ABSTRACT
INTRODUCTION: Direct transport from the scene of injury to a trauma centre reduces saves lives. In Ontario, paramedics use the field trauma triage standard (FTTS) to determine if a patient meets trauma bypass criteria. Recent studies have questioned the efficacy of the FTTS in identifying severely injured patients. The objective of this study was to determine the predictive performance of the FTTS on the need for trauma center care in patients who were transported to a trauma center. METHODS: This was a single-center health records study of patients transported by ambulance directly to a level 1 trauma center. Hospital based trauma center need and injury severity score-based need were defined. Bivariate associations with one or more FTTS criteria were tested using the Wilcoxon two-sample test for continuous variables, and the Chi-square or Fisher's exact test for categorical indicators. The sensitivity and specificity of each category of the FTTS were calculated. RESULTS: There were 1427 patients included in the study, with 76% men, mean age of 40, and 76% had a blunt mechanism. The overall sensitivity and specificity of the FTTS was 90.9% and 20.8% for hospital-based need and 91.6% and 20.3 for injury severity need. The most sensitive variable for hospital-based need was physiologic criteria (53.7). Mechanism of injury was the most sensitive criteria for injury severity need (54.8). Physiological criteria had the highest association with hospital-based and injury severity need (adjusted odds ratios 7.5 [95% CI 5.8-9.8] and 5.1 [95% CI 3.9-6.7]). CONCLUSIONS: The FTTS has fair performance in identifying the need for hospital-based and injury severity need. Systolic blood pressure less than 90 mmHg, Glasgow Coma Scale (motor) less than 6, and falls greater than 6 m were most predictive of trauma center need. Improving prehospital trauma triage is critical to ensure timely transport to a trauma centre.
RéSUMé: INTRODUCTION: Le transport direct de la scène de la blessure à un centre de traumatologie permet de sauver des vies. En Ontario, les ambulanciers paramédicaux utilisent la norme de triage des traumatismes sur le terrain (FTTS) pour déterminer si un patient répond aux critères de pontage traumatique. Des études récentes ont remis en question l'efficacité du FTTS dans l'identification des patients gravement blessés. L'objectif de cette étude était de déterminer la performance prédictive du FTTS sur le besoin de soins en centre de traumatologie chez les patients qui ont été transportés dans un centre de traumatologie. MéTHODES: Il s'agissait d'une étude des dossiers médicaux d'un seul centre portant sur des patients transportés par ambulance directement à un centre de traumatologie de niveau 1. Les besoins des centres de traumatologie hospitaliers et les besoins basés sur le score de gravité des blessures ont été définis. Les associations bivariées avec un ou plusieurs critères FTTS ont été testées à l'aide du test à deux échantillons de Wilcoxon pour les variables continues et du test de Fisher pour les indicateurs catégoriels. La sensibilité et la spécificité de chaque catégorie du FTTS ont été calculées. RéSULTATS: Il y avait 1427 patients inclus dans l'étude, avec 76% d'hommes, âge moyen de 40, et 76% avaient un mécanisme émoussé. La sensibilité et la spécificité globales du FTTS étaient de 90,9 % et de 20,8 % pour les besoins hospitaliers et de 91,6 % et de 20,3 % pour les besoins de gravité des blessures. La variable la plus sensible pour les besoins hospitaliers était les critères physiologiques (53,7). Le mécanisme de blessure était le critère le plus sensible pour le besoin de gravité de la blessure (54,8). Les critères physiologiques étaient les plus associés aux besoins hospitaliers et aux besoins en matière de gravité des blessures (rapports de cotes ajustés de 7,5 [IC à 95 % 5,8-9,8] et 5,1 [IC à 95 % 3,9-6,7]). CONCLUSION: Le FTTS a un rendement équitable pour ce qui est de déterminer le besoin de soins hospitaliers et de gravité des blessures. La pression artérielle systolique inférieure à 90mmHg, l'échelle de coma de Glasgow (moteur) inférieure à 6 et les chutes supérieures à 6m étaient les plus prédictives des besoins du centre de traumatologie. L'amélioration du triage des traumatismes avant l'hospitalisation est essentielle pour assurer un transport rapide vers un centre de traumatologie.
