0.024) during the COVID-19 outbreak. CONCLUSION: There was a significant decrease in the rate of survival to hospital discharge of patients with OHCA during the COVID-19 outbreak in Thailand. Maintaining the first responder response quality and encouraging prehospital advanced airway insertion might improve the survival rate during the COVID-19 outbreak.

The Psychological Well-Being of Southeast Asian Frontline Healthcare Workers during COVID-19: A Multi-Country Study.

OBJECTIVES: This study examined the prevalence of anxiety, depression, and job burnout among frontline healthcare workers (HCWs) across six Southeast Asian countries (Indonesia, Malaysia, Philippines, Singapore, Thailand, Vietnam) during the COVID-19 pandemic in 2021. We also investigated the associated risk and protective factors. METHODS: Frontline HCWs (N = 1381) from the participating countries participated between 4 January and 14 June 2021. The participants completed self-reported surveys on anxiety (GAD-7), depression (PHQ-8), and job burnout (PWLS). Multivariate logistic regressions were performed with anxiety, depression, and job burnout as outcomes and sociodemographic and job characteristics and HCW perceptions as predictors. RESULTS: The average proportion of HCWs reporting moderate anxiety, moderately severe depression, and job burnout across all countries were 10%, 4%, and 20%, respectively. Working longer hours than usual (Odds ratio [OR] = 1.82; 3.51), perceived high job risk (1.98; 2.22), and inadequate personal protective equipment (1.89; 2.11) were associated with increased odds of anxiety and job burnout while working night shifts was associated with increased risk of depression (3.23). Perceived good teamwork was associated with lower odds of anxiety (0.46), depression (0.43), and job burnout (0.39). CONCLUSION: Job burnout remains a foremost issue among HCWs. Potential opportunities to improve HCW wellness are discussed.

A retrospective multi-centre cohort study: Pre-hospital survival factors of out-of-hospital cardiac arrest (OHCA) patients in Thailand.

OBJECTIVE: This study aimed to explore significant pre-hospital factors affecting the survivability of Out-of-Hospital Cardiac Arrest (OHCA) patients in countries with developing EMS systems. METHOD: A retrospective cohort study was conducted examining data from January 1, 2017 to December 31, 2020 from Utstein Registry databases in Thailand, collected through Pan-Asian Resuscitation Outcomes Study (PAROS). Data were collected from three centres, including regional, suburban-capital, and urban-capital hospitals. The primary endpoint of this study was 30-day survival or discharged alive after an OHCA event. The multivariable risk regression was done by modified Poisson regression with robust error variance to explore the association between 30-day survival and pre-hospital factors with potential confounders adjustments. FINDINGS: Of 1,240 OHCA cases transferred by Emergency Medical Services (EMS), 42 patients (3.4%) were discharged alive after 30 days, including 22 (8.6%), 8 (3.0%), and 12 (1.7%) from regional, suburban-capital, and urban-capital centres, respectively. The initial arrest rhythm was 89.7% unshockable, with no significant variations across the three centres. Overall, bystander Cardiopulmonary Resuscitation (CPR) was 40.4%. However, bystander CPR with Automated External Defibrillator (AED) application was 0.8%. Bystander CPR significantly increased 30-day survival probability (aRR 1.88, 95% CI 1.01 to 3.51; p 0.049). Additionally, reducing the EMS response time by one minute significantly increased OHCA survivability (aRR 1.12, 95% CI 1.04 to 1.20; p 0.001). CONCLUSIONS: Response time and bystander CPR are the factors that improve the 30-day survival outcomes of OHCA patients. In contrast, scene time, transport time, and pre-hospital advanced airway management didn't improve 30-day OHCA survival.

Effect of Nighttime on Prehospital Care and Outcomes of Road Traffic Injuries in Asia: A Cross-Sectional Study of Data from the Pan-Asian Trauma Outcomes Study (PATOS).

