ST-Segment Elevation Myocardial Infarction and Out-of-Hospital Cardiac Arrest: Contemporary Management From the Multicenter START Registry.

BACKGROUND: Recent studies suggest that primary percutaneous coronary intervention (PCI) and targeted temperature management (TTM) improve outcome in ST-segment elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA). The objective of this study was to evaluate a contemporary series of patients with STEMI and OHCA to characterize treatment approaches and predictors of neurologic outcome. METHODS: From January 2009 through November 2012, a total of 239 patients who underwent emergent coronary angiography at 10 medical centers across the United States were enrolled. All patients suffered OHCA with STEMI on either the prehospital or post-resuscitation electrocardiogram. Neurologic outcome was assessed using the cerebral performance category (CPC) score. Predictors of neurologic outcome were determined using multivariate logistic regression analysis. The primary endpoint was in-hospital survival with good neurologic function (CPC score 1 or 2). RESULTS: Mean age was 60 ± 13 years, 72% were male, and the majority of patients had a history of cardiovascular event. Initial rhythm was ventricular fibrillation in 72%. At hospital presentation, 76% of patients were intubated, 37% were in cardiogenic shock, and 33% were receiving vasopressors. Primary PCI was performed in 74%, with an average door-to-balloon time of 95 ± 77 minutes, and TTM was used in 51%. Forty-four percent of patients had full neurologic recovery (CPC score 1) and 55% had good neurologic function. Overall in-hospital survival rate was 66%. Independent predictors of in-hospital survival with good neurologic function were: receiving bystander cardiopulmonary resuscitation, location of arrest, receiving drug-eluting stents, and not experiencing a recurrent cardiac arrest. CONCLUSIONS: Short-term survival for patients with STEMI and OHCA undergoing emergent coronary angiography and revascularization with TTM in this contemporary, multicenter registry was high and neurologic outcome was good in more than half of patients.

Time to Cooling Is Associated with Resuscitation Outcomes.

Our purpose was to analyze evidence related to timing of cooling from studies of targeted temperature management (TTM) after return of spontaneous circulation (ROSC) after cardiac arrest and to recommend directions for future therapy optimization. We conducted a preliminary review of studies of both animals and patients treated with post-ROSC TTM and hypothesized that a more rapid cooling strategy in the absence of volume-adding cold infusions would provide improved outcomes in comparison with slower cooling. We defined rapid cooling as the achievement of 34°C within 3.5 hours of ROSC without the use of volume-adding cold infusions, with a ≥3.0°C/hour rate of cooling. Using the PubMed database and a previously published systematic review, we identified clinical studies published from 2002 through 2014 related to TTM. Analysis included studies with time from collapse to ROSC of 20-30 minutes, reporting of time from ROSC to target temperature and rate of patients in ventricular tachycardia or ventricular fibrillation, and hypothermia maintained for 20-24 hours. The use of cardiopulmonary bypass as a cooling method was an exclusion criterion for this analysis. We compared all rapid cooling studies with all slower cooling studies of ≥100 patients. Eleven studies were initially identified for analysis, comprising 4091 patients. Two additional studies totaling 609 patients were added based on availability of unpublished data, bringing the total to 13 studies of 4700 patients. Outcomes for patients, dichotomized into faster and slower cooling approaches, were determined using weighted linear regression using IBM SPSS Statistics software. Rapid cooling without volume-adding cold infusions yielded a higher rate of good neurological recovery than slower cooling methods. Attainment of a temperature below 34°C within 3.5 hours of ROSC and using a cooling rate of more than 3°C/hour appear to be beneficial.

Stabilization and Management of the Acutely Agitated or Psychotic Patient.

Acutely agitated or psychotic patients are particularly challenging to manage in the emergency department. Often these patients present with little or no history, and an adequate assessment may initially be difficult because of the condition of the patient. This article discusses basic concepts regarding agitation, and the related management goals and strategies.

The emergency cardiac arrest response team (eCART): a novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest.

BACKGROUND: Out-of hospital cardiac arrest (OHCA) is associated with significant mortality. Therapeutic hypothermia is one of the few interventions that have been shown to increase post-arrest survival as well as enhance neurologic recovery. Despite clinical guidelines recommending the use of therapeutic hypothermia (TH) following cardiac arrest, utilization rates by physicians remain low. We hypothesized that the development of a multi-disciplinary emergency cardiac arrest response team (eCART) would enhance therapeutic hypothermia utilization in the emergency department for OHCA. METHODS AND RESULTS: An eCART (emergency department cardiac arrest response team) was created at a single site academic urban emergency department. The eCART team consisted of a physician hypothermia consultant, a cardiologist, a clinical pharmacist, a respiratory therapist and a chaplain. These providers were notified by page prior to the arrival of an OHCA patient and responded to the ED in person or by phone to support the resuscitation. Analysis of pre- and post-intervention data demonstrated a significant increase in the rate of TH utilization (64% to 96%). There was a non-significant decrease in the time to target temperature. CONCLUSIONS: The creation of a coordinated, multi-disciplinary care team, providing real-time support for OHCA patients increased TH utilization in an emergency department.

Disorders of sodium and water balance.

Dysnatremias occur simultaneously with disorders in water balance. The first priority is to correct dehydration; once the patient is euvolemic, the sodium level can be reassessed. In unstable patients with hyponatremia, the clinician should rapidly administer hypertonic saline. In unstable patients with hypernatremia, the clinician should administer isotonic intravenous fluid. In stable patients with either hyponatremia or hypernatremia, the clinician should aim for correction over 24 to 48 hours, with the maximal change in serum sodium between 8 to 12 mEq/L over the first 24 hours. This rate of correction decreases the chances of cerebral edema or osmotic demyelination syndrome.

Evaluation and management of bradydysrhythmias in the emergency department.

Bradydysrhythmias represent a collection of cardiac conduction abnormalities that span the spectrum of emergency presentations, from relatively benign conditions to conditions that represent serious, life-threatening emergencies. This review presents the electrocardiographic findings seen in common bradydysrhythmias and emphasizes prompt recognition of these patterns. Underlying etiologies that may accompany these conduction abnormalities are discussed, including bradydysrhythmias that are reflex mediated (including trauma induced) and those with metabolic, environmental, infectious, and toxicologic causes. Evidence regarding the management of bradydysrhythmias in the emergency department is limited; however, there are data to guide the approach to the unstable bradycardic patient. When decreased end-organ perfusion is present, the use of atropine, beta agonists, and transcutaneous or transvenous pacing may be required.