Subject(s)
Injury Severity Score , Trauma Centers , Triage , Wounds and Injuries , Humans , Triage/methods , Triage/standards , Male , Retrospective Studies , Female , Adult , Ontario , Wounds and Injuries/therapy , Wounds and Injuries/diagnosis , Wounds and Injuries/epidemiology , Middle Aged , Emergency Medical Services/standards , Emergency Medical Services/organization & administrationABSTRACT
Importance: For pediatric out-of-hospital cardiac arrest (OHCA), emergency medical services (EMS) may elect to transport to the hospital during active cardiopulmonary resuscitation (CPR) (ie, intra-arrest transport) or to continue on-scene CPR for the entirety of the resuscitative effort. The comparative effectiveness of these strategies is unclear. Objective: To evaluate the association between intra-arrest transport compared with continued on-scene CPR and survival after pediatric OHCA, and to determine whether this association differs based on the timing of intra-arrest transport. Design, Setting, and Participants: This cohort study included pediatric patients aged younger than 18 years with EMS-treated OHCA between December 1, 2005 and June 30, 2015. Data were collected from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective 10-site OHCA registry in the US and Canada. Data analysis was performed from May 2022 to February 2024. Exposures: Intra-arrest transport, defined as an initiation of transport prior to the return of spontaneous circulation, and the interval between EMS arrival and intra-arrest transport. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Patients who underwent intra-arrest transport at any given minute after EMS arrival were compared with patients who were at risk of undergoing intra-arrest transport within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. We examined subgroups based on age (<1 year vs ≥1 year). Results: Of 2854 eligible pediatric patients (median [IQR] age, 1 [0-9] years); 1691 males [59.3%]) who experienced OHCA between December 2005 and June 2015, 1892 children (66.3%) were treated with intra-arrest transport and 962 children (33.7%) received continued on-scene CPR. The median (IQR) time between EMS arrival and intra-arrest transport was 15 (9-22) minutes. In the propensity score-matched cohort (3680 matched cases), there was no significant difference in survival to hospital discharge between the intra-arrest transport group and the continued on-scene CPR group (87 of 1840 patients [4.7%] vs 95 of 1840 patients [5.2%]; risk ratio [RR], 0.81 [95% CI, 0.59-1.10]). Survival to hospital discharge was not modified by the timing of intra-arrest transport (P value for the interaction between intra-arrest transport and time to matching = .10). Among patients aged younger than 1 year, intra-arrest transport was associated with lower survival to hospital discharge (RR, 0.52; 95% CI, 0.33-0.83) but there was no association for children aged 1 year or older (RR, 1.22; 95% CI, 0.77-1.93). Conclusions and Relevance: In this cohort study of a North American OHCA registry, intra-arrest transport compared with continued on-scene CPR was not associated with survival to hospital discharge among children with OHCA. However, intra-arrest transport was associated with a lower likelihood of survival to hospital discharge among children aged younger than 1 year.