Introduction: Emergency response to a road traffic injury (RTI) plays a crucial role in patient survival, and the quality of the emergency response should be consistent regardless of the time of day. The aim of this study was to investigate prehospital care and survival outcomes compared between emergency response to RTI during the day and emergency response to RTI at night in Asia.Method: This cross-sectional study used data from the Pan-Asian Trauma Outcome Study (PATOS) that was conducted during 2015-2018. We included RTI patients who were transported to the emergency department (ED) by ground ambulance. That group was then categorized according to the time that the ambulance arrived on-scene. On-scene arrival during 8:00 am to 7:59 pm was defined as the daytime group, and arrival during 8:00 pm to 7:59 am was defined as the nighttime group. Multiple logistic regression was employed to identify factors associated with nighttime prehospital interventions and survival outcomes after adjustment for age, alcohol consumption, and injury severity score (ISS).Results: The final analysis included 20,105 RTI patients. Of those, 12,043 (60%) accidents occurred during the daytime, and 8,062 (40%) occurred at night. RTI patients at night were younger (mean age: 35.7 ± 17.3 vs. 39.5 ± 20.7; p < 0.001), had more alcohol consumption (15.0% vs. 4.2%; p < 0.001), and had more severe injuries (mean ISS: 6.5 ± 7.5 vs. 5.8 ± 7.0; p < 0.001) compared to the daytime group. The nighttime group had increased prehospital immobilization (adjusted odds ratio [aOR]: 1.22, 95% confidence interval [CI]: 1.14-1.31) and more prehospital intravenous (IV) access (aOR 1.36, 95%CI: 1.22-1.51). There was no significant difference in either basic or advanced airway management between the daytime and nighttime groups. The nighttime group had decreased survival in the ED (aOR: 0.80, 95%CI: 0.65-0.98); however, nighttime on-scene arrival did not impact survival to discharge (aOR: 1.10, 95%CI: 0.91-1.33).Conclusion: In the PATOS community, RTI patients that sustained their injuries at night received significantly more prehospital immobilization and IV access, and they had significantly decreased survival in the ED. The results of this study can be used to develop and enhance strategies to improve the care and outcomes of nighttime RTI in Asia.

The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients.

BACKGROUND: Although the 0/1 h high-sensitivity cardiac troponin T (0/1 hs-cTnT) algorithm and many risk scores have been validated for use in emergency departments (EDs), their utility in high-acuity ED patients has not been validated. We aimed to validate the 0/1 hs-cTnT algorithm and the HEART, TIMI, GRACE, T-MACS and NOTR risk scores before and after combining the 0/1 algorithm in high-acuity ED chest pain patients. METHODS: A prospective observational study was conducted in the high-acuity ED of Siriraj Hospital, a tertiary hospital in Bangkok, Thailand. Adult patients with chest pain were enrolled between November 2018 and November 2019. The primary outcome was 30-day major adverse cardiac events (30-day MACE), defined as a composite of mortality, acute myocardial infarction, significant coronary stenosis and revascularization procedures. RESULTS: Of 350 recruited patients, 59 (16.9%) developed 30-day MACE. For the 0/1 hs-cTnT algorithm, sensitivity and negative predictive value (NPV) were 91.3% (95%CI 79.2-97.6%) and 97.2% (95%CI 93.2-98.9%), respectively. Specificity and positive predictive value were 79.6% (95%CI 72.8-85.2%) and 53.9% (95%CI 46.2-61.3%), respectively. Of the risk scores, the HEART score had the highest area under the receiver operator characteristic curve (0.74 [95%CI 0.68-0.81]). Combining the 0/1 hs-cTnT algorithm, a TIMI score cut-off of ≤1 had the best sensitivity and NPV (both 100%) and identified the greatest proportion of patients (24.3%) suitable for safe discharge. CONCLUSION: The 0/1 hs-cTnT algorithm may be feasible in Asian high-acuity ED patients. The HEART score outperformed other scores in predicting 30-day MACE. Combining the 0/1 hs-cTnT algorithm with a TIMI cut-off score ≤ 1 had the best rule-out performance.

Role of Point-of-Care Testing in Reducing Time to Treatment Decision-Making in Urgency Patients: A Randomized Controlled Trial.

INTRODUCTION: Shortening emergency department (ED) visit time can reduce ED crowding, morbidity and mortality, and improve patient satisfaction. Point-of-care testing (POCT) has the potential to decrease laboratory turnaround time, possibly leading to shorter time to decision-making and ED length of stay (LOS). We aimed to determine whether the implementation of POCT could reduce time to decision-making and ED LOS. METHODS: We conducted a randomized control trial at the Urgency Room of Siriraj Hospital in Bangkok, Thailand. Patients triaged as level 3 or 4 were randomized to either the POCT or central laboratory testing (CLT) group. Primary outcomes were time to decision-making and ED LOS, which we compared using Mann-Whitney-Wilcoxon test. RESULTS: We enrolled a total of 248 patients: 124 in the POCT and 124 in the CLT group. The median time from arrival to decision was significantly shorter in the POCT group (106.5 minutes (interquartile [IQR] 78.3-140) vs 204.5 minutes (IQR 165-244), p <0.001). The median ED LOS of the POCT group was also shorter (240 minutes (IQR 161.3-410) vs 395.5 minutes (IQR 278.5-641.3), p <0.001). CONCLUSION: Using a point-of-care testing system could decrease time to decision-making and ED LOS, which could in turn reduce ED crowding.

