Challenges of remotely witnessed emergencies - A case of international out-of-hospital cardiac arrest recognition via video call.

We present the first report, to our knowledge, of an Out-of-hospital cardiac arrest (OHCA) witnessed during a remote international video meeting. We report an emergency system activation and OHCA resuscitation initiated after an OHCA in a 41-year-old otherwise healthy female in Houston, Texas witnessed by a co-worker in Australia during a 1-on-1 Zoom video call. Remotely witnessed emergencies such as OHCA present unique challenges to successful cardiac resuscitation and will likely become significantly more common in the future as remote video calls increase.

Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury.

BACKGROUND AND OBJECTIVE: Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital]. METHODS: Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts. RESULTS: Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)]. CONCLUSION: While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.

Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension.

STUDY OBJECTIVE: Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension. METHODS: This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort. RESULTS: Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort. CONCLUSION: Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (<90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.

Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document.

Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness.EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts.Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts.Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method.Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion.To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position.When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.

Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association.

Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.

Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids).

STUDY OBJECTIVE: We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS: The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS: There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION: Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

Prehospital Protocols Reducing Long Spinal Board Use Are Not Associated with a Change in Incidence of Spinal Cord Injury.

Introduction: Many emergency medical services (EMS) agencies have de-emphasized or eliminated the use of long spinal boards (LSB) for patients with possible spinal injury. We sought to determine if implementation of spinal motion restriction (SMR) protocols, which reduce LSB use, was associated with an increase in spinal cord injury (SCI). Methods: This retrospective observational study includes EMS encounters from January 1, 2013 to December 31, 2015 submitted by SMR-adopting ground-based agencies to a state EMS database with hospital discharge data. Encounters were excluded if SMR implementation date was unknown, occurred during a 3-month run-in period, or were duplicates. Study samples include patients with traumatic injury (TI), possible spinal trauma (P-ST), and verified spinal trauma (V-ST) using hospital discharge ICD-9/10 diagnosis codes. The incidence of SCI before and after implementation of SMR was compared using Chi-squared and logistic regression. Results: From 1,005,978 linked encounters, 104,315 unique encounters with traumatic injury and known SMR implementation date were identified with 51,199 cases of P-ST and 5,178 V-ST cases. The incidence of SCI in the pre-SMR and post-SMR interval for each group was: TI, 0.20% vs. 0.22% (p = 0.390); P-ST, 0.40% vs. 0.45% (p = 0.436); and V-ST, 4.04% vs. 4.37% (p = 0.561). Age and injury severity adjusted odds ratio of SCI in the highest risk cohort of patients with V-ST was 1.097 after SMR implementation (95% CI 0.818-1.472). Conclusion: In this limited study, no change in the incidence of SCI was identified following implementation of SMR protocols. Prospective evaluation of this question is necessary to evaluate the safety of SMR protocols.

2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Cardiopulmonary resuscitation is a lifesaving technique for victims of sudden cardiac arrest. Despite advances in resuscitation science, basic life support remains a critical factor in determining outcomes. The American Heart Association recommendations for adult basic life support incorporate the most recently published evidence and serve as the basis for education and training for laypeople and healthcare providers who perform cardiopulmonary resuscitation.

Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association.

The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a national process to develop and implement evidence-based guidelines for cardiac resuscitation systems of care. Significant experience has been gained with implementing these systems, and new evidence has accumulated. This update describes recent advances in the science of cardiac resuscitation systems and evidence of their effectiveness, as well as recent progress in dissemination and implementation throughout the United States. Emphasis is placed on evidence published since the original recommendations (ie, including and since 2010).

Death by Suicide-The EMS Profession Compared to the General Public.

BACKGROUND: In 2016, nearly 45,000 deaths in the United States were attributed to suicide making this the 10th leading cause of death for all ages. National survey data suggest that among Emergency Medical Technicians (EMTs), including firefighters and Paramedics, rates of suicide are significantly higher than among the general public. EMTs face high levels of acute and chronic stress as well as high rates of depression and substance abuse, which increase their risk of suicide. OBJECTIVE/AIM: To determine the statewide Mortality Odds Ratio (MOR) of suicide completion among EMTs as compared to non-EMTs in Arizona. METHODS: We analyzed the Arizona Vital Statistics Information Management System Electronic Death Registry of all adult (≥18) deaths between January 1, 2009 and December 31, 2015. Manual review of decedent occupation was performed to identify the EMT cohort; all other deaths were included in the non-EMT cohort. Using the underlying cause of death as the outcome, we calculated the MOR of both the EMT and non-EMT cohorts. RESULTS: There were a total of 350,998 deaths during the study period with 7,838 categorized as suicide. The proportion of deaths attributed to suicide among EMTs was 5.2% (63 of 1,205 total deaths) while the percentage among non-EMTs was 2.2% (7,775/349,793) (p < 0.0001). The crude Mortality Odds Ratio for EMTs compared with non-EMTs was [cMOR 2.43; 95% CI (1.88-3.13)]. After adjusting for gender, age, race, and ethnicity, EMTs had higher odds that their death was by suicide than non-EMTs [aMOR: 1.39; 95% CI (1.06-1.82)]. CONCLUSION: In this statewide analysis, we found that EMTs had a significantly higher Mortality Odds Ratio due to suicide compared to non-EMTs. Further research is necessary to identify the underlying causes of suicide among EMTs and to develop effective prevention strategies.

Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial.

Background: Chronic pain is common and challenging to treat. Although cognitive behavioral therapy (CBT) is efficacious, its benefit in disadvantaged populations is largely unknown. Objective: To evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT01967342). Setting: Community health centers serving low-income patients in Alabama. Patients: Adults (aged 19 to 71 years) with mixed chronic pain. Interventions: CBT and EDU delivered in 10 weekly 90-minute group sessions. Measurements: Self-reported, postintervention pain intensity (primary outcome) and physical function and depression (secondary outcomes). Results: 290 participants were enrolled (70.7% of whom were women, 66.9% minority group members, 72.4% at or below the poverty level, and 35.8% reading below the fifth grade level); 241 (83.1%) participated in posttreatment assessments. Linear mixed models included all randomly assigned participants. Members of the CBT and EDU groups had larger decreases in pain intensity scores between baseline and posttreatment than participants receiving usual care (estimated differences in change scores-CBT: -0.80 [95% CI -1.48 to -0.11]; P = 0.022; EDU: -0.57 [CI, -1.04 to -0.10]; P = 0.018). At 6-month follow-up, treatment gains were not maintained in the CBT group but were still present in the EDU group. With regard to physical function, participants in the CBT and EDU interventions had greater posttreatment improvement than those receiving usual care, and this progress was maintained at 6-month follow-up. Changes in depression (secondary outcome) did not differ between either the CBT or EDU group and the usual care group. Limitations: Participants represented a single health care system. Self-selection bias may have been present. Conclusion: Simplified group CBT and EDU interventions delivered at low-income clinics significantly improved pain and physical function compared with usual care. Primary Funding Source: Patient-Centered Outcomes Research Institute.

Quantification of ventilation volumes produced by compressions during emergency department cardiopulmonary resuscitation.

BACKGROUND: Clinical investigations have shown improved outcomes with primary compression cardiopulmonary resuscitation strategies. It is unclear whether this is a result of passive ventilation via chest compressions, a low requirement for any ventilation during the early aspect of resuscitation or avoidance of inadvertent over-ventilation. OBJECTIVES: To quantify whether chest compressions with guideline-compliant depth (>2 in) produce measurable and substantial ventilation volumes during emergency department resuscitation of out-of-hospital cardiac arrest. METHODS: This was a prospective, convenience sampling of adult non-traumatic out-of-hospital cardiac arrest patients receiving on-going cardiopulmonary resuscitation in an academic emergency department from June 1, 2011 to July 30, 2013. Cardiopulmonary resuscitation quality files were analyzed using R-Series defibrillator/monitors (ZOLL Medical) and ventilation data were measured using a Non-Invasive Cardiac Output monitor (Philips/Respironics, Wallingford, CT). RESULTS: cardiopulmonary resuscitation quality data were analyzed from 21 patients (17 males, median age 59). The median compression depth was 2.2 in (IQR = 1.9, 2.5) and the median chest compression fraction was 88.4% (IQR = 82.2, 94.1). We were able to discern 580 ventilations that occurred during compressions. The median passive tidal volume recorded during compressions was 7.5 ml (IQR 3.5, 12.6). While the highest volume recorded was 45.8 ml, 81% of the measured tidal volumes were <20 ml. CONCLUSION: Ventilation volume measurements during emergency department cardiopulmonary resuscitation after out-of-hospital cardiac arrest suggest that chest compressions alone, even those meeting current guideline recommendations for depth, do not provide physiologically significant tidal volumes.

Duration of Coma in Out-of-Hospital Cardiac Arrest Survivors Treated With Targeted Temperature Management.

