Prehospital Tranexamic Acid for Severe Trauma.

BACKGROUND: Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. METHODS: We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury. RESULTS: A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups. CONCLUSIONS: Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).

Did lockdown influence bystanders' willingness to perform cardiopulmonary resuscitation? A worldwide registry-based perspective.

AIM: Bystander cardiopulmonary resuscitation (CPR) significantly increases the survival rate after out-of-hospital cardiac arrest. Using population-based registries, we investigated the impact of lockdown due to Covid-19 on the provision of bystander CPR, taking background changes over time into consideration. METHODS: Using a registry network, we invited all registries capable of delivering data from 1. January 2017 to 31. December 2020 to participate in this study. We used negative binominal regression for the analysis of the overall results. We also calculated the rates for bystander CPR. For every participating registry, we analysed the incidence per 100000 inhabitants of bystander CPR and EMS-treated patients using Poisson regression, including time trends. RESULTS: Twenty-six established OHCA registries reported 742 923 cardiac arrest patients over a four-year period covering 1.3 billion person-years. We found large variations in the reported incidence between and within continents. There was an increase in the incidence of bystander CPR of almost 5% per year. The lockdown in March/April 2020 did not impact this trend. The increase in the rate of bystander CPR was also seen when analysing data on a continental level. We found large variations in incidence of bystander CPR before and after lockdown when analysing data on a registry level. CONCLUSION: There was a steady increase in bystander CPR from 2017 to 2020, not associated with an increase in the number of ambulance-treated cardiac arrest patients. We did not find an association between lockdown and bystanders' willingness to start CPR before ambulance arrival, but we found inconsistent patterns of changes between registries.

Prehospital Telestroke vs Paramedic Scores to Accurately Identify Stroke Reperfusion Candidates: A Cluster Randomized Controlled Trial.

BACKGROUND AND OBJECTIVE: Stroke reperfusion therapy is time critical. Improving prehospital diagnostic accuracy including the likelihood of large vessel occlusion can aid with efficient and appropriate diversion decisions to optimize onset-to-treatment time. In this study, we investigated whether prehospital telestroke improves diagnostic accuracy when compared with paramedic assessments and assessed feasibility. METHODS: We conducted a pragmatic, community-based, cluster randomized controlled trial comparing the diagnostic accuracy of telestroke assessments inside the ambulance with a modified Los Angeles Motor Scale (PASTA score). The primary outcome was the accuracy of predicting reperfusion candidates; secondary outcomes were accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of either approach to identify IV thrombolysis (IVT) and endovascular thrombectomy (EVT) candidates and true stroke patients by study group. The accuracy of telestroke and PASTA assessments was compared against in-person assessment in the emergency department and with the final diagnosis/intervention for the patient. We also monitored for technical challenges. RESULTS: We recruited 76 patients (35 telestroke and 41 PASTA) between August 2019 and September 2020. The mean age was 72.2 (±14.6) years. Telestroke was 100% (95% CI 90%-100%) and PASTA 70.7% (54.5%-83.9%) accurate in predicting reperfusion candidates compared with preimaging emergency department neurologist assessment (p < 0.001). When compared with actual reperfusion therapy administered, the predictive accuracy was 80% (63.1%-91.6%) and 60.1% (44.5%-75.8%) for telestroke and PASTA, respectively (p < 0.001). In predicting the administration of IVT, telestroke was 80% (63.1-91.6) and PASTA was 56.1% (39.8-71.5) accurate (p < 0.001). In predicting intervention with EVT, telestroke was 88.6% (73.3-96.8) and PASTA 56.1% (39.8-71.5) accurate (p = 0.005). The service model proved technically feasible and was acceptable to neurologists. DISCUSSION: Prehospital telestroke assessment is feasible, accurate, and superior to the PASTA score in predicting acute reperfusion therapies, presenting an effective option to guide prehospital diversion decisions. TRIAL REGISTRATION: The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001678189).anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378655&isReview=true. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that intra-ambulance telestroke evaluation has a greater diagnostic accuracy compared with the PASTA score performed by paramedics in distinguishing hyperacute stroke patients who are candidates for reperfusion therapy.