Subject(s)
Cardiopulmonary Resuscitation , Emergency Medical Services , Out-of-Hospital Cardiac Arrest , Registries , Transportation of Patients , Humans , Child , Male , Cardiopulmonary Resuscitation/methods , Female , Child, Preschool , Out-of-Hospital Cardiac Arrest/therapy , Out-of-Hospital Cardiac Arrest/mortality , Infant , Adolescent , Transportation of Patients/methods , Transportation of Patients/statistics & numerical data , Emergency Medical Services/methods , Emergency Medical Services/statistics & numerical data , Cohort Studies , Infant, Newborn , Canada/epidemiology , Prospective StudiesABSTRACT
Background: Airway management is a core component of the treatment of cardiac arrest. Where a rescuer cannot establish a patent airway to provide oxygenation and ventilation using standard basic and advanced airway techniques, there may be a need to consider emergency front-of-neck airway access (eFONA, e.g., cricothyroidotomy), but there is limited evidence to inform this approach. Objectives: This scoping review aims to identify the evidence for the use of eFONA techniques in patients with cardiac arrest. Methods: In November 2023, we searched Medline, Embase, and Cochrane Central to identify studies on eFONA in adults. We included randomised controlled trials, non-randomised studies, and case series with at least five cases that described any use of eFONA. We extracted data, including study setting, population characteristics, intervention characteristics, and outcomes. Our analysis focused on four key areas: incidence of eFONA, eFONA success rates, clinical outcomes, and complications. Results: The search identified 21,565 papers, of which 18,934 remained after de-duplication. After screening, we included 69 studies (53 reported incidence, 40 reported success rate, 38 reported clinical outcomes; 36 studies reported complications). We identified only one randomised controlled trial. Across studies, there was a total of 4,457 eFONA attempts, with a median of 31 attempts (interquartile range 16-56.5) per study. There was marked heterogeneity across studies that precluded any pooling of data. There were no studies that included only patients in cardiac arrest. Conclusion: The available evidence for eFONA is extremely heterogeneous, with no studies specifically focusing on its use in adults with cardiac arrest.
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BACKGROUND: Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown. OBJECTIVES: To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT. METHOD: Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates. RESULTS: We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, pâ¯<â¯0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, pâ¯<â¯0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, pâ¯=â¯0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; pâ¯=â¯0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; pâ¯<â¯0.001) were predictors of survival; however, STE was not. CONCLUSION: We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.
Subject(s)
Coronary Angiography , Electric Countershock , Electrocardiography , Out-of-Hospital Cardiac Arrest , Percutaneous Coronary Intervention , Ventricular Fibrillation , Humans , Coronary Angiography/statistics & numerical data , Coronary Angiography/methods , Out-of-Hospital Cardiac Arrest/therapy , Out-of-Hospital Cardiac Arrest/mortality , Ventricular Fibrillation/therapy , Ventricular Fibrillation/complications , Male , Female , Electric Countershock/methods , Electric Countershock/statistics & numerical data , Middle Aged , Percutaneous Coronary Intervention/methods , Electrocardiography/methods , Aged , Cardiopulmonary Resuscitation/methods , ST Elevation Myocardial Infarction/complications , ST Elevation Myocardial Infarction/therapy , ST Elevation Myocardial Infarction/mortality , ST Elevation Myocardial Infarction/diagnosisABSTRACT
BACKGROUND: The DOSE VF randomized controlled trial (RCT) employed a pragmatic definition of refractory ventricular fibrillation (VF after three successive shocks). However, it remains unclear whether the underlying rhythm during the first three shocks was shock-refractory or recurrent VF. OBJECTIVE: To explore the relationship between alternate defibrillation strategies employed during the DOSE VF RCT and the type of VF, either shock-refractory VF or recurrent VF, on patient outcomes. METHODS: We performed a secondary analysis of the DOSE VF RCT. We categorized cases as shock-refractory or recurrent VF based on pre-randomization shocks (shocks 1-3). We then analyzed all subsequent (post-randomization) shocks to assess the impact of standard, vector change (VC) or double sequential external defibrillation (DSED) shocks on clinical outcomes employing logistic regression adjusted for Utstein variables, antiarrhythmics, and epinephrine. RESULTS: We included 345 patients; 60 (17%) shock-refractory VF, and 285 (83%) recurrent VF. Patients in recurrent VF had greater survival than shock-refractory VF (OR: 2.76 95% CI [1.04, 7.27]). DSED was superior to standard defibrillation for survival overall, and for patients with shock-refractory VF (28.6% vs 0%, p = 0.041) but not for those in recurrent VF. DSED was superior to standard defibrillation for return of spontaneous circulation (ROSC) and neurologic survival for shock-refractory and recurrent VF. VC defibrillation was not superior for survival or ROSC overall, for shock-refractory, or recurrent VF groups, but was superior for VF termination across all groups. CONCLUSION: DSED appears to be the superior defibrillation strategy in the DOSE VF trial, irrespective of whether the preceding VF is shock-refractory or recurrent.
