Ventilatory improvement with mechanical ventilator versus bag in non-traumatic out-of-hospital cardiac arrest: SYMEVECA study, phase 1.

AIM: To analyze differences in ventilatory parameters and outcome with different ventilatory methods during CPR. METHODS: Pragmatic prospective quasi-experimental study in out-of-hospital urban environment. Patients over 18 years of age in non-traumatic cardiac arrest, attended by an emergency medical service between April 2021 and September 2022, were included. Two groups were compared according to the ventilatory method: mechanical ventilator (IPPV, tidal volume 7 ml/kg, frequency 10-12 bpm) or manual resuscitator bag. The main variables of interest are those of gasometry performed 15 minutes after intubation or when spontaneous circulation is recovered and final outcome. Patients were followed up to hospital discharge. RESULTS: Of the 359 patients attended, 150 were included (71 in IPPV and 79 with a bag). In patients with arterial blood gases, pCO2 was 67.8 ± 21.1 in the IPPV group vs 95.9 ± 39.0 mmHg in the bag group (p = 0.006) and pH was 7.00 ± 0.18 vs 6.92 ± 0.18 (p = 0.18). With a venous sample, the pCO2 was 68.1 ± 18.9 vs 89.5 ± 26.5 mmHg (p < 0.001) and the pH was 7.03 ± 0.15 vs 6.94 ± 0.17 (p = 0.005), respectively. Survival with CPC 1-2 to hospital discharge was 15.6% with IPPV and 11.3% with bag (p = 0.44). CONCLUSION: The use of a mechanical ventilator in IPPV was associated with a better ventilatory status during CPR compared to the use of the bag, without conclusive data regarding its clinical repercussion with the sample collected.

Prognostic value of metabolic parameters measured by first responders attending patients with severe trauma: associations with the New Injury Severity Score and mortality. / Valor pronóstico de los parámetros metabólicos medidos en la asistencia inicial a pacientes con trauma grave: asociación con la puntuación de la escala NISS y la mortalidad.

OBJECTIVES: Patients with severe or potentially severe trauma must be identified early, a challenge in prehospital settings. This study aimed to analyze the possible diagnostic and prognostic usefulness of analytical markers recorded in the early moments of care. MATERIAL AND METHODS: Observational study of information extracted from the prospective multicenter Code Trauma database for 2016-2019, excluding data for isolated head injuries. Using the New Injury Severity Score (NISS), we classified cases into 4 levels of severity. NISS and mortality were considered the dependent variables in inferential analyses. We calculated the areas under receiver operating characteristic curves, identified optimal cutoff points (Youden index), and calculated positive (PPV) and negative predictive values.. RESULTS: Of the 1039 trauma patients in the registry, 709 were included in the study. Their mean (SD) age was 40.4 (17.3) years, and 77.3% were men. Motorcycle accidents were the most common causes of trauma (in 21%), and mortality was 12.1%. Lactate concentration, pH, PCO2, hemoglobin concentration, hematocrit, and blood sugar were significantly associated with severity and mortality. The PPVs corresponding to pH for the 4 NISS score groups (34-41, 42-49, 50-59, and $ 60) and mortality, respectively, were 61.2, 64.1, 70.7, 62.2, and 66.6. The PPVs of traditionally used clinical variables were lower. CONCLUSION: Patients with more severe trauma had lower pH values and higher PCO2, lactate, and base excess values. PCO2, pH, and blood sugar findings were the best predictors of severity. Metabolic variables are better predictors than traditionally recorded hemodynamic variables.

OBJETIVO: En entornos de emergencia prehospitalarios, la detección temprana de un paciente con trauma grave o potencialmente crítico es un desafío. El objetivo es analizar las posibilidades diagnósticas y pronóstico de los parámetros analíticos obtenidos en los primeros momentos de la asistencia inicial. METODO: Estudio observacional multicéntrico de la base de datos prospectiva "Código Trauma" de 2016-2019 excluyendo el trauma craneoencefálico aislado. La evaluación de las lesiones se realizó utilizando el New Injury Severity Score (NISS). Los pacientes fueron clasificados en 4 grupos según nivel de gravedad. Para el análisis inferencial, las puntuaciones NISS y el resultado de mortalidad se consideraron variables dependientes. Se realizó el análisis de la curva ROC, puntos de corte óptimos mediante el índice de Youden y se calcularon los valores predictivos positivo (VPP) y negativo. RESULTADOS: De los 1.039 pacientes traumatizados del registro, 709 fueron incluidos en el estudio, con una edad media de 40,4 años (DE 17,3), 77,3% eran varones, el mecanismo lesional principal accidentes de moto (21%) y la mortalidad del 12,1%. El pH, lactato, pCO2, hemoglobina, hematocrito y glucemia influyeron significativamente en gravedad y mortalidad. El VPP de mortalidad para pH fue 61,2, 64,1, 70,7, 62,2 y 66,6 para los grupos de NISS 34- 41, 42-49, 50-59 y $ 60 puntos la mortalidad, respectivamente. Las variables clínicas clásicas obtuvieron valores más bajos. CONCLUSIONES: Los pacientes con mayor gravedad presentaron menor pH y concentraciones más altas de pCO2, lactato y exceso de bases. El pH, la pCO2 y la glucemia tuvieron la mayor capacidad predictiva de gravedad. La capacidad predictiva de los valores metabólicos es superior a la de los valores hemodinámicos clásicos.

Prognostic value of venous blood analysis at the start of CPR in non-traumatic out-of-hospital cardiac arrest: association with ROSC and the neurological outcome.

BACKGROUND: The knowledge of new prognostic factors in out-of-hospital cardiac arrest (OHCA) that can be evaluated since the beginning of cardiopulmonary resuscitation (CPR) manoeuvres could be helpful in the decision-making process of prehospital care. We aim to identify metabolic variables at the start of advanced CPR at the scene that may be associated with two main outcomes of CPR (recovery of spontaneous circulation (ROSC) and neurological outcome). METHODS: Prospective observational study of all non-traumatic OHCA in patients older than 17 years assisted by emergency medical services (EMS), with doctor and nurse on board, between January 2012 and December 2017. Venous blood gases were sampled upon initially obtaining venous access to determine the initial values of pH, pCO2, HCO3-, base excess (BE), Na+, K+, Ca2+ and lactate. ROSC upon arrival at the hospital and neurological status 30 days later (Cerebral Performance Categories (CPC) scale) were recorded. RESULTS: We included 1552 patients with OHCA with blood test data in a 6-year period. ROSC was achieved in 906 cases (58.4%), and good neurological recovery at 30 days (CPC I-II) occurred in 383 cases (24.68%). In multivariate analysis, we found a significant relationship between non-recovery of spontaneous circulation (no-ROSC) and low pH levels (adjusted odds ratio (OR) 0.03 (0.002-0.59), p = 0.020), high pCO2 levels (adjusted OR 1.03 [1.01-1.05], p = 0.008) and high potassium levels (adjusted OR 2.28 [1.43-3.61], p = 0.008). Poor neurological outcomes were associated with low pH levels (adjusted OR 0.06 [0.02-0.18], p < 0.001), high pCO2 (adjusted OR 1.05 [1.03-1.08], p < 0.001), low HCO3- (adjusted OR 0.97 [0.94-0.999], p = 0.044), low BE (adjusted OR 0.96 [0.93-0.98], p < 0.001) and high potassium levels (adjusted OR 1.37 [1.16-1.60], p < 0.001). CONCLUSION: There is a significant relationship between severe alterations of venous blood-gas variables and potassium at the start of CPR of non-traumatic OHCA and low-ROSC rate and neurological prognosis.

[Incidence of acute agitation and variation in acute agitation management by emergency services]. / Incidencia y variabilidad de manejo de la agitación aguda en los servicios de emergencias médicas.

OBJECTIVES: To describe the management of acute agitation by Spanish emergency medical services (EMS) and assess the incidence of acute agitation. MATERIAL AND METHODS: Observational descriptive study based on aggregate data from unpublished internal EMS reports. RESULTS: Seven participating emergency services received 4 306 213 emergency calls in 2013; 111 599 (2.6%, or 6.2 calls per 1000 population) were categorized as psychiatric emergencies. A total of 84 933 interventions (4.2%, or 4 per 1000 population) were required; 37 951 of the calls concerned agitated patients (1.9%, or 2 cases per 1000 population). Only 3 EMS mandated a specific procedure for their responders to use in such cases. CONCLUSION: The agitated patient is a common problem for EMS responders. Few teams apply specific procedures for managing these patients.

OBJETIVO: Evaluar la incidencia y el manejo de la agitación aguda por los servicios de emergencias médicas (SEM) en España. METODO: Estudio observacional descriptivo que utiliza datos agregados de las memorias de actividad o datos internos no publicados de los SEM. RESULTADOS: Durante el año 2013, los 7 SEM participantes recibieron 4.306.213 llamadas, de las cuales 111.599 (2,6%; 6,2 llamadas/1.000 habitantes) fueron categorizadas como psiquiátricas. Las actuaciones requeridas por motivos psiquiátricos fueron 84.933 (4,2% del total de actuaciones; 4,0 actuaciones/1.000 habitantes) y, de estas, 37.951 fueron por pacientes agitados (1,9% del total de actuaciones; 2,0 actuaciones/1.000 habitantes). Solo 3 SEM disponían de un procedimiento específico para los equipos asistenciales de atención al paciente psiquiátrico y al paciente agitado. CONCLUSIONES: El paciente agitado es un problema común en los equipos asistenciales de los SEM. Pocos de estos equipos cuentan con procedimientos específicos de actuación ante estos casos.

[Relation between myocardial infarction and circadian rhythm in patients attended in a prehospital emergency service]. / Relación entre infarto de miocardio y ritmo circadiano en pacientes atendidos por un servicio de emergencias prehospitalario.

BACKGROUND AND OBJECTIVES: The aim of this study is to analyze the presence of circadian rhythm in the time of onset of symptoms of acute myocardial infarction treated by a prehospital emergency system and the influence of modifiable cardiovascular risk factors and non-modifiable as modulators of that circadian rhythm. PATIENTS AND METHODS: Retrospective analysis of 709 patients clinically diagnosed with acute myocardial infarction on-site in the prehospital setting. The variables were time to onset of symptoms, age, sex, previous ischemic heart disease, hypertension, diabetes mellitus, hyperlipidemia and smoking. We analyzed the rhythm with cosinor multiple sinusoid method, with 3 harmonics (24, 12 and 8h) for the adjustment. RESULTS: The time of onset of pain showed circadian rhythm (P <,001), peaking at 10.39 and a valley at 4.28, showing a sinusoidal curve fitting bimodal aspect with a predominant morning peak and another evening one of lower amplitude. All subgroups categorized by the study variables showed circadian rhythm, with a cosine curve similar to the global infarction. Smokers had a predominantly evening peak. CONCLUSIONS: Acute myocardial infarction shows a circadian rhythm. Smoking and diabetes mellitus can modify the standard incidence rate of occurrence of myocardial infarction.