Genome Sequences of 14 Siphophages That Infect Serratia marcescens.

We announce the complete genome sequences of 14 Serratia bacteriophages isolated from wastewater treatment plants. These phages define two previously undescribed types which we call the Carrot-like phage cluster (phages Carrot, BigDog, LittleDog, Niamh, Opt-148, Opt-169, PhooPhighters, Rovert, Serratianator, Stoker, Swain, and Ulliraptor) and Tlacuache-like phage cluster (Tlacuache and Opt-155).

Analysis of Trend and Associated Factors of Neuropsychological Development of Infants and Toddlers Based on Longitudinal Data.

OBJECTIVE: To explore the trend and associated factors of neuropsychological development of infants and toddlers in China. METHODS: A longitudinal study was conducted among 619 infants and toddlers (2914 person-times) aged 0 to 36 months from different provinces or cities in China from January 2013 to December 2019. RESULTS: The development age of each area increased with the extension of follow-up time, but this upward trend slowed down with physiological age at first measurement increasing. Among a low age group and each area, most of the development qualification rates in different follow-up periods were higher than that in the baseline (p < 0.05); however, many of them were not higher than that in the baseline among the medium or high age group (p > 0.05). For the areas of gross motor and self-care, the growth of qualification rate with the extension of follow-up was not obvious in the medium and high age group (both p trend > 0.05). Some impact factors of development in all areas were identified. CONCLUSIONS: The neuropsychological development delay of various areas of infants and toddlers, especially that of gross motor and self-care, should be paid early (within 1 years old) and constant attention. The impact of gender and maternal age on the development of young children has been further confirmed in the present study.

High flow oxygen and risk of mortality in patients with a suspected acute coronary syndrome: pragmatic, cluster randomised, crossover trial.

OBJECTIVE: To determine the association between high flow supplementary oxygen and 30 day mortality in patients presenting with a suspected acute coronary syndrome (ACS). DESIGN: Pragmatic, cluster randomised, crossover trial. SETTING: Four geographical regions in New Zealand. PARTICIPANTS: 40 872 patients with suspected or confirmed ACS included in the All New Zealand Acute Coronary Syndrome Quality Improvement registry or ambulance ACS pathway during the study periods. 20 304 patients were managed using the high oxygen protocol and 20 568 were managed using the low oxygen protocol. Final diagnosis of ST elevation myocardial infarction (STEMI) and non-STEMI were determined from the registry and ICD-10 discharge codes. INTERVENTIONS: The four geographical regions were randomly allocated to each of two oxygen protocols in six month blocks over two years. The high oxygen protocol recommended oxygen at 6-8 L/min by face mask for ischaemic symptoms or electrocardiographic changes, irrespective of the transcapillary oxygen saturation (SpO2). The low oxygen protocol recommended oxygen only if SpO2 was less than 90%, with a target SpO2 of less than 95%. MAIN OUTCOME MEASURE: 30 day all cause mortality determined from linkage to administrative data. RESULTS: Personal and clinical characteristics of patients managed under both oxygen protocols were well matched. For patients with suspected ACS, 30 day mortality for the high and low oxygen groups was 613 (3.0%) and 642 (3.1%), respectively (odds ratio 0.97, 95% confidence interval 0.86 to 1.08). For 4159 (10%) patients with STEMI, 30 day mortality for the high and low oxygen groups was 8.8% (n=178) and 10.6% (n=225), respectively (0.81, 0.66 to 1.00) and for 10 218 (25%) patients with non-STEMI was 3.6% (n=187) and 3.5% (n=176), respectively (1.05, 0.85 to 1.29). CONCLUSION: In a large patient cohort presenting with suspected ACS, high flow oxygen was not associated with an increase or decrease in 30 day mortality. TRIAL REGISTRATION: ANZ Clinical Trials ACTRN12616000461493.