Subject(s)
Electric Countershock , Out-of-Hospital Cardiac Arrest , Recurrence , Ventricular Fibrillation , Humans , Ventricular Fibrillation/therapy , Ventricular Fibrillation/complications , Electric Countershock/methods , Male , Female , Middle Aged , Aged , Out-of-Hospital Cardiac Arrest/therapy , Out-of-Hospital Cardiac Arrest/mortality , Cardiopulmonary Resuscitation/methodsABSTRACT
Randomized controlled trials (RCTs) are a gold standard in research and crucial to our understanding of resuscitation science. Many trials in resuscitation have had neutral findings, questioning which treatments are effective in cardiac resuscitation. While it is possible than many interventions do not improve patient outcomes, it is also possible that the large proportion of neutral findings are partially due to design limitations. RCTs can be challenging to implement, and require extensive resources, time, and funding. In addition, conducting RCTs in the out-of-hospital setting provides unique challenges that must be considered for a successful trial. This article will outline many important aspects of conducting trials in resuscitation in the out-of-hospital setting including patient and outcome selection, trial design, and statistical analysis.
ABSTRACT
The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.
Subject(s)
Cardiopulmonary Resuscitation , Emergency Medical Services , Out-of-Hospital Cardiac Arrest , Premature Birth , Adult , Female , Child , Infant, Newborn , Humans , First Aid , Consensus , Out-of-Hospital Cardiac Arrest/therapy , Cardiopulmonary Resuscitation/methodsABSTRACT
BACKGROUND: Animal studies suggest the efficacy of double sequential external defibrillation (DSED) may depend on the interval between the two shocks, or "DSED interval". No human studies have examined this concept. OBJECTIVES: To determine the relationship between DSED interval and termination of ventricular fibrillation (VFT), return of spontaneous circulation (ROSC), survival to hospital discharge, and favourable neurological status (MRS ≤ 2) for patients in refractory VF. METHODS: We performed a retrospective review of adult (≥18 years) out-of-hospital cardiac arrest between January 2015 and May 2022 with refractory VF who received ≥1 DSED shock. DSED interval was divided into four pre-defined categories. We examined the association between DSED interval and patient outcomes using general estimated equation logistic regression or Fisher's exact test. RESULTS: Among 106 included patients, 303 DSED shocks were delivered (median 2, IQR 1-3). DSED intervals of 75-125 ms (OR 0.39, 95% CI 0.16-0.98), 125-500 ms (OR 0.36, 95% CI 0.16-0.82), and >500 ms (OR 0.27, 95% CI 0.11-0.63) were associated with lower probability of VF termination compared to <75 ms interval. DSED interval of >75 ms was associated with lower probability of ROSC compared to <75 ms interval (OR 0.37, 95% CI 0.14-0.98). No association was noted between DSED interval and survival to hospital discharge or neurologic outcome. CONCLUSIONS: Among patients in refractory VF a DSED interval of less than 75 ms was associated with improved rates of VF termination and ROSC. No association was noted between DSED interval and survival to hospital discharge or neurologic outcome.
Subject(s)
Cardiopulmonary Resuscitation , Emergency Medical Services , Out-of-Hospital Cardiac Arrest , Adult , Humans , Electric Countershock , Ventricular Fibrillation/complications , Ventricular Fibrillation/therapy , Retrospective Studies , Patient DischargeABSTRACT
The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.
