ED prognostication of comatose cardiac arrest patients undergoing therapeutic hypothermia is unreliable.

BACKGROUND: Therapeutic hypothermia (TH) improves patient survival with good neurologic outcome after cardiac arrest. The value of early clinician prognostication in the emergency department (ED) has not been studied in this patient population. OBJECTIVE: To determine if physicians can accurately predict survival and neurologic outcome at hospital discharge of resuscitated, comatose out-of-hospital cardiac arrest (OHCA) patients treated in a post-cardiac arrest clinical pathway that included TH. METHODS: This was a prospective, observational study conducted at a tertiary referral center. Participants were physicians involved in the resuscitation of OHCA patients treated with a clinical pathway that included TH. Immediately after patient resuscitation in the ED, physicians recorded their prediction of patient survival and neurologic outcome on a standardized questionnaire. Neurologic outcome was assessed by the cerebral performance category. RESULTS: Forty-two physicians completed questionnaires on 17 patients enrolled from October 2009 to March 2010. Sensitivity and specificity of physician prediction of patient survival were 0.67 (95% confidence interval [CI], 0.45-0.83) and 0.82 (95% CI, 0.59-0.94), respectively, with an area under the curve of 0.74 (95% CI, 0.61-0.88), a positive likelihood ratio (+LR) of 3.72 (95% CI, 1.30-11.02), and a -LR of 0.40 (95% CI, 0.21-0.77). Sensitivity and specificity of physician prediction of good neurologic outcome were 0.40 (95% CI, 0.20-0.64) and 0.69 (95% CI, 0.50-0.84), respectively, with an area under the curve of 0.55 (95% CI, 0.39-0.70), a +LR of 1.29 (95% CI, 0.56-3.03), and a -LR of 0.87 (95% CI, 0.53-1.41). CONCLUSIONS: Physicians poorly prognosticate both survival and neurologic outcome in comatose OHCA patients undergoing TH. Premature prognostication in the ED is unreliable and should be avoided.

Out-of-hospital stroke screen accuracy in a state with an emergency medical services protocol for routing patients to acute stroke centers.

STUDY OBJECTIVE: Emergency medical services (EMS) protocols, which route patients with suspected stroke to stroke centers, rely on the use of accurate stroke screening criteria. Our goal is to conduct a statewide EMS agency evaluation of the accuracies of the Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) for identifying acute stroke patients. METHODS: We conducted a retrospective study in North Carolina by linking a statewide EMS database to a hospital database, using validated deterministic matching. We compared EMS CPSS or LAPSS results (positive or negative) to the emergency department diagnosis International Classification of Diseases, Ninth Revision codes. We calculated sensitivity, specificity, and positive and negative likelihood ratios for the EMS diagnosis of stroke, using each screening tool. RESULTS: We included 1,217 CPSS patients and 1,225 LAPSS patients evaluated by 117 EMS agencies from 94 North Carolina counties. Most EMS agencies contributing data had high annual patient volumes and were governmental agencies with nonvolunteer, emergency medical technician-paramedic service level providers. The CPSS had a sensitivity of 80% (95% confidence interval [CI] 77% to 83%) versus 74% (95% CI 71% to 77%) for the LAPSS. Each had a specificity of 48% (CPSS 95% CI 44% to 52%; LAPSS 95% CI 43% to 53%). CONCLUSION: The CPSS and LAPSS had similar test characteristics, with each having only limited specificity. Development of stroke screening scales that optimize both sensitivity and specificity is required if these are to be used to determine transport diversion to acute stroke centers.

A geographic information system analysis of the impact of a statewide acute stroke emergency medical services routing protocol on community hospital bypass.

BACKGROUND: Our goal was to determine if a statewide Emergency Medical Services (EMSs) Stroke Triage and Destination Plan (STDP), specifying bypass of hospitals unable to routinely treat stroke patients with thrombolytics (community hospitals), changed bypass frequency of those hospitals. METHODS: Using a statewide EMS database, we identified stroke patients eligible for community hospital bypass and compared bypass frequency 1-year before and after STDP implementation. RESULTS: Symptom onset time was missing for 48% of pre-STDP (n = 2385) and 29% of post-STDP (n = 1612) cases. Of the remaining cases with geocodable scene addresses, 58% (1301) in the pre-STDP group and 61% (2,078) in the post-STDP group were ineligible for bypass, because a community hospital was not the closest hospital to the stroke event location. Because of missing data records for some EMS agencies in 1 or both study periods, we included EMS agencies from only 49 of 100 North Carolina counties in our analysis. Additionally, we found conflicting hospital classifications by different EMS agencies for 35% of all hospitals (n = 38 of 108). Given these limitations, we found similar community hospital bypass rates before and after STDP implementation (64%, n = 332 of 520 vs. 63%, n = 345 of 552; P = .65). CONCLUSIONS: Missing symptom duration time and data records in our state's EMS data system, along with conflicting hospital classifications between EMS agencies limit the ability to study statewide stroke routing protocols. Bypass policies may apply to a minority of patients because a community hospital is not the closest hospital to most stroke events. Given these limitations, we found no difference in community hospital bypass rates after implementation of the STDP.

Amputation Versus Staged Reconstruction for Severe Fibular Hemimelia: Assessment of Psychosocial and Quality-of-Life Status and Physical Functioning in Childhood.