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Relieving Dyspnea in Emergency Palliative Patients With Do-Not-Intubate Status: A Randomized Crossover Study.

STUDY OBJECTIVE: Palliative patients often visit the emergency department (ED) with respiratory distress during their end-of-life period. The goal of management is alleviating dyspnea and providing comfort. High-flow nasal cannula may be an alternative oxygen-delivering method for palliative patients with do-not-intubate status. We therefore aim to compare the efficacy of high-flow nasal cannula with conventional oxygen therapy in improving dyspnea of palliative patients with do-not-intubate status who have hypoxemic respiratory failure in the ED. METHODS: This randomized, nonblinded, crossover study was conducted with 48 palliative patients aged 18 years or older with do-not-intubate status who presented with hypoxemic respiratory failure to the ED of Siriraj Hospital, Bangkok, Thailand. The participants were randomly allocated to conventional oxygen therapy for 60 minutes, followed by high-flow nasal cannula for 60 minutes (n=24) or vice versa (n=24). The primary outcome was modified Borg scale score. The secondary outcomes were numeric rating scale score of dyspnea and vital signs. RESULTS: Intention-to-treat analysis included 44 patients, 22 in each group. Baseline mean modified Borg scale score was 7.6 (SD 2.2) (conventional oxygen therapy first) and 8.2 (SD 1.8) (high-flow nasal cannula first). At 60 minutes, mean modified Borg scale score in patients receiving conventional oxygen therapy and high-flow nasal cannula was 4.9 (standard of mean 0.3) and 2.9 (standard of mean 0.3), respectively (mean difference 2.0; 95% confidence interval 1.4 to 2.6). Results for the numeric rating scale score of dyspnea were similar to those for the modified Borg scale score. Respiratory rates were lower with high-flow nasal cannula (mean difference 5.9; 95% confidence interval 3.5 to 8.3), and high-flow nasal cannula was associated with a significantly lower first-hour morphine dose. CONCLUSION: High-flow nasal cannula was superior to conventional oxygen therapy in reducing the severity of dyspnea in the first hour of treatment in patients with do-not-intubate status and hypoxemic respiratory failure.

Outcomes of Emergency Medical Service Usage in Severe Road Traffic Injury during Thai Holidays.

INTRODUCTION: Thailand has the highest mortality from road traffic injury (RTI) in the world. There are usually higher incident rates of RTI in Thailand over long holidays such as New Year and Songkran. To our knowledge, there have been no studies that describe the impact of emergency medical service (EMS) utilization by RTI patients in Thailand. We sought to determine the outcomes of EMS utilization in severe RTIs during the holidays. METHODS: We conducted a retrospective review study by using a nationwide registry that collected RTI data from all hospitals in Thailand during the New Year holidays in 2008-2015 and Songkran holidays in 2008-2014. A severe RTI patient was defined as one who was admitted, transferred to another hospital, or who died at the emergency department (ED) or during referral. We excluded patients who died at the scene, those who were not transported to the ED, and those who were discharged from the ED. Outcomes associated with EMS utilization were identified by using multiple logistic regression and adjusted by using factors related to injury severity. RESULTS: Overall we included 100,905 patients in the final analysis; 39,761 severe RTI patients (39.40%; 95% confidence interval [CI] 95% CI [39.10%-39.71%]) used EMS transportation to hospitals. Severe RTI patients transported by EMS had a significantly higher mortality rate in the ED and during referral than that those who were not (2.00% vs. 0.78%, p < 0.001). Moreover, EMS use was significantly associated with increased mortality rate in the first 24 hours of admission to hospitals (1.38% for EMS use vs. 0.57% for no EMS use, p < 0.001). EMS utilization was a significant predictor of mortality in EDs and during referral (adjusted odds ratio [OR] 2.19; 95% CI [1.88-2.55]), and mortality in the first 24 hours of admission (adjusted OR 2.31; 95% CI [1.95-2.73]). CONCLUSION: In this cohort, severe RTI patients transported by EMS had a significantly higher mortality rate than those who went to hospitals using private vehicles during these holidays.

The feasibility of the 1-h high-sensitivity cardiac troponin T algorithm to rule-in and rule-out acute myocardial infarction in Thai emergency patients: an observational study.