Predictive Model Construction for Social-Emotional Competence of Toddlers in Shanghai, China: A Population-Based Study.

OBJECTIVE: To construct a simple model containing predictors derived from Chinese Learning Accomplishment Profile (C-LAP) to better the evaluation of the social-emotional development of toddlers aged 24-36 months. METHOD: The test results by C-LAP system and demographic information of toddlers aged 24-36 months were collected between 2013 and 2019 in Shanghai, China, whose guardians were voluntary to accept the investigation. We developed a norm with the dataset based on the study population. With the norm, stepwise regression and best subset analysis were applied to select predictors. RESULTS: Relying on the norm established and stepwise regression and also the best subset analysis, an optimal model containing only 6 indicators was finally determined and the nomogram of the model was constructed. In the training and validation dataset, the AUCs of the optimal model were 0.95 (95% CI: 0.94-0.96) and 0.88 (95% CI: 0.85-0.90), respectively. When the cutoff point of the model was set at 0.04, its sensitivity in training and validation dataset was 0.969 and 0.949, respectively, and the specificity in training and validation dataset is 0.802 and 0.736, respectively. CONCLUSION: A simplified predictive model which includes only 6 items derived from C-LAP is developed to evaluate the probabilities of being at risk of developmental problem in social-emotional development for toddlers aged 24-36 months. Meanwhile, specificity and sensitivity of the model may be high enough for future fast screening.

Changes in demand for emergency ambulances during a nationwide lockdown that resulted in elimination of COVID-19: an observational study from New Zealand.

OBJECTIVE: To examine the impact of a 5-week national lockdown on ambulance service demand during the COVID-19 pandemic in New Zealand. DESIGN: A descriptive cross-sectional, observational study. SETTING: High-quality data from ambulance electronic clinical records, New Zealand. PARTICIPANTS: Ambulance records were obtained from 588 690 attendances during pre-lockdown (prior to 17 February 2020) and from 36 238 records during the lockdown period (23 March to 26 April 2020). MAIN OUTCOME MEASURES: Ambulance service utilisation during lockdown was compared with pre-lockdown: (a) descriptive analyses of ambulance events and proportions of event types for each period, (b) absolute rates of ambulance attendance (event types/week) for each period. RESULTS: During lockdown, ambulance patients were more likely to be attended at home and less likely to be aged between 16 and 25 years. There was a significant increase in the proportion of lower acuity patients (Status 3 and Status 4) attended (p<0.001) and a corresponding increase in patients not transported from scene (p<0.001). Road traffic crashes (p<0.001) and alcohol-related incidents (p<0.001) significantly decreased. There was a decrease in the absolute number of weekly ambulance attendances (ratio (95% CI), 0.89 (0.87 to 0.91), p<0.001), attendances to respiratory conditions (0.74 (0.61 to 0.86), p=0.01), and trauma (0.81 (0.77 to 0.85), p<0.001). However, there was a significant increase in ambulance attendances for mental health conditions (1.37 (1.22 to 1.51), p=0.005). CONCLUSIONS: Despite the relative absence of COVID-19 in the community during the 5-week nationwide lockdown, there were significant differences in ambulance utilisation during this period. The lockdown was associated with an increase in ambulance attendances for mental health conditions and is of concern. In considering future lockdowns, the potential implications on a population's mental well-being will need to be seriously considered against the benefits of elimination of virus transmission.

The impact of a national COVID-19 lockdown on acute coronary syndrome hospitalisations in New Zealand (ANZACS-QI 55).