STUDY OBJECTIVE: We evaluate the time to awakening after out-of-hospital cardiac arrest in patients treated with targeted temperature management and determine whether there was an association with any patient or event characteristics. METHODS: This was a prospective, observational cohort study of consecutive adult survivors of out-of-hospital cardiac arrest of presumed cardiac cause who were treated with targeted temperature management between January 1, 2008, and March 31, 2014. Data were obtained from hospitals and emergency medical services agencies responding to approximately 90% of Arizona's population as part of a state-sponsored out-of-hospital cardiac arrest quality improvement initiative. RESULTS: Among 573 out-of-hospital cardiac arrest patients who completed targeted temperature management, 316 became responsive, 60 (19.0%) of whom woke up at least 48 hours after rewarming. Eight patients (2.5%) became responsive more than 7 days after rewarming, 6 of whom were discharged with a good Cerebral Performance Category score (1 or 2). There were no differences in standard Utstein variables between the early and late awakeners. The early awakeners were more likely to be discharged with a good Cerebral Performance Category score (odds ratio 2.93; 95% confidence interval 1.09 to 7.93). CONCLUSION: We found that a substantial proportion of adult out-of-hospital cardiac arrest survivors treated with targeted temperature management became responsive greater than 48 hours after rewarming, with a resultant good neurologic outcome.

The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury.

STUDY OBJECTIVE: Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination. METHODS: All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out-of-hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: <10 years, out-of-hospital oxygen saturation ≤10%, and out-of-hospital systolic blood pressure <40 or >200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure <90 mm Hg) or hypoxia (saturation <90%) was assessed with multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, interhospital transfer, and trauma center. RESULTS: Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death. CONCLUSION: In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.

Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality.

STUDY OBJECTIVE: Out-of-hospital hypotension has been associated with increased mortality in traumatic brain injury. The association of traumatic brain injury mortality with the depth or duration of out-of-hospital hypotension is unknown. We evaluated the relationship between the depth and duration of out-of-hospital hypotension and mortality in major traumatic brain injury. METHODS: We evaluated adults and older children with moderate or severe traumatic brain injury in the preimplementation cohort of Arizona's statewide Excellence in Prehospital Injury Care study. We used logistic regression to determine the association between the depth-duration dose of hypotension (depth of systolic blood pressure <90 mm Hg integrated over duration [minutes] of hypotension) and odds of inhospital death, controlling for significant confounders. RESULTS: There were 7,521 traumatic brain injury cases included (70.6% male patients; median age 40 years [interquartile range 24 to 58]). Mortality was 7.8% (95% confidence interval [CI] 7.2% to 8.5%) among the 6,982 patients without hypotension (systolic blood pressure ≥90 mm Hg) and 33.4% (95% CI 29.4% to 37.6%) among the 539 hypotensive patients (systolic blood pressure <90 mm Hg). Mortality was higher with increased hypotension dose: 0.01 to 14.99 mm Hg-minutes 16.3%; 15 to 49.99 mm Hg-minutes 28.1%; 50 to 141.99 mm Hg-minutes 38.8%; and greater than or equal to 142 mm Hg-minutes 50.4%. Log2 (the logarithm in base 2) of hypotension dose was associated with traumatic brain injury mortality (adjusted odds ratio 1.19 [95% CI 1.14 to 1.25] per 2-fold increase of dose). CONCLUSION: In this study, the depth and duration of out-of-hospital hypotension were associated with increased traumatic brain injury mortality. Assessments linking out-of-hospital blood pressure with traumatic brain injury outcomes should consider both depth and duration of hypotension.

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes.

INTRODUCTION: Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. METHODS: This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0-35.9°C [Low Temperature (LT)]; 36.0-37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. RESULTS: 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. CONCLUSION: In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.

Cardiocerebral Resuscitation: An Approach to Improving Survival of Patients With Primary Cardiac Arrest.

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. In the United States, OHCA accounts for more premature deaths than any other cause. For over a half-century, the national "Guidelines" for resuscitation have recommended the same initial treatment of primary and secondary cardiac arrests. Using this approach, the overall survival of patients with OHCA, while quite variable, was generally very poor. One reason is that the etiologies of cardiac arrests are not all the same. The vast majority of nontraumatic OHCA in adults are due to a "primary" cardiac arrest, rather than secondary to respiratory arrest. Decades of research and ongoing reviews of the literature led the University of Arizona Sarver Heart Center Resuscitation Research Group to conclude in 2003 that the national guidelines for patients with primary cardiac arrest were not optimal. Therefore, we instituted a new, nonguidelines approach to the therapy of primary cardiac arrest that dramatically improved survival. We called this approach cardiocerebral resuscitation (CCR), as it is the heart and the brain that are the most vulnerable and therefore need to be the focus of resuscitation efforts for these patients. In contrast, cardiopulmonary resuscitation should be reserved for respiratory arrests. Cardiocerebral resuscitation evolved into 3 components: the community, with emphasis for lay individuals to "Check, Call, Compress" and use an automated external defibrillator if available; the Emergency Medical Services, that emphasizes delayed intubation in favor of passive ventilation, urgent and near continuous chest compressions before and immediately after a single indicated shock, and the early administration of epinephrine; and the third component, added in 2007, the designations of hospitals in Arizona that request this designation and agree to receive patients with return of spontaneous circulation following OHCA and to institute state-of-the-art postresuscitation care that includes urgent therapeutic mild hypothermia and cardiac catheterization as a Cardiac Receiving Center. Each component of CCR is critical for optimal survival of patients with primary OHCA. In each city, county, and state where CCR was instituted, the result was a marked increase in survival of the subgroup of patients with OHCA most likely to survive, for example, those with a shockable rhythm. The purpose of this invited article on CCR is to review this alternative approach to resuscitation of patients with primary cardiac arrest and to encourage its adoption worldwide so that more lives can be saved.

