Compliance with CPR quality guidelines and survival after 30 days following out-of-hospital cardiac arrest. A retrospective study.

BACKGROUND: Our study assessed the quality of cardiopulmonary resuscitation (CPR) given by emergency medical services in Southern Ostrobothnia Finland, as is advised in the international guidelines. The goal was to evaluate the current quality of CPR given to patients who suffered an out-of-hospital cardiac arrest and to examine possible measures for improving emergency medical services. METHODS: A retrospective study was conducted on out-of-hospital cardiac arrest patients in Southern Ostrobothnia, Finland, during a three-year period. Confounding caused by each patient's individual medical history was addressed by calculating Charlson Comorbidity Index (CCI), a score describing individual's risk for death in 10 years. The Utstein analysis and the CPR metrics were acquired from the medical records hospital district in question and analysed in an orderly manner using SPSS. Descriptive statistics are presented as mean (SD) and median [IQR]. RESULTS: We found that of the 349 patients, 144 (41%) received ROSC, 96 (28%) survived to the hospital and 51 (15%) survived for at least 30 days. CPR metrics data were available for 181 patients. CCIs were 3.0 versus 5.0 (p = .157) for the ones who did and those who did not survive at least 30 days. Correspondingly, following metrics were as follows: Mean compression depth was 5.1 (1.3) versus 5.6 (0.8) cm (p = .088), median 28 [18;40] versus 40 [26;54]% of the compressions were in target depth (p = .015) and median compression rate was 113 [109;119] versus 112 [108;120] min-1 (p = .757). The median no-flow fraction was 5.1 [2.8;7.1] versus 3.7 [2.5;5.5] s (p = .073). Ventricular fibrillation (OR 8.74, 95% CI 2.89-26.43, p < .001), public location (OR 3.163, 95% CI 1.03-9.69, p = .044) and compression rate of 100-110/min (OR 7.923, 95% CI 2.11-29.82, p = .002) were related to survival. CONCLUSION: Patients who suffered out-of-hospital cardiac arrest in Southern Ostrobothnia received CPR that met the international CPR quality target values. The proportion of unintentional pauses during CPR was low and the 30-day survival rate exceeded the international average.

Procedural Sedation Intubation in a Paramedic-Staffed Helicopter Emergency Medical System in Northern Finland.

OBJECTIVE: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. METHODS: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. RESULTS: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. CONCLUSION: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.

Medical priority dispatch codes-comparison with National Early Warning Score.

BACKGROUND: In Finland, calls for emergency medical services are prioritized by educated non-medical personnel into four categories-from A (highest risk) to D (lowest risk)-following a criteria-based national dispatch protocol. Discrepancies in triage may result in risk overestimation, leading to inappropriate use of emergency medical services units and to risk underestimation that can negatively impact patient outcome. To evaluate dispatch protocol accuracy, we assessed association between priority assigned at dispatch and the patient's condition assessed by emergency medical services on the scene using an early warning risk assessment tool. METHODS: Using medical charts, clinical variables were prospectively recorded and evaluated for all emergency medical services missions in two hospital districts in Northern Finland during 1.1.2014-30.6.2014. Risk assessment was then re-categorized as low, medium, or high by calculating the National Early Warning Score (NEWS) based on the patients' clinical variables measured at the scene. RESULTS: A total of 12,729 emergency medical services missions were evaluated, of which 616 (4.8%) were prioritized as A, 3193 (25.1%) as B, 5637 (44.3%) as C, and 3283 (25.8%) as D. Overall, 67.5% of the dispatch missions were correctly estimated according to NEWS. Of the highest dispatch priority missions A and B, 76.9 and 78.3%, respectively, were overestimated. Of the low urgency missions (C and D), 10.7% were underestimated; 32.0% of the patients who were assigned NEWS indicating high risk had initially been classified as low urgency C or D priorities at the dispatch. DISCUSSION AND CONCLUSION: The present results show that the current Finnish medical dispatch protocol is suboptimal and needs to be further developed. A substantial proportion of EMS missions assessed as highest priority were categorized as lower risk according to the NEWS determined at the scene, indicating over-triage with the protocol. On the other hand, only a quarter of the high risk NEWS patients were classified as the highest priority at dispatch, indicating considerable under-triage with the protocol.

Cutting the Prehospital On-Scene Time of Stroke Thrombolysis in Helsinki: A Prospective Interventional Study.