BACKGROUND: Countries with a high incidence of coronavirus 2019 (COVID-19) reported reduced hospitalisations for acute coronary syndromes (ACS) during the pandemic. This study describes the impact of a nationwide lockdown on ACS hospitalisations in New Zealand (NZ), a country with a low incidence of COVID-19. METHODS: All patients admitted to a NZ Hospital with ACS who underwent coronary angiography in the All NZ ACS Quality Improvement registry during the lockdown (23 March - 26 April 2020) were compared with equivalent weeks in 2015-2019. Ambulance attendances and regional community troponin-I testing were compared for lockdown and non-lockdown (1 July 2019 to 16 February 2020) periods. FINDINGS: Hospitalisation for ACS was lower during the 5-week lockdown (105 vs. 146 per-week, rate ratio 0•72 [95% CI 0•61-0•83], p = 0.003). This was explained by fewer admissions for non-ST-segment elevation ACS (NSTE-ACS; p = 0•002) but not ST-segment elevation myocardial infarction (STEMI; p = 0•31). Patient characteristics and in-hospital mortality were similar. For STEMI, door-to-balloon times were similar (70 vs. 72 min, p = 0•52). For NSTE-ACS, there was an increase in percutaneous revascularisation (59% vs. 49%, p<0•001) and reduction in surgical revascularisation (9% vs. 15%, p = 0•005). There were fewer ambulance attendances for cardiac arrests (98 vs. 110 per-week, p = 0•04) but no difference for suspected ACS (408 vs. 420 per-week, p = 0•44). Community troponin testing was lower throughout the lockdown (182 vs. 394 per-week, p<0•001). INTERPRETATION: Despite the low incidence of COVID-19, there was a nationwide decrease in ACS hospitalisations during the lockdown. These findings have important implications for future pandemic planning. FUNDING: The ANZACS-QI registry receives funding from the New Zealand Ministry of Health.

Measuring stroke and transient ischemic attack burden in New Zealand: Protocol for the fifth Auckland Regional Community Stroke Study (ARCOS V).

Aim: The goal of this paper is to provide a protocol for conducting a fifth population-based Auckland Regional Community Stroke study (ARCOS V) in New Zealand. Methods and Discussion: In this study, for the first time globally, (1) stroke and TIA burden will be determined using the currently used clinical and tissue-based definition of stroke, in addition to the WHO clinical classifications of stroke used in all previous ARCOS studies, as well as more advanced criteria recently suggested for an "ideal" population-based stroke incidence and outcomes study; and (2) age, sex, and ethnic-specific trends in stroke incidence and outcomes will be determined over the last four decades, including changes in the incidence of acute cerebrovascular events over the last decade. Furthermore, information at four time points over a 40-year period will allow the assessment of effects of recent changes such as implementation of the FAST campaign, ambulance pre-notification, and endovascular treatment. This will enable more accurate projections for health service planning and delivery. Conclusion: The methods of this study will provide a foundation for future similar population-based studies in other countries and populations.

Relationship between socioeconomic factors, distribution of public access defibrillators and incidence of out-of-hospital cardiac arrest.

BACKGROUND: Survival from out-of-hospital cardiac arrest (OHCA) is improved when public access defibrillators are used. Areas of socioeconomic deprivation may have higher rates of OHCA and thus a greater demand for public access defibrillators. We aimed to determine if there was a relationship between socioeconomic factors, the geographic distribution of public access defibrillators (PADs) and incidence of OHCA. METHOD: Socioeconomic deprivation data was obtained from the Census-based 2013 Index of Deprivation. Spatial information for PADs was obtained from a New Zealand PAD database (AED Locations) in 2016 and 2018. Location data for OHCA was obtained from the St John New Zealand OHCA registry for the period 1 October 2013 to 30 June 2016. Relationships between these variables were analysed using a Poisson regression analysis. RESULTS: Cardiac arrest incidence increased with increasing deprivation. The incidence in the most deprived areas of 156.5 events per 100,000 person years (135.4-180.9, 95% CI) is double the incidence in the least deprived areas at 78.0 events per 100,000 person years (66.4-91.7, 95% CI). Significant increases in the rates of OHCA were observed with every 1% increase in proportions of Maori (1.0%, 0.61-1.4%, 95% CI, p = 0.001), Pacific Peoples (0.6%, 0.21-0.9%, p = 0.005), >65 year olds (3.7%, 3.0-4.3%, p < 0.001), and males (3.7%, 1.8-5.6%, p < 0.001). In 2018, the decile 10 areas had the lowest coverage of PADs (65% of these areas contained a PAD) compared with less deprived areas (68-84%, median 81%). CONCLUSIONS: The most socioeconomically deprived communities had the highest incidence of OHCA and the least availability of PADs. This provides impetus for targeted PAD placement in areas of higher deprivation.