BACKGROUND: The 3-h high-sensitivity cardiac troponin T (hs-cTnT) algorithm is the most commonly used scheme to diagnose acute myocardial infarction. The 1-h hs-cTnT algorithm has recently been approved by the European Society of Cardiology as an alternative algorithm for earlier diagnosis. If the hs-cTnT test cannot discriminate the diagnosis of the patient at 1 h, the patient is defined as observational group. Their test must be repeated at 3 h. A high prevalence of this group may indicate a low clinical utility of the 1-h hs-cTnT algorithm. This study was aimed to estimate the proportion of the observational group in Thai emergency department (ED) patients and also the time to rule-in/out between both the algorithms. METHODS: A historical control study was conducted in patients with chest pain for 1-12 h at the ED of Siriraj Hospital, Bangkok, Thailand. The study compared two groups: one prospective group of all patients evaluated with the 1-h hs-cTnT algorithm between June and September 2017 and one historical control group evaluated with the 3-h hs-cTnT algorithm between January and March 2017. RESULTS: A total of 130 patients were included (3-h hs-cTnT algorithm group n = 65 and 1-h hs-cTnT algorithm group n = 65). Twelve patients [18.5% (95% CI 10.0-30.1)] were categorized as observational group in the 1-h hs-cTnT algorithm group. The mean rule-in/out times in the 3-h hs-cTnT algorithm and 1-h hs-cTnT algorithm groups were 238 min (SD 63.3) and 134 min (SD 68.5), respectively (both p < 0.001). The time to disposition was also shortened in the 1-h hs-cTnT algorithm group (p <  0.001). Multivariable regression analysis performed to identify and adjust for confounders among patient characteristics revealed no significant confounders. CONCLUSIONS: The use of the 1-h hs-cTnT algorithm in the ED resulted in an acceptable proportion in the observational group and a decreased time to rule-in/out compared with the 3-h hs-cTnT algorithm.

Apneic Oxygenation May Not Prevent Severe Hypoxemia During Rapid Sequence Intubation: A Retrospective Helicopter Emergency Medical Service Study.

OBJECTIVE: This study sought to determine the effectiveness of apneic oxygenation in preventing hypoxemia during prehospital rapid sequence intubation (RSI). METHODS: We performed a case-cohort study using a pre-existing database looking at intubation management by a single helicopter emergency medical service between July 2013 and June 2015. Apneic oxygenation using high-flow nasal cannula (15 L/min) was introduced to the standard RSI protocol in July 2014. Severe hypoxemia was defined as an incidence of oxygen saturation less than 90%. We compared patients who received apneic oxygenation during RSI with patients who did not using the Fisher exact test. RESULTS: Ninety-three patients were identified from the database; 29 (31.2%) received apneic oxygenation. Nineteen patients had an incidence of severe hypoxemia during RSI (20.43%; 95% confidence interval, 12.77%-30.05%). There was no statistically significant difference between the rate of severe hypoxemia between patients in the apneic oxygenation group versus the control group (17.2% vs. 21.9%, P = .78). CONCLUSION: In this study, patients who received apneic oxygenation did not show a statistically significant difference in severe hypoxemia during RSI.

Emergency dispatcher assistance decreases time to defibrillation in a public venue: a randomized controlled trial.

BACKGROUND: We attempted to determine the effect of prearrival instructions that included the specific location of automated external defibrillators (AEDs) in a public venue on the time to defibrillation in a simulated cardiac arrest scenario using untrained bystanders. METHODS: The study was a randomized controlled trial at an urban shopping mall. Participants were asked to retrieve an AED and come back to defibrillate a mannequin. Only the experimental group received the location of the AED. We measured the percentage of shocks that were delivered in less than 3 minutes from the start of the scenario and also recorded several other time intervals. RESULTS: Thirty-nine participants completed the study, with 20 participants in the experimental group. The median time to defibrillation in the experimental group was 2.6 minutes (interquartile range, 2.4-2.8) which was significantly less than the control group's median time of 5.9 minutes (interquartile range, 4.38-7.65). Ninety percent (95% confidence interval, 68.3%-98.8%) of the participants in the experimental group defibrillated within 3 minutes, which was significantly different from the control group (10.5%; 95% confidence interval, 1.3%-33.1%). CONCLUSION: In this study, a prearrival protocol providing participants with the location of the nearest AED in a public building resulted in a significant decrease in the time required to deliver a simulated shock. Further investigations in various types of public settings are needed to confirm the results.