Subject(s)
Cardiopulmonary Resuscitation , Emergency Medical Services , Out-of-Hospital Cardiac Arrest , Premature Birth , Adult , Female , Child , Infant, Newborn , Humans , First Aid , Consensus , Out-of-Hospital Cardiac Arrest/diagnosis , Out-of-Hospital Cardiac Arrest/therapyABSTRACT
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, ß-adrenergic receptor antagonists (also known as ß-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
Subject(s)
Humans , Cardiopulmonary Resuscitation , Advanced Cardiac Life Support/standards , Drug Overdose/complications , Poisoning/complications , Heart Arrest/therapy , Antidotes/therapeutic useABSTRACT
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, ß-adrenergic receptor antagonists (also known as ß-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
Subject(s)
Cardiopulmonary Resuscitation , Heart Arrest , Humans , Adrenergic beta-Antagonists , American Heart Association , Benzodiazepines , Digoxin , Heart Arrest/chemically induced , Heart Arrest/therapy , United StatesABSTRACT
Introduction: Over 400,000 out-of-hospital cardiac arrest (OHCA) occur each year in Canada and the United States with less than 10% survival to hospital discharge. Cardiac arrest is a heterogenous condition and patient outcomes are impacted by a multitude of factors. Prognostication is recommended at 72 hours after return of spontaneous circulation (ROSC), however there may be other factors that could predict patient outcome earlier in the post-arrest period. The objective of our study was to develop and internally validate a novel clinical prediction rule to risk stratify patients early in the post-cardiac arrest period. Methods: We performed a retrospective cohort study of adult (≥18 years) post-cardiac arrest patients between 2010 and 2015 from the Epistry Cardiac Arrest database in Toronto. Our primary analysis used ordinal logistic regression to examine neurologic outcome at discharge using the modified Rankin Scale (mRS). Our secondary analysis used logistic regression for neurologic outcome and survival to hospital discharge. Models were internally validated using bootstrap validation. Results: A total of 3432 patients met our inclusion criteria. Our clinical prediction model was able to predict neurologic outcome on an ordinal scale using our predefined variables with an AUC of 0.89 after internal validation. The predictive performance was maintained when examining neurologic outcome as a binary variable and survival to hospital discharge. Conclusion: We were able to develop a model to accurately risk stratify adult cardiac arrest patients early in the post-cardiac arrest period. Future steps are needed to externally validate this model in other healthcare settings.
ABSTRACT
Deep brain stimulation devices can disrupt cardiac rhythm interpretation by causing electrocardiogram artifact. We report the case of a deep brain stimulating device initiating ventricular fibrillation simulated electrocardiogram artifact in the prehospital setting. Mimicked ventricular fibrillation due to a deep brain stimulator has not been documented, and if unrecognized could influence unwarranted or potentially harmful clinical decisions.
Subject(s)
Emergency Medical Services , Ventricular Fibrillation , Humans , Ventricular Fibrillation/diagnosis , Ventricular Fibrillation/therapy , Artifacts , Arrhythmias, Cardiac , Brain , ElectrocardiographyABSTRACT
Pre-hospital resuscitation of critically injured patients traditionally includes supplemental oxygen therapy to address potential hypoxemia. The objective of this study was to explore the association between pre-hospital hypoxemia, hyperoxemia, and mortality in patients with traumatic brain injury (TBI) and traumatic shock. We hypothesized that both hypoxemia and hyperoxemia would be associated with increased mortality. We used the Resuscitation Outcomes Consortium Prospective Observational Prehospital and Hospital Registry for Trauma (ROC PROPHET) database of critically injured patients to identify a severe TBI cohort (pre-hospital Glasgow Coma Scale [GCS] 3-8) and a traumatic shock cohort (systolic blood pressure ≤90 mm Hg and pre-hospital GCS >8). Arterial blood gas (ABG) obtained within 30 min of hospital arrival was required for inclusion. Patients with hypoxemia (PaO2 <80 mm Hg) and hyperoxemia (PaO2 >400 mm Hg) were compared to those with normoxemia (PaO2 80-400 mm Hg) with regard to the primary outcome measure of in-hospital mortality in both the TBI and traumatic shock cohorts. Multiple logistic regression was used to calculate odds ratios (ORs) after adjustment for multiple covariables. In addition, regression spline curves were generated to estimate the risk of death as a continuous function of PaO2 levels. A total of 1248 TBI patients were included, of whom 396 (32%) died before hospital discharge. Associations between hypoxemia and increased mortality (OR, 1.8; 95% confidence interval [CI], 1.2-2.8; p = 0.008) and between hyperoxemia and decreased mortality (OR, 0.6; 95% CI, 0.4-0.9; p = 0.018) were observed. A total of 582 traumatic shock patients were included, of whom 52 (9%) died before hospital discharge. No statistically significant associations were observed between in-hospital mortality and either hypoxemia (OR, 1.0; 95% CI, 0.4-2.4; p = 0.987) or hyperoxemia (OR, 1.9; 95% CI, 0.6-5.7; p = 0.269). Among patients with severe TBI but not traumatic shock, hypoxemia was associated with an increase of in-hospital mortality and hyperoxemia was associated with a decrease of in-hospital mortality.