An audit of change in clinical practice: from oxygen-driven to air-driven nebulisers for prehospital patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

BACKGROUND: In developed countries, ambulances normally carry oxygen cylinders, but not compressed air. Treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) with oxygen-driven nebulisers can result in hypercapnia and acidosis. Attempts to avoid this have involved interrupted administration of oxygen. However, small battery-powered air nebulisers are now available. This study aims to compare the prehospital oxygen saturations and treatment of patients suffering from AECOPD before and after the introduction of air nebulisers. METHODS: The oxygen saturations and treatment of 200 AECOPD patients before and 200 AECOPD patients after the introduction of air nebulisers were compared. Compliance with a target saturation of 88-92% was calculated. RESULTS: The median final oxygen saturation was lower for the post-intervention category (94%) than the pre-intervention category (96%). There was an increase in air nebuliser use from 0 to 56% (P < 0.001) and a decrease in oxygen use from 100 to 71.5% (P < 0.001). There was a numerical increase in the proportion of patients arriving at hospital with oxygen saturations of 88-92% following introduction of the air nebulisers (24 vs 16.5%) and a decrease in patients arriving with high saturations (67.5 vs 76.5%). The likelihood of achieving the target oxygen saturations following introduction of air nebulisers increased (odds ratio 1.598; 95% confidence interval 0.974, 2.621). CONCLUSION: The introduction of prehospital air nebulisers resulted in a reduction in oxygen therapy in patients with AECOPD and a lower median prehospital oxygen saturation. This study supports the use of air nebulisers in the prehospital setting.

Out-of-hospital Cardiac Arrest Patient Characteristics: Comparing ventricular arrhythmia and Pulseless Electrical Activity.

BACKGROUND: The proportion of patients suffering out-of-hospital cardiac arrest presenting with ventricular arrhythmias/ventricular fibrillation (VT/VF) is decreasing, while the proportion presenting with pulseless electrical activity (PEA) is increasing. Cardiac arrest interventions target VT/VF and survival rates from PEA are much lower. The aim of this study was to compare clinical characteristics of those suffering PEA and VT/VF. METHODS: We examined the past medical history of all patients suffering cardiac arrest in the Wellington region between 2008-2012 and compared clinical features of those with PEA to VT/VF. RESULTS: We identified 749 cardiac arrests in the study period, and were able to obtain detailed medical histories in 735 (98%) cases. The presenting rhythm was VF/VT in 337 (46%) cases, PEA in 127 (17%), and asystole in 271 (37%). Patients with PEA were older (68±14 versus 63±15 years, p=0.003), a higher proportion were female (35% versus 22%, p=0.002) and were less likely to have prior cardiovascular disease than those with VT/VF (48% versus 59%, p=0.03). Respiratory disease was more common in those with PEA (35% versus 23%, p=0.008). CONCLUSION: The population suffering PEA differs from the VT/VF cohort in a number of ways, and PEA is associated with significantly worse outcomes.

Regulating our emergency care paramedics.

