The Impact of the Storm Emma on Irish Emergency Department Attendances.

Aim The impact of severe weather events on Irish EDs has not yet been characterised. The aim of this study was to examine the impact of Storm Emma on the attendance patterns to an Irish ED. Methods Data was collected for 64hrs prior to the red alert (Pre-Red), 38hrs of the red alert (Red) and for the 256 hrs (10 days) post the red alert (Post-Red) during Storm Emma. A Comparison was made with the same time periods in 2017. Results There was a statistically significant decrease in attendance during the Red period in 2018, compared with 2017 (119 vs. 234, p<0.001), with a rebound surge in attendances in the Post-Red period (1,861 vs 1,578, p<0.001). Mean patient experience times were significantly longer in the Post-Red period in 2018 (9.5+/-9.5hrs vs 7.9+/-8.2hrs, p<0.001). Conclusion This study has detailed the impact of a severe weather event on an Irish ED and will help inform preparedness for the future.

Telephone Follow-Up of Mild Traumatic Brain Injury; A Feasibility Study

Background This study investigates the prevalence of Post-Concussion Syndrome (PCS) one-year post-injury in patients that were treated for Mild Traumatic Brain Injury (mTBI) in the Clinical Decision Unit (CDU) of Cork University Hospital's (CUH) Emergency Department. Methods Adults treated for mTBI in 2013 completed a telephone questionnaire comprising the Rivermead Post Concussion Symptoms Questionnaire (RPQ), the Short Form 12 (SF-12), and the EuroQol Health Outcome Assessment Tool (EQ5D5L). Results There were 112 patients identified. Of these, 57 (51%) were successfully contacted. The median age was 40 (IQR 27.5 ­ 57.5) and 58% were male. The most common mechanism of injury was a mechanical fall (28%). PCS of at least mild severity was present in 12 (21%). Overall, females tended to have worse outcomes (mean Physical Function score; males: females, 97.7: 76; p < 0.004). Conclusions mTBI patients continue to suffer from PCS at one-year post-injury and females had a worse physical function outcome.

A Descriptive Study Of The Burden Of Animal-Related Trauma At Cork University Hospital.

Farming is the most dangerous occupation in Ireland1 and the incidence of farm accidents is rising. This study examines major farm animal-related trauma treated at Cork University Hospital over a 5 year period. There were 54 patients admitted to Cork University Hospital (C.U.H.) with major farm animal-related trauma. The median age was 56 years, 85% were male and the median hospital length of stay was four days. Older patients had longer lengths of stay; 5.5 vs 4 days (p=0.026). Tibia/fibula fractures were the most common injuries (N=13, 24%); head injury occurred in six patients (11%). There were 32 (59%) patients who required surgery, the majority for orthopaedic injuries. There were nine patients (16.7%) admitted to the intensive care unit; their median ICU stay was four days. Injury prevention and treatment strategies require that the age profile, mechanism of injury and injury patterns of farmers sustaining animal-related trauma is recognised.

The MERIT 3 project: Alerting general practitioners to cardiac arrest in the community.

BACKGROUND: The work context of the general practitioner (GP) potentially lends itself to the provision of early community based, cardiac arrest care. GPs have traditionally encountered out of hospital cardiac arrest (OHCA) as a component of routine patient care but have not been formally linked with the statutory ambulance service. Computer aided dispatch technology now allows real time GP text message alert to nearby cardiac arrest events. AIM: To examine the feasibility, uptake and outcome of a novel scheme to alert GPs to nearby OHCA events in their communities. METHODS: GPs are recruited to voluntarily participate in a cardiac arrest text alert initiative called the 'MERIT 3' project. GPs indicate the hours during which they wish to receive OHCA text alerts, and also specify a geo-location from which they will receive alerts to OHCA events occurring within a specified radius. Data on alerts, responses, OHCA incidents and outcomes are gathered prospectively, using ambulance control and GP data and with corroborative data from the national OHCA registry. RESULTS: 423 general practices throughout Ireland were invited to participate. In the initial 12 months, 100 GPs from 85 individual practices have enrolled, 74 GPs have received alerts and 26 GPs have responded to incidents. Only 222/781 (28.4%) text alerts issued by ambulance control have proven to be recognised as cardiac arrests with resuscitation attempts. GPs have attended 51/776 (6.6%) OHCA incidents to which they have been alerted, with resuscitation undertaken in 34 cases with three survivors. CONCLUSION: Text alert activation of GPs to nearby OHCA events has proven feasible, with significant activity during the establishment period, but a low survival rate which is similar to the overall national OHCA survival rate. A high proportion of alerts do not involve resuscitation opportunities.