ABSTRACT
OBJECTIVES: The objectives of this project were to collect and analyze clinical governance documents related to family-centred care and cardiac arrest care in Canadian EMS organizations; and to improve the family-centredness of out-of-hospital cardiac arrest care through experience-based co-design. METHODS: We conducted qualitative document analysis of Canadian EMS clinical governance documents related to family-centred and cardiac arrest care, combining elements of content and thematic analysis methods. We then used experience-based co-design to develop a family-centred out-of-hospital cardiac arrest care policy and procedure template. RESULTS: Thirty-five Canadian EMS organizations responded to our requests, representing service area coverage for 80% of the Canadian population. Twenty documents were obtained for review and six overarching themes were identified: addressing family in event of in-home death, importance of family, family member escort, provider discretion and family presence discouraged. Informed by our qualitative analysis we then co-designed a policy and procedure template was created that prioritizes patient care while promotes family-centredness. CONCLUSIONS: There were few directives to support family-centred care by Canadian EMS organizations. A family-centred out-of-hospital cardiac arrest care policy and procedure template was developed using experience-based co-design to assist EMS organizations improve the family-centredness of out-of-hospital cardiac arrest care.
RéSUMé: OBJECTIFS: Les objectifs de ce projet étaient de recueillir et d'analyser des documents de gouvernance clinique liés aux soins centrés sur la famille et aux soins de l'arrêt cardiaque dans les organisations canadiennes de SMU; et d'améliorer le caractère centré sur la famille des soins en cas d'arrêt cardiaque à l'extérieur de l'hôpital grâce à une co-conception fondée sur l'expérience. MéTHODES: Nous avons effectué une analyse qualitative des documents de gouvernance clinique des SMU canadiens liés aux soins axés sur la famille et aux arrêts cardiaques, en combinant des éléments de contenu et des méthodes d'analyse thématique. Nous avons ensuite utilisé la co-conception fondée sur l'expérience pour élaborer un modèle de politique et de procédure de soins en cas d'arrêt cardiaque centrés sur la famille en dehors de l'hôpital. RéSULTATS: Trente-cinq organisations Canadiennes de SMU ont répondu à nos demandes, ce qui représente une couverture de zone de service pour 80 % de la population canadienne. Vingt documents ont été obtenus aux fins d'examen et six thèmes principaux ont été cernés: s'adresser à la famille en cas de décès à domicile, l'importance de la famille, accompagnement d'un membre de la famille, la discrétion du fournisseur et la présence de la famille découragée. Éclairés par notre analyse qualitative, nous avons ensuite co-conçu un modèle de politique et de procédure qui priorise les soins aux patients tout en favorisant l'orientation familial. CONCLUSIONS: Il y avait peu de directives pour soutenir les soins axés sur la famille par les organisations canadiennes de SMU. Un modèle de politique de soins d'arrêt cardiaque centré sur la famille a été élaboré à l'aide d'une co-conception basée sur l'expérience pour aider les organisations de SMU à améliorer l'orientation familiale des soins en cas d'arrêt cardiaque hors hôpital.