Ambulance paramedics administering emergency care to patients are delivering a health service as defined in the Health Practitioners Competence Assurance Act, 2003. Paramedics practice a wide range of skills without direct supervision and these can potentially put the public at risk if the paramedic is not competent. Paramedic practice is also rapidly expanding beyond the traditional ambulance role. However, this emerging profession falls outside the Act and paramedics remain unregistered. In this paper we state the case for extending regulation to these frontline healthcare professionals.

How effectively can young people perform dispatcher-instructed cardiopulmonary resuscitation without training?

AIMS: Survival from out-of-hospital cardiac arrest is increased by bystander cardiopulmonary resuscitation (CPR). Bystander performance can be improved when CPR instructions are delivered by a calltaker at the Emergency Communications Centre. Little is known about a young person's ability to understand these instructions and perform CPR correctly. We assessed the ability of a group of untrained young people to effectively apply these directions to an adult resuscitation manikin. METHODS: 87 youngsters aged 7-15 years with no previous training in CPR were separately equipped with a mobile phone and an adult assessment manikin. They phoned the emergency number (111) and were automatically diverted to a senior emergency medical dispatcher (EMD). The EMD delivered resuscitation instructions which complied fully with Medical Priority Dispatch System (version 12.1). Performance was monitored using a Laerdal Computerised Skill Reporting System. RESULTS: Average compression depth increased with age from 10.3 mm to 30 mm for 8 and 15 year olds respectively. 100 compressions per minute was achieved in youngsters aged 10 years and older but the rate fatigued over time and improved after interruption for two ventilations. Those aged 11 years and older consistently compressed the chest from 31 mm to 50mm. Only one participant could successfully ventilate the manikin by mouth-to-mouth. CONCLUSION: This study demonstrates that untrained youngsters should perform compression-only CPR. From 11 years of age, they can effectively perform dispatcher-directed CPR by compressing the chest at an appropriate rate and depth. However, their technique benefits from formal training.

Comparative audit of oxygen use in the prehospital setting in acute COPD exacerbation over 5†years.

BACKGROUND: In 2009 the Wellington Free Ambulance implemented an education programme to reduce high concentration oxygen delivery to patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of this audit was to compare pre-hospital oxygen delivery to patients with AECOPD before and after the programme. METHODS: An audit of patients who presented to Wellington Regional Hospital by ambulance with an AECOPD in 2005 and then in 2010, after implementation of the education programme. Oxygen therapy was categorised as: HIGH, supplemental high concentration oxygen therapy ≥3 L/min and/or delivery via high concentration mask; NEB, high concentration oxygen only during nebuliser use; or LOW, neither of these. RESULTS: In 2005 those in the HIGH, NEB and LOW categories were 81 (75.0%), 18 (16.7%) and 9 (8.3%) of 108 identified patients. In 2010 those in the HIGH, NEB and LOW categories were 80 (44.0%), 61 (33.5%) and 41 (22.5%) of 182 identified patients. The proportions of patients in the three oxygen groups were significantly different between 2005 and 2010 (p<0.001). CONCLUSIONS: The proportion of patients administered supplemental high concentration oxygen therapy markedly decreased between 2005 and 2010 following implementation of the education programme. However, in 2010 more than half of the patients not managed with high concentration oxygen therapy were still exposed to high concentration oxygen through the use of oxygen-driven nebulisers. To reduce exposure to high concentration oxygen in AECOPD the use of air-driven nebulisers or metered dose inhalers with spacers is required.

The Wellington Life Flight Helicopter Emergency Medical Service (HEMS): a retrospective audit against new Ministry of Health criteria.