Association between Prehospital CPR Quality and End-Tidal Carbon Dioxide Levels in Out-of-Hospital Cardiac Arrest.

INTRODUCTION: International Guidelines recommend measurement of end-tidal carbon dioxide (EtCO2) to enhance cardiopulmonary resuscitation (CPR) quality and optimize blood flow during CPR. Numerous factors impact EtCO2 (e.g., ventilation, metabolism, cardiac output), yet few clinical studies have correlated CPR quality and EtCO2 during actual out-of-hospital cardiac arrest (OHCA) resuscitations. The purpose of this study was to describe the association between EtCO2 and CPR quality variables during OHCA. METHODS: This is an observational study of prospectively collected CPR quality and capnography data from two EMS agencies participating in a statewide resuscitation quality improvement program. CPR quality and capnography data from adult (≥18 years) cardiac resuscitation attempts (10/2008-06/2013) were collected and analyzed on a minute-by-minute basis using RescueNet™ Code Review. Linear mixed effect models were used to evaluate the association between (log-transformed) EtCO2 level and CPR variables: chest compression (CC) depth, CC rate, CC release velocity (CCRV), ventilation rate. RESULTS: Among the 1217 adult OHCA cases of presumed cardiac etiology, 925 (76.0%) had a monitor-defibrillator file with CPR quality data, of which 296 (32.0%) cases had >1 minute of capnography data during CPR. After capnography quality review, 66 of these cases (22.3%) were excluded due to uninterpretable capnography, resulting in a final study sample of 230 subjects (mean age 68 years; 69.1% male), with a total of 1581 minutes of data. After adjustment for other CPR variables, a 10 mm increase in CC depth was associated with a 4.0% increase in EtCO2 (p < 0.0001), a 10 compression/minute increase in CC rate with a 1.7% increase in EtCO2 (p = 0.02), a 10 mm/second increase in CCRV with a 2.8% increase in EtCO2 (p = 0.03), and a 10 breath/minute increase in ventilation rate with a 17.4% decrease in EtCO2 (p < 0.0001). CONCLUSION: When controlling for known CPR quality variables, increases in CC depth, CC rate and CCRV were each associated with a statistically significant but clinically modest increase in EtCO2. Given the small effect sizes, the clinical utility of using EtCO2 to guide CPR performance is unclear. Further research is needed to determine the practicality and impact of using real-time EtCO2 to guide CPR delivery in the prehospital environment.

Rationale, Methodology, and Implementation of a Dispatcher-assisted Cardiopulmonary Resuscitation Trial in the Asia-Pacific (Pan-Asian Resuscitation Outcomes Study Phase 2).

Abstract Background. Survival outcomes from out-of-hospital cardiac arrest (OHCA) in Asia are poor (2-11%). Bystander cardiopulmonary resuscitation (CPR) rates are relatively low in Asia. Dispatcher-assisted CPR (DA-CPR) has recently emerged as a potentially cost-effective intervention to increase bystander CPR and survival from OHCA. The Pan-Asian Resuscitation Outcomes Study (PAROS), an Asia-Pacific cardiac arrest registry, was set up in 2009, with the aim of understanding OHCA as a disease in Asia and improving OHCA survival. The network has adopted DA-CPR as part of its strategy to improve OHCA survival. Objective. This article aims to describe the conceptualization, study design, potential benefits, and difficulties for implementation of DA-CPR trial in the Asia-Pacific. Methods. Two levels of intervention, basic and comprehensive, will be offered to PAROS participating sites. The basic level consists of implementation of a DA-CPR protocol and training program, while the comprehensive level consists of implementation of the basic level, with the addition of a dispatch quality measurement tool, quality improvement program, and community education program. Sites that are not able to implement the package will contribute control data. The primary outcome of the study is survival to hospital discharge or survival to 30 days post cardiac arrest. DA-CPR and bystander CPR are secondary outcomes. Conclusion. Implementation of DA-CPR requires concerted efforts by EMS leaders and supervisors, dispatchers, hospital stakeholders, policy makers, and the general public. The DA-CPR trial implemented by the PAROS sites, if successful, can serve as a model for other countries considering such an intervention in their EMS systems.