BACKGROUND: Fibular hemimelia, a congenital disorder characterized by the partial or complete absence of the fibula, tibial growth inhibition, and foot and ankle deformity and deficiency, is the most common deficiency of long bones. The purpose of the present study of children with congenital fibular hemimelia was to examine the functional and psychosocial outcomes at a minimum of 2 years after treatment either with amputation and a prosthesis or with reconstruction and lengthening. METHODS: Twenty children who were managed with primary amputation were compared with 22 children who were managed with staged limb reconstruction. The average age of the patients at the time of evaluation was 9 years (range, 5 to 15 years). Patients and parents completed psychosocial, quality-of-life, and satisfaction surveys. Patients underwent instrumented gait analysis and a timed 25 or 50-yard dash. The number and nature of surgical procedures were recorded from a retrospective chart review. RESULTS: Families of children managed with amputation had lower economic and educational levels and were more ethnically diverse compared with the families of children managed with limb reconstruction. Scores on psychosocial and quality-of-life surveys were comparable with those from healthy patient populations. Parents of males treated with amputation perceived a lower school-related quality of life for their child; socioeconomic and ethnic differences between groups might account for this finding. Statistically but not clinically significant differences were measured during instrumented gait analysis at a self-selected walking speed and during a timed 25 or 50-yard dash. The majority of patients and parents reported satisfaction with the treatment method selected and would select the same treatment method again. CONCLUSIONS: At this interim stage of growth, there were no significant functional or psychological differences between groups. Both groups were satisfied with the outcome in mid-childhood, irrespective of the selection of amputation or limb reconstruction. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated with Delayed Cooling in Cardiac Arrest Patients.

Therapeutic hypothermia has been shown to improve neurologic outcome in medical cardiac arrest patients, yet little is known about factors that delay target temperature achievement. Our primary aim was to identify factors associated with not achieving our institutional "door-to-cool" (DTC) performance goal (emergency department [ED] arrival to temperature of 34°C) of ≤4 hours. Secondary aims included whether achievement of DTC goal was associated with timing of bolus neuromuscular blockade (NMB), survival, or functional outcome. This was a retrospective cohort study of a medical cardiac arrest quality improvement (QI) database that included patients treated from November 2007 to August 2012. The database was queried for patient demographics, arrest characteristics, specific cooling techniques used, whether patients underwent emergent computed tomography imaging or cardiac catheterization, and patient outcomes. Logistic regression was used to assess the factors associated with DTC goal performance and outcomes. We enrolled 327 patients, median age 58, median return of spontaneous circulation (ROSC) time of 21 minutes (interquartile range [IQR] 14-29 minutes), and shockable initial rhythm in 61%. One hundred forty-four (44%) patients survived to hospital discharge, 133 (41%) with good functional outcome, as defined as cerebral performance category 1-2. Induction with cold IV fluids [OR 0.50 (CI: 0.29-0.85)] and NMB administration within 2 hours of ED arrival [OR 2.95 (CI: 1.17-7.43)] was associated with achieving DTC goal. Logistic regression showed that achievement of DTC goal ≤4 hours [OR 0.59 (0.32-1.09)] was not associated with good functional outcome. In our single-center cohort, initiation of cold intravenous fluids (IVF) and early NMB administration were associated with improved DTC goal performance of 4 hours. However, patients achieving DTC goals were not associated with improved outcomes.

Troponin Marker for Acute Coronary Occlusion and Patient Outcome Following Cardiac Arrest.

INTRODUCTION: The utility of troponin as a marker for acute coronary occlusion and patient outcome after out-of-hospital cardiac arrest (OHCA) is unclear. We sought to determine whether initial or peak troponin was associated with percutaneous coronary intervention (PCI), OHCA survival or neurological outcome. METHODS: Single-center retrospective-cohort study of OHCA patients treated in a comprehensive clinical pathway from November 2007 to October 2012. Troponin I levels were acquired at presentation, four and eight hours after arrest, and then per physician discretion. Cardiac catheterization was at the cardiologist's discretion. Survival and outcome were determined at hospital discharge, with cerebral performance category score 1-2 defined as a good neurological outcome. RESULTS: We enrolled 277 patients; 58% had a shockable rhythm, 44% survived, 41% good neurological outcome. Of the 107 (38%) patients who underwent cardiac catheterization, 30 (28%) had PCI. Initial ED troponin (median, ng/mL) was not different in patients requiring PCI vs no PCI (0.32 vs 0.09, p=0.06), although peak troponin was higher (4.19 versus 1.57, p=0.02). Of the 85 patients who underwent cardiac catheterization without STEMI (n=85), there was no difference in those who received PCI vs no PCI in initial troponin (0.22 vs 0.06, p=0.40) or peak troponin (2.58 vs 1.43, p=0.27). Regarding outcomes, there was no difference in initial troponin in survivors versus non-survivors (0.09 vs 0.22, p=0.11), or those with a good versus poor neurological outcome (0.09 vs 0.20, p=0.11). Likewise, there was no difference in peak troponin in survivors versus non-survivors (1.64 vs 1.23, p=0.07), or in those with a good versus poor neurological outcome (1.57 vs 1.26, p=0.14). CONCLUSION: In our single-center patient cohort, peak troponin, but not initial troponin, was associated with higher likelihood of PCI, while neither initial nor peak troponin were associated with survival or neurological outcome in OHCA patients.