BACKGROUND AND PURPOSE: Significant portion of the prehospital delay consists of minutes spent on the scene with the patient. We implemented a training program for the emergency medical services personnel with the aim to optimize the on-scene time (OST) and to study the impact of different elements of prehospital practice to the OST duration. METHODS: In this prospective interventional study, key operational emergency medical service performance variables were analyzed from all thrombolysis candidates transported to the Helsinki University Hospital emergency department. The catchment period was 4 months before and 4 months after the implementation. RESULTS: One hundred and forty-one patients were managed as thrombolysis candidates before and 148 patients after the training program implementation. The OST duration for the groups was 25 (20.5-31) and 22.5 (18-28.5) minutes, respectively (P<0.001). Physician consultations via telephone were associated with a longer (odds ratio 0.546 [0.333-0.893]) and advanced life support training with a shorter OST (odds ration 1.760 [1.070-2.895]). CONCLUSIONS: Implementation of the emergency medical services training program successfully decreased the OST of thrombolysis candidates by 10%. Higher expertise level of the ambulance crew was associated with shorter OST, and decisions to consult a physician via telephone were reflected by longer OST.

Feasibility of LMA Supreme for airway management in unconscious patients by ALS paramedics.

BACKGROUND: Airway management to ensure sufficient gas exchange is of major importance in emergency care. The accepted basic technique is to maintain an open airway and perform artificial ventilation in emergency situations is bag-valve mask (BVM) ventilation with manual airway management without airway adjuncts or with an oropharyngeal tube (OPA) only. Endotracheal intubation (ETI) is often referred to as the golden standard of airway management, but is associated with low success rates and significant insertion-related complications when performed by non-anaesthetists. Supraglottic devices (SADs) are one alternative to ETI in these situations, but there is limited evidence regarding the use of SAD in non-cardiac arrest situations. LMA Supreme (LMA-S) is a new SAD which theoretically has an advantage concerning the risk of aspiration due to an oesophageal inlet gastric tube port. METHODS: Forty paramedics were recruited to participate in the study. Adult (>18 years) patients, unconscious due to medical or traumatic cause with a GCS score corresponding to 3-5 and needed airway management were included in the study. Our aim was to study the feasibility of LMA-S as a primary airway method in unconscious patients by advanced life support (ALS) trained paramedics in prehospital care. RESULTS: Three regional Emergency Medical Service (EMS) services participated and 21 patients were treated during the survey. The LMA-S was placed correctly on the first attempt in all instances 21/21 (100%), with a median time to first ventilation of 9.8 s. Paramedics evaluated the insertion to be easy in every case 21/21 (100%). Because of air leak later in the patient care, the LMA-S was exchanged to an LT-D in two cases and to ETI in three cases (23.81%) by the paramedics. Regurgitation occurred after insertion two times out of 21 (9.52%) and in one of these cases (4.76%), paramedics reported regurgitation inside the LMA-S. CONCLUSION: We conclude that the LMA-S seems to be relatively easy and quick to insert in unconscious patients by paramedics. However, we found out that there were ventilation related problems with the LMA-S. Further studies are warranted.

Novel electrophilic synthesis of 6-[¹8F]fluorodopamine and comprehensive biological evaluation.

PURPOSE: 6-[(18)F]Fluorodopamine (4-(2-aminoethyl)-5-[(18)F]fluorobenzene-1,2-diol, 6-[(18)F]FDA) is a tracer for imaging sympathetically innervated tissues. Previous electrophilic labelling methods produced 6-[(18)F]FDA with low specific radioactivity (SA) which has limited its wider use. Our aim was to employ electrophilic labelling and increase the SA to around 15 GBq/µmol. We also sought to determine an extensive biodistribution pattern for 6-[(18)F]FDA in rats in order to thoroughly identify tissues with dense sympathetic innervation that were specifically labelled with 6-[(18)F]FDA. In addition, to investigate the safety profile of 6-[(18)F]FDA in larger animals, we performed in vivo studies in pigs. METHODS: 6-[(18)F]FDA was synthesised using high SA electrophilic [(18)F]F(2) as the labelling reagent. Biodistribution and metabolism of 6-[(18)F]FDA was determined ex vivo in rats, and in vivo studies were done in pigs. RESULTS: 6-[(18)F]FDA was synthesised with 2.6 ± 1.1% radiochemical yield. The total amount of purified 6-[(18)F]FDA was 663 ± 291 MBq at the end of synthesis (EOS). SA, decay corrected to EOS, was 13.2 ± 2.7 GBq/µmol. Radiochemical purity exceeded 99.0%. Specific uptake of 6-[(18)F]FDA was demonstrated in heart, lung, pancreas, adrenal gland, lower large intestine (LLI), eye, thyroid gland, spleen and stomach tissue. 6-[(18)F]FDA in rat plasma declined rapidly, with a half-life of 2 min, indicating fast metabolism. In vivo PET studies in pigs confirmed the tracer could be used safely without pharmacological effects. CONCLUSION: 6-[(18)F]FDA was synthesised with good radiopharmaceutical quality and yields high enough for several human PET studies. The SA of 6-[(18)F]FDA was improved by 50- to 500-fold compared to previous electrophilic methods. Uptake of 6-[(18)F]FDA was specific in various peripheral organs, indicating that 6-[(18)F]FDA PET can be used to investigate sympathoneural functions beyond cardiac studies when higher specific uptake is achieved.