AIM: To analyse the clinical and operational indications for activating the Wellington Life Flight helicopter emergency medical service (HEMS) against draft Ministry of Health (MOH) criteria. METHOD: Wellington HEMS records for 3 years were reviewed. Details of mission location, timings, medical procedures, patient demographics, and primary reasons for dispatch were analysed. RESULTS: 471 missions were reviewed. The main reasons for helicopter dispatch were anticipated time savings (47%), geographical access (36%), provision of skills (7%), or a combination (10%). In 62% of total missions, a road ambulance and helicopter were both dispatched. The helicopter was dispatched after the road ambulance had arrived at the scene in 52% of these cases, with a median lag time of 11 minutes and 12 seconds, and median waiting on scene time of 27 minutes 28 seconds. The road ambulance arrived first in 77% of cases. The median arrival time by air was 26 minutes compared to 11 minutes 45 seconds by road. In contrast, the transfer to hospital by helicopter was quicker in 99% of cases, with a median flight time of 15 minutes compared to 49 minutes by road. CONCLUSION: Wellington HEMS offers advantage over the road ambulance when dispatched and utilised appropriately. The majority of missions satisfied the MOH activation criteria but time-saving issues became apparent. Changes to the Helicopter Dispatch Flowchart have been proposed as a result. Further studies are required to assess any improvement in HEMS response times as the service develops. This data provides a benchmark for audits of future operational and clinical performance.

HyperOxic Therapy OR NormOxic Therapy after out-of-hospital cardiac arrest (HOT OR NOT): a randomised controlled feasibility trial.

AIMS: To investigate the feasibility of delivering titrated oxygen therapy to adults with return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) caused by ventricular fibrillation (VF) or ventricular tachycardia (VT). METHODS: We used a multicentre, randomised, single blind, parallel groups design to compare titrated and standard oxygen therapy in adults resuscitated from VF/VT OHCA. The intervention commenced in the community following ROSC and was maintained in the emergency department and the Intensive Care Unit. The primary end point was the median oxygen saturation by pulse oximetry (SpO2) in the pre-hospital period. RESULTS: 159 OHCA patients were screened and 18 were randomised. 17 participants were analysed: nine in the standard care group and eight in the titrated oxygen group. In the pre-hospital period, SpO2 measurements were lower in the titrated oxygen therapy group than the standard care group (difference in medians 11.3%; 95% CI 1.0-20.5%). Low measured oxygen saturation (SpO2<88%) occurred in 7/8 of patients in the titrated oxygen group and 3/9 of patients in the standard care group (P=0.05). Following hospital admission, good separation of oxygen exposure between the groups was achieved without a significant increase in hypoxia events. The trial was terminated because accumulated data led the Data Safety Monitoring Board and Management Committee to conclude that safe delivery of titrated oxygen therapy in the pre-hospital period was not feasible. CONCLUSIONS: Titration of oxygen in the pre-hospital period following OHCA was not feasible; it may be feasible to titrate oxygen safely after arrival in hospital.

Survival from out-of-hospital cardiac arrest in Wellington in relation to socioeconomic status and arrest location.

AIMS: The study examined the influence of physical location on survival from out-of-hospital cardiac arrest (OHCA). Firstly, OHCAs occurring in residential settings were compared to those occurring in public locations. Secondly, the residential OHCAs were classified according to socioeconomic status and the relationship between socioeconomic status and outcome from OHCA was examined. METHODS: For all OHCAs that occurred between 1 July 2007 and 30 June 2010, we compared OHCA characteristics and outcomes between public and residential locations, and for residential locations examined across deciles of socioeconomic status. RESULTS: Of the 445 arrests that occurred during the study period, 413 met the inclusion criteria. Survival from OHCA in public locations was approximately twice that for residential OHCA (19.8% vs 10.7%, p=0.021). We found no association between survival from residential OHCA and socioeconomic status. Similarly, we found no association between socioeconomic status and witnessing of the event, bystander cardiopulmonary resuscitation, the initial presenting rhythm, and ambulance response time. CONCLUSION: Residential OHCA in the Wellington region has a much poorer prognosis than OHCA in public locations. There is no evidence to suggest that any socioeconomic group in the Wellington region is disadvantaged when a community and ambulance response is required for an OHCA.