In-hospital Cardiac Arrest at Cork University Hospital.

We describe the incidence and outcomes of in-hospital cardiac arrest (IHCA) at Cork University Hospital over a one year time period (2011), prior to the implementation of national early warning scoring (NEWS) systems. There were 43 217 coded CUH admissions, in 2011, to 518 in-patient beds. The Hospital In-Patient Enquiry Database was used to identify adults (>/= 18 years) who sustained IHCA. Available Utstein variables were collected. Fifty-two patients were found to be incorrectly coded IHCA. 17 of 63 (27.0%) IHCA survived to discharge. IHCA with shockable rhythm had significantly higher survival. IHCA survival was significantly lower on wards versus any other hospital location. Median days of stay prior to arrest were significantly different between survivors and non-survivors. All survivors (n = 17) had intact neurological outcome post-event. Our outcomes from IHCA are poorest on hospital wards when compared to other areas of the hospital. Those that survive have excellent function and one-year survival.

Changing climate and nutrient transfers: Evidence from high temporal resolution concentration-flow dynamics in headwater catchments.

We hypothesise that climate change, together with intensive agricultural systems, will increase the transfer of pollutants from land to water and impact on stream health. This study builds, for the first time, an integrated assessment of nutrient transfers, bringing together a) high-frequency data from the outlets of two surface water-dominated, headwater (~10km(2)) agricultural catchments, b) event-by-event analysis of nutrient transfers, c) concentration duration curves for comparison with EU Water Framework Directive water quality targets, d) event analysis of location-specific, sub-daily rainfall projections (UKCP, 2009), and e) a linear model relating storm rainfall to phosphorus load. These components, in combination, bring innovation and new insight into the estimation of future phosphorus transfers, which was not available from individual components. The data demonstrated two features of particular concern for climate change impacts. Firstly, the bulk of the suspended sediment and total phosphorus (TP) load (greater than 90% and 80% respectively) was transferred during the highest discharge events. The linear model of rainfall-driven TP transfers estimated that, with the projected increase in winter rainfall (+8% to +17% in the catchments by 2050s), annual event loads might increase by around 9% on average, if agricultural practices remain unchanged. Secondly, events following dry periods of several weeks, particularly in summer, were responsible for high concentrations of phosphorus, but relatively low loads. The high concentrations, associated with low flow, could become more frequent or last longer in the future, with a corresponding increase in the length of time that threshold concentrations (e.g. for water quality status) are exceeded. The results suggest that in order to build resilience in stream health and help mitigate potential increases in diffuse agricultural water pollution due to climate change, land management practices should target controllable risk factors, such as soil nutrient status, soil condition and crop cover.

Dominant mechanisms for the delivery of fine sediment and phosphorus to fluvial networks draining grassland dominated headwater catchments.

