Assessing feasibility of proposed extracorporeal cardiopulmonary resuscitation programmes for out-of-hospital cardiac arrest in Scotland via geospatial modelling.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) can improve survival for refractory out-of-hospital cardiac arrest (OHCA). We sought to assess the feasibility of a proposed ECPR programme in Scotland, considering both in-hospital and pre-hospital implementation scenarios. METHODS: We included treated OHCAs in Scotland aged 16-70 between August 2018 and March 2022. We defined those clinically eligible for ECPR as patients where the initial rhythm was ventricular fibrillation, ventricular tachycardia, or pulseless electrical activity, and where pre-hospital return of spontaneous circulation was not achieved. We computed the call-to-ECPR access time interval as the amount of time from emergency medical service (EMS) call reception to either arrival at an ECPR-ready hospital or arrival of a pre-hospital ECPR crew. We determined the number of patients that had access to ECPR within 45 min, and estimated the number of additional survivors as a result. RESULTS: A total of 6,639 OHCAs were included in the geospatial modelling, 1,406 of which were eligible for ECPR. Depending on the implementation scenario, 52.9-112.6 (13.8-29.4%) OHCAs per year had a call-to-ECPR access time within 45 min, with pre-hospital implementation scenarios having greater and earlier access to ECPR for OHCA patients. We further estimated that an ECPR programme in Scotland would yield 11.8-28.2 additional survivors per year, with the pre-hospital implementation scenarios yielding higher numbers. CONCLUSION: An ECPR programme for OHCA in Scotland could provide access to ECPR to a modest number of eligible OHCA patients, with pre-hospital ECPR implementation scenarios yielding higher access to ECPR and higher numbers of additional survivors.

Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study.

BACKGROUND: Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations. METHODS: A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI). RESULTS: 30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension. CONCLUSION: Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.

Predictors of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia: a multi-centre observational study.

BACKGROUND: Post-intubation hypotension (PIH) after prehospital emergency anaesthesia (PHEA) is prevalent and associated with increased mortality in trauma patients. The objective of this study was to compare the differential determinants of PIH in adult trauma patients undergoing PHEA. METHODS: This multi-centre retrospective observational study was performed across three Helicopter Emergency Medical Services (HEMS) in the UK. Consecutive sampling of trauma patients who underwent PHEA using a fentanyl, ketamine, rocuronium drug regime were included, 2015-2020. Hypotension was defined as a new systolic blood pressure (SBP) < 90 mmHg within 10 min of induction, or > 10% reduction if SBP was < 90 mmHg before induction. A purposeful selection logistic regression model was used to determine pre-PHEA variables associated with PIH. RESULTS: During the study period 21,848 patients were attended, and 1,583 trauma patients underwent PHEA. The final analysis included 998 patients. 218 (21.8%) patients had one or more episode(s) of hypotension ≤ 10 min of induction. Patients > 55 years old; pre-PHEA tachycardia; multi-system injuries; and intravenous crystalloid administration before arrival of the HEMS team were the variables significantly associated with PIH. Induction drug regimes in which fentanyl was omitted (0:1:1 and 0:0:1 (rocuronium-only)) were the determinants with the largest effect sizes associated with hypotension. CONCLUSION: The variables significantly associated with PIH only account for a small proportion of the observed outcome. Clinician gestalt and provider intuition is likely to be the strongest predictor of PIH, suggested by the choice of a reduced dose induction and/or the omission of fentanyl during the anaesthetic for patients perceived to be at highest risk.

Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM).

BACKGROUND: Pre hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic-termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM. METHODS: A retrospective observational study of consecutive trauma patients ≥ 16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015-2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher's exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95% CI)), p value. The study design complied with the STROBE (Strengthening The Reporting of Observational studies in Epidemiology) reporting guidelines. RESULTS: In the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥ 16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28-63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs-90.2% and 87.4% respectively, OR 1.3 (95% CI 0.7-2.5), p = 0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt. CONCLUSION: In an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.

Does the level of socioeconomic deprivation at the location of cardiac arrest in an English region influence the likelihood of receiving bystander-initiated cardiopulmonary resuscitation?

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality. Administration of cardiopulmonary resuscitation (CPR) by a bystander witnessing a cardiac arrest has been shown to increase the likelihood of return of spontaneous circulation and survival. This study analyses the association between the socioeconomic status of the location where a person suffers a cardiac arrest and the proportion of victims with OHCA receiving bystander CPR. METHODS: Retrospective analysis of all OHCAs occurring in North East England from 1 January 2011 to 31 December 2011: data obtained from the North East Cardiac Arrest Network Registry. RESULTS: Of 3179 OHCAs with an attempt at resuscitation, 623 patients received bystander-initiated CPR (19.6%). From quintile (Q) 1 to Q5 (most deprived to least deprived), bystander-initiated CPR rates increased from 14.5% to 23.3% (p for trend <0.001). Patients in the least deprived quintile were significantly more likely to receive bystander-initiated CPR when compared with those in the most deprived quintile (OR=1.78, 95% CI 1.32 to 2.39, p≤0.001). CONCLUSIONS: Increasing socioeconomic status at the location of cardiac arrest is positively associated with the likelihood of bystander CPR for OHCA in this region of England.

Difficulties in diagnosing tuberculosis of the cervix in a post menopausal woman: Case report and literature review.

Tuberculosis (TB) of the cervix is a rare disease, especially in developed countries. We presented a patient with primary TB of the cervix with no concurrent immune deficiency or HIV infections. The case clinically mimicked carcinoma of the cervix. Difficulties in diagnosis have been discussed. Given the recent increase in migration patterns including travel from TB endemic areas, an abnormal-looking cervix should be regarded with a degree of suspicion for TB.