Management of adult cardiac arrest in the COVID-19 era: consensus statement from the Australasian College for Emergency Medicine.

INTRODUCTION: The global pandemic of coronavirus disease 2019 (COVID-19) has caused significant worldwide disruption. Although Australia and New Zealand have not been affected as much as some other countries, resuscitation may still pose a risk to health care workers and necessitates a change to our traditional approach. This consensus statement for adult cardiac arrest in the setting of COVID-19 has been produced by the Australasian College for Emergency Medicine (ACEM) and aligns with national and international recommendations. MAIN RECOMMENDATIONS: In a setting of low community transmission, most cardiac arrests are not due to COVID-19. Early defibrillation saves lives and is not considered an aerosol generating procedure. Compression-only cardiopulmonary resuscitation is thought to be a low risk procedure and can be safely initiated with the patient's mouth and nose covered. All other resuscitative procedures are considered aerosol generating and require the use of airborne personal protective equipment (PPE). It is important to balance the appropriateness of resuscitation against the risk of infection. Methods to reduce nosocomial transmission of COVID-19 include a physical barrier such as a towel or mask over the patient's mouth and nose, appropriate use of PPE, minimising the staff involved in resuscitation, and use of mechanical chest compression devices when available. If COVID-19 significantly affects hospital resource availability, the ethics of resource allocation must be considered. CHANGES IN MANAGEMENT: The changes outlined in this document require a significant adaptation for many doctors, nurses and paramedics. It is critically important that all health care workers have regular PPE and advanced life support training, are able to access in situ simulation sessions, and receive extensive debriefing after actual resuscitations. This will ensure safe, timely and effective management of the patients with cardiac arrest in the COVID-19 era.

Prognosis of Acute Subdural Hematoma in the Elderly: A Systematic Review.

Acute subdural hematoma (aSDH) is among the most common injury types encountered by neurosurgeons, and carries a poor prognosis, particularly in the elderly. As the incidence of aSDH in the elderly population rises, identifying those patients who may benefit from operative intervention is crucial. This systematic review aimed to identify data on prognostic factors or indices, such as the modified frailty index, that may help predict outcome, and hence guide management. A comprehensive search of online databases was conducted by two independent authors, and data on prognostic factors and outcomes were extracted. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Of 769 studies identified in the initial search, 7 satisfied inclusion and exclusion criteria. Mortality and morbidity varied considerably among studies. Initial Glasgow Coma Scale (GCS) of 3-8 was the most consistently reported negative prognostic feature. Several studies evaluated the impact of medical comorbidities and premorbid frailty, but were limited by small sample size. A previous history of pneumonia was shown to increase the risk of Glasgow Outcome Score (GOS) 1-3 (odds ratio [OR] 6.4 [95% CI 1.6-25.2], p = 0.04) in a single study, which also reported a greater increase in GOS at 3 months in those with fewer than five comorbidities (56% vs. 19%, p < 0.01). There are limited data describing prognostic factors or the use of frailty indices within the specific group of elderly patients with aSDH. Prospective research is needed to evaluate the utility of accurate and validated assessments of frailty to enhance the neurosurgeon's ability to appropriately manage this complex and expanding patient group.

Factors delaying admission to a hospital-based stroke unit in India.

Limited information is available from India and other developing countries regarding the various factors that contribute to a delay in hospital admission after stroke. The stroke unit of the Christian Medical College, Ludhiana, in Northwest India prospectively studied the various factors contributing to delay in hospital admission during a 15-month period ending September 2003. Patients or their relatives were interviewed within 48 hours of admission using a structured questionnaire. Of the 147 patients interviewed, 99 (67%) were men and the mean age was 59.7 +/- 14.1 years. A total of 43 (29%) patients presented within 3 hours of stroke onset. Only 12% of patients came by ambulance. Directly reaching the stroke department (P < .001, odds ratio [OR] 4.2, confidence interval [CI] 3.13-8.45), distance 10 km or less from the hospital (P < .03, OR 4.0, CI 1.12-9.24), and presence of aphasia (P < .03, OR 3.7, CI 1.47-7.92) were the factors associated with an early arrival. We found a considerable delay in the early arrival of patients to our stroke department. Both local physicians and the public should be educated about the importance of an early referrals and presentation to the stroke centers.

Knowledge of stroke among stroke patients and their relatives in Northwest India.

BACKGROUND: The knowledge of warning symptoms and risk factors for stroke has not been studied among patients with stroke in developing countries. AIMS: We aimed to assess the knowledge of stroke among patients with stroke and their relatives. SETTINGS AND DESIGN: Prospective tertiary referral hospital-based study in Northwest India. MATERIALS AND METHODS: Trained nurses and medical interns interviewed patients with stroke and transient ischemic attack and their relatives about their knowledge of stroke symptoms and risk factors. STATISTICAL ANALYSIS: Univariable and multivariable logistic regression were used. RESULTS: Of the 147 subjects interviewed, 102 (69%) were patients and 45 (31%) were relatives. There were 99 (67%) men and 48 (33%) women and the mean age was 59.7+/-14.1 years. Sixty-two percent of respondents recognized paralysis of one side as a warning symptom and 54% recognized hypertension as a risk factor for stroke. In the multivariable logistic regression analysis, higher education was associated with the knowledge of correct organ involvement in stroke (OR 2.6, CI 1.1- 6.1, P =0.02), whereas younger age (OR 2.7, CI 1.1-7.0, P =0.04) and higher education (OR 4.1, CI 1.5-10.9, P =0.005) correlated with a better knowledge regarding warning symptoms of stroke. CONCLUSIONS: In this study cohort, in general, there is lack of awareness of major warning symptoms, risk factors, organ involvement and self-recognition of stroke. However younger age and education status were associated with better knowledge. There is an urgent need for awareness programs about stroke in this study cohort.

Public awareness of warning symptoms, risk factors, and treatment of stroke in northwest India.

BACKGROUND AND PURPOSE: This study assessed public awareness of warning symptoms, risk factors, and treatment of stroke in Ludhiana, Punjab, North West India. METHODS: A hospital-based survey was conducted between February 2002 and September 2002 by the Stroke section of Christian Medical College. The study subjects were relatives of patients without history of stroke, attending the outpatient department of the hospital. Trained medical students, interns, and a nurse interviewed subjects using a structured, pretested, open-ended questionnaire. RESULTS: Nine hundred forty-two individuals were interviewed during the study period (56.4% men, mean age 40.1 years, age range 15 to 80 years). Forty-five percent of the subjects did not recognize the brain as the affected organ in stroke. In the multivariate analysis, higher education (P<0.001; odds ratio 2.6; 95%, CI 1.8 to 3.8) and upper socioeconomic status (P<0.005; odds ratio 1.6; CI, 1.1 to 2.2) correlated with a better knowledge of which organ was affected in stroke. Twenty-three percent of the participants did not know a single warning symptom of stroke. Twenty-one percent of the subjects could not identify even a single risk factor for stroke. Seven percent of the study population believed that oil massage would improve stroke victims. A small proportion of subjects believed in witchcraft, faith healing, homeopathic, and ayurvedic treatment (3%). CONCLUSIONS: This hospital-based survey reveals a better awareness of stroke warning signs and risk factors. However, knowledge regarding the organ involved, etiology, and treatment of stroke is lacking. Considerable education is needed to increase public awareness in modern concepts of stroke treatment.

Use of ultrasound and surgery in adults with acute scrotal pain.

BACKGROUND: The epidemiology of patients with acute scrotal pain presenting to the emergency department (ED) is largely unknown. Urgent surgical referral is recommended for patients presenting with suspected testicular torsion. However, we have noted an increasing use of Doppler ultrasound (US) as an adjunctive tool in the evaluation of patients with acute scrotal pain. This study aimed to retrospectively review the presentation of patients with acute scrotal pain to a tertiary ED and the use of ultrasound in the assessment of acute scrotal pain. METHODS: An explicit chart review was performed including all patients presenting to an adult tertiary ED between 2003 and 2008 with acute scrotal pain. The timing of presentation, initial assessment, review by the Urology team and the use of US were recorded. The diagnosis recorded at hospital discharge was the primary end point, while follow-up at outpatient clinic or private urologist rooms was used as a secondary end point. RESULTS: There were 329 patients with acute scrotal pain during the study period, with 294 patients included in the study. Of these, 173 (58.8%) had a US scan performed in the ED. There were 44 (15.0%) patients who underwent scrotal exploration, with 19 having a prior US. There was a significant increase in the use of US over the study period. CONCLUSIONS: Colour-flow duplex Doppler ultrasonography appeared to play an increasing role in the assessment for patients presenting with acute testicular pain. Rapid and more reliable assessments of these patients may be possible through greater education of emergency personnel in ultrasonography techniques.