Recent advances in monitoring technology have enabled high frequency, in-situ measurements of total phosphorus and total reactive phosphorus to be undertaken with high precision, whilst turbidity can provide an excellent surrogate for suspended sediment. Despite these measurements being fundamental to understanding the mechanisms and flow paths that deliver these constituents to river networks, there is a paucity of such data for headwater agricultural catchments. The aim of this paper is to deduce the dominant mechanisms for the delivery of fine sediment and phosphorus to an upland river network in the UK through characterisation of the temporal variability of hydrological fluxes, and associated soluble and particulate concentrations for the period spanning March 2012-February 2013. An assessment of the factors producing constituent hysteresis is undertaken following factor analysis (FA) on a suite of measured environmental variables representing the fluvial and wider catchment conditions prior to, and during catchment-wide hydrological events. Analysis indicates that suspended sediment is delivered to the fluvial system predominantly via rapidly responding pathways driven by event hydrology. However, evidence of complex, figure-of-eight hysteresis is observed following periods of hydrological quiescence, highlighting the importance of preparatory processes. Sediment delivery via a slow moving, probably sub-surface pathway does occur, albeit infrequently and during low magnitude events at the catchment outlet. Phosphorus is revealed to have a distinct hysteretic response to that of suspended sediment, with sub-surface pathways dominating. However, high magnitude events were observed to exhibit threshold-like behaviour, whereby activation and connection of usually disconnected depositional zones to the fluvial networks results in the movement of vast phosphorus fluxes. Multiple pathways are observed for particulate and soluble constituents, highlighting the challenges faced in mitigating the delivery of contaminant fluxes to headwater river systems.

Urban and rural differences in out-of-hospital cardiac arrest in Ireland.

BACKGROUND: More than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities. AIM: To use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings. METHODS: The geographical coordinates of incident locations were identified and co-ordinates were then classified as 'urban' or 'rural' according to the Irish Central Statistics Office (CSO) definition. RESULTS: 1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001). Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43-7.31)). CONCLUSION: There are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.

Reduced nutrient pollution in a rural stream following septic tank upgrade and installation of runoff retention measures.

Surface water quality in the UK and much of Western Europe has improved in recent decades, in response to better point source controls and the regulation of fertilizer, manure and slurry use. However, diffuse sources of pollution, such as leaching or runoff of nutrients from agricultural fields, and micro-point sources including farmyards, manure heaps and septic tank sewerage systems, particularly systems without soil adsorption beds, are now hypothesised to contribute a significant proportion of the nutrients delivered to surface watercourses. Tackling such sources in an integrated manner is vital, if improvements in freshwater quality are to continue. In this research, we consider the combined effect of constructing small field wetlands and improving a septic tank system on stream water quality within an agricultural catchment in Cumbria, UK. Water quality in the ditch-wetland system was monitored by manual sampling at fortnightly intervals (April-October 2011 and February-October 2012), with the septic tank improvement taking place in February 2012. Reductions in nutrient concentrations were observed through the catchment, by up to 60% when considering total phosphorus (TP) entering and leaving a wetland with a long residence time. Average fluxes of TP, soluble reactive phosphorus (SRP) and ammonium-N (NH4-N) at the head of the ditch system in 2011 (before septic tank improvement) compared to 2012 (after septic tank improvement) were reduced by 28%, 9% and 37% respectively. However, TP concentration data continue to show a clear dilution with increasing flow, indicating that the system remained point source dominated even after the septic tank improvement.

High frequency variability of environmental drivers determining benthic community dynamics in headwater streams.

Headwater streams are an important feature of the landscape, with their diversity in structure and associated ecological function providing a potential natural buffer against downstream nutrient export. Phytobenthic communities, dominated in many headwaters by diatoms, must respond to physical and chemical parameters that can vary in magnitude within hours, whereas the ecological regeneration times are much longer. How diatom communities develop in the fluctuating, dynamic environments characteristic of headwaters is poorly understood. Deployment of near-continuous monitoring technology in sub-catchments of the River Eden, NW England, provides the opportunity for measurement of temporal variability in stream discharge and nutrient resource supply to benthic communities, as represented by monthly diatom samples collected over two years. Our data suggest that the diatom communities and the derived Trophic Diatom Index, best reflect stream discharge conditions over the preceding 18-21 days and Total Phosphorus concentrations over a wider antecedent window of 7-21 days. This is one of the first quantitative assessments of long-term diatom community development in response to continuously-measured stream nutrient concentration and discharge fluctuations. The data reveal the sensitivity of these headwater communities to mean conditions prior to sampling, with flow as the dominant variable. With sufficient understanding of the role of antecedent conditions, these methods can be used to inform interpretation of monitoring data, including those collected under the European Water Framework Directive and related mitigation efforts.

Differential proteomic analysis of a polymicrobial biofilm.

Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia exist in a polymicrobial biofilm associated with chronic periodontitis. The aim of this study was to culture these three species as a polymicrobial biofilm and to determine proteins important for bacterial interactions. In a flow cell all three species attached and grew as a biofilm; however, after 90 h of culture P. gingivalis and T. denticola were closely associated and dominated the polymicrobial biofilm. For comparison, planktonic cultures of P. gingivalis and T. denticola were grown separately in continuous culture. Whole cell lysates were subjected to SDS-PAGE, followed by in-gel proteolytic H2¹6O/H2¹8O labeling. From two replicates, 135 and 174 P. gingivalis proteins and 134 and 194 T. denticola proteins were quantified by LC-MALDI TOF/TOF MS. The results suggest a change of strategy in iron acquisition by P. gingivalis due to large increases in the abundance of HusA and HusB in the polymicrobial biofilm while HmuY and other iron/haem transport systems decreased. Significant changes in the abundance of peptidases and enzymes involved in glutamate and glycine catabolism suggest syntrophy. These data indicate an intimate association between P. gingivalis and T. denticola in a biofilm that may play a role in disease pathogenesis.

Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia.

INTRODUCTION: Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of paediatric traumatic OHCA. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged less than 16 years of age. Cases were linked with their coronial findings. RESULTS: Between 2000 and 2009, EMS attended 33,722 OHCAs including 2187 adult traumatic OHCAs. There were 538 (1.6%) OHCAs in children less than 16 years of age of which n=64 were due to trauma. The median age (IQR) of paediatric traumatic OHCA was 7 (4.5-13) years and 44 were male (69%). Bystander CPR was performed in 22 cases (34.4%). The first recorded rhythm by EMS was asystole seen in 42 (66%), PEA in 14 (22%) cases and VF in 2 cases (3%). Cardiac output was present in 7 (11%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 35 (55%) patients of whom 7 (20%) achieved ROSC and were transported, and 1 (3%) survived to hospital discharge with severe neurological sequelae; 14(40%) were transported with CPR of whom none survived. Coronial cause of death was multiple injuries in 35%, head injury in 33%, head and neck injury in 10%, chest injuries in 10% and other causes (12%). CONCLUSIONS: Traumatic aetiology of OHCA when compared to the incidence of adult traumatic OHCAs is uncommon. Resuscitation efforts are seldom effective and associated with poor neurological outcome.

Resuscitation of out-of-hospital cardiac arrests in residential aged care facilities in Melbourne, Australia.

INTRODUCTION: CPR in patients in residential aged care facilities (RACF) deserves careful consideration. We examined the characteristics, management and outcomes of out-of-hospital cardiac arrest (OHCA) in RACF patients in Melbourne, Australia. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs occurring in RACFs in Melbourne. The characteristics and outcomes were compared to non-RACF patients in the VACAR. RESULTS: Between 2000 and 2009 there were 30,006 OHCAs, 2350 (7.8%) occurring in a RACF. A shockable rhythm was present in 179 (7.6%) patients on arrival of paramedics of whom bystander CPR had been performed in 118 (66%); 173 (97%) received an EMS attempted resuscitation. ROSC was achieved in 71 (41%) patients and 15 (8.7%) patients survived to leave hospital. Non shockable rhythm was present in 2171 patients (92%) of whom 804 (37%) had an attempted resuscitation by paramedics. ROSC was achieved in 176 patients (22%) and 10 patients (1.2%) were discharged alive. Survival from OHCA occurring in a RACF was less than survival in those aged >70 years of age who suffered OHCA in their own homes (1.8% vs. 4.7%, p=0.001). On multivariable analysis, witnessed OHCA (OR 3.0, 95% CI 2.4-3.7) and the presence of bystander CPR (OR 4.6, 95% CI 3.7-5.8) was associated with the paramedic decision to resuscitate. CONCLUSION: Resuscitation of patients in RACF is not futile. However, informed decisions concerning resuscitation status should be made by patients and their families on entry to a RACF. Where it is appropriate to perform resuscitation, outcomes may be improved by the provision of BLS training and possibly AED equipment to RACF staff.

Out-of-hospital cardiac arrests in young adults in Melbourne, Australia-adding coronial data to a cardiac arrest registry.

AIM: We aim to describe the coronial findings of young adults where the out-of-hospital cardiac arrest (OHCA) aetiology was 'presumed cardiac'. METHODS: Presumed cardiac aetiology OHCAs occurring in young adults aged 16-39 years were identified using the Victorian Ambulance Cardiac Arrest Registry (VACAR) and available coronial findings reviewed. RESULTS: We identified 841 young adult OHCAs where the Utstein aetiology was 'presumed cardiac'. Of these 740 died and 572 (77%) OHCAs were matched to coroner's findings. On review of the coroner's cause of death, 230 (40.2%) had a 'confirmed cardiac' aetiology, 221 (38.6%) were proven 'non-cardiac', 97 (17%) were inconclusive and 24 (4.2%) cases remained 'open'. 'Confirmed cardiac' causes of OHCA were ischemic heart disease (n=126, 55%), cardiomegaly (n=26, 11.3%), cardiomyopathy (n=25, 11%), congenital heart disease (n=15, 6.5%), cardiac tamponade due to dissecting thoracic aorta aneurysm (n=10, 4.3%), myocarditis (n=8, 3.5%), arrhythmia (n=7, 3%), others (n=13, 5.7%). 'Non-cardiac' causes of OHCA were epilepsy/sudden unexplained death in epilepsy (SUDEP) (n=56, 25%), pulmonary embolism (n=29, 13%), subarachnoid haemorrhage (n=17, 7.7%), other intracranial bleed (n=7, 3.2%), pneumonia (n=17, 7.7%), DKA (n=16, 7.2%), other complications of diabetes mellitus (n=8, 3.6%), complications of obesity (n=9, 4%), haemorrhage (n=12, 5.4%), sepsis (n=8, 3.6%), peritonitis (n=6, 2.7%), aspiration (n=6, 2.7%), renal failure (n=5, 2.3%), asthma (n=5, 2.3%), complications of anorexia (n=3) and alcohol abuse (n=2), thyrotoxicosis (n=2), meningitis (n=1) and others (n=12). Compared with coroner's diagnosed 'non-cardiac' OHCAs, 'confirmed cardiac' were more likely to be witnessed (41% vs 23%, p≤0.01), receive bystander CPR (35% vs 20%, p≤0.001), have a shockable rhythm (27% vs 6.3%, p<0.001) and have EMS attempted resuscitation (62% vs 44%, p<0.001). DISCUSSION: Linking OHCA registries with coronial databases for aetiology of the arrest will improve the quality of the data and should be considered by all OHCA registries, particularly for young adult OHCA.

Cardiac arrest outcomes before and after the 2005 resuscitation guidelines implementation: evidence of improvement?

BACKGROUND: Previous studies have reported improvements in out-of-hospital cardiac arrest (OHCA) outcomes with the introduction of the 2005 cardiopulmonary resuscitation guidelines however they have not adjusted for underlying trends in OHCA survival. We compare outcomes before and after the 2005 guideline changes adjusting for underlying trends in OHCA survival. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for adult (≥16 years) OHCA of presumed cardiac aetiology, unwitnessed by paramedics with attempted resuscitation. Outcomes for OHCA occurring between 2003 and 2005 were compared with 2007-2009. Segmented regression analysis of interrupted time series data was performed, adjusting for known predictors, to examine changes in survival to hospital and survival to hospital discharge. RESULTS: For the pre- and post- guideline periods there were 3115 and 3248 OHCAs, respectively. Asystole increased as presenting rhythm (33-43%, p<0.001) as did median EMS response times (7.1-7.8 min, p<0.001) over the two periods. VF/VT arrests decreased (40-35.5%, p=0.001) as did bystander witnessed arrests (63-59%, p=0.002). On univariate analysis survival to hospital discharge improved between the two periods (9.4-11.8%, p=0.002) due to improved outcomes in VF/VT (19-28%, p<0.001). Segmented regression analysis of interrupted time series data showed improvement in the rate of survival to get to hospital for shockable and non-shockable rhythms [OR (95% CI)=1.54 (1.10-2.15, p=0.01) and 1.45 (1.10-2.00, p=0.02), respectively] following implementation of the guidelines however survival to hospital discharge did not improve [OR=1.07 (0.70-1.62, p=0.70) and 1.40 (0.69-2.85, p=0.40), respectively]. CONCLUSIONS: OHCA outcomes have improved since introduction of the 2005 CPR guidelines, but multivariable segmented regression analysis adjusting for pre-existing trends in survival suggests that this improvement may not be due to implementation of the 2005 resuscitation guidelines.

Out-of-hospital cardiac arrests in young adults in Melbourne, Australia.

BACKGROUND: Characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in young adults are not well described in Australia. METHODS: A 10-year retrospective case review of all OHCA in young adults (aged 16-39) and not witnessed by EMS, was performed using data from the Victorian Ambulance Cardiac Arrest Registry (VACAR). RESULTS: Between 2000 and 2009 there were 30,006 adult cardiac arrests of which 3912 (13%) were in this age group. The median (IQR) age was 30 (25-35) years for both sexes with a 3:1 male to female ratio. Overdose was the most common precipitant (33.5%) followed by presumed cardiac (20%). Bystander CPR occurred in 21.2%, EMS median response time was 7 min and resuscitation was attempted in 36% of OHCAs. The presenting rhythm was asystole in 84.6%, PEA in 8.8% and VF/VT in 6.6%. Survival to hospital discharge, for all cause OHCA where resuscitation was attempted, was similar for young adult and older adults (8.8% vs 8.4%, p=0.2). However, for presumed cardiac aetiology OHCA, young adults had a greater proportion of survivors (14.8% vs 9.0%, p<0.001). Cardiac arrest with shockable rhythm (VF/pulseless VT) had a survival rate of 31.2% for young adults compared to 18.5% for older adults (p<0.001). CONCLUSION: Survival to hospital discharge rates from OHCA due to a 'presumed cardiac' precipitant in young adults is much better than older adults, however, all cause OHCA survival is similar. Multi agency novel upstream preventive strategies aimed at tackling drug overdose may reduce this aetiology of OHCA and save lives.

Paediatric hanging associated out of hospital cardiac arrest in Melbourne, Australia: characteristics and outcomes.

INTRODUCTION: Hanging is a rare but devastating cause of out of hospital cardiac arrest (OHCA). The characteristics and outcomes of hanging associated OHCA in the paediatric age group are described. METHODS: The Victorian Ambulance Cardiac Arrest Registry was searched for patients aged less than 18 years where the precipitant cause of OHCA was hanging. Results were cross checked with the coronial database. RESULTS: During the years 2000-2009, there were 680 paediatric cardiac arrests of which 53 (7.8%) were precipitated by hanging with an incidence of 4.4 per million paediatric patients (<18 years) per year. Median age was 16 (IQR 14-17) years and 58.5% were males. Five were unintentional hangings; median age 3 (IQR 2-4) years. The youngest deliberate hanging associated OHCA was aged 10 years. Most hangings occurred in a house (85%) and bystander cardiopulmonary resuscitation (CPR) was performed in 30%. Asystole was the most common initial cardiac arrest rhythm seen in 50 cases (94%) while three patients had pulseless electrical activity. The emergency medical services (EMS) attempted resuscitation in 18 patients (34%), inserting an endotracheal tube in 13 patients. The majority (n=41) were not transported; seven patients were transported with return of spontaneous circulation (ROSC) and five patients were transported with ongoing CPR. Victims who had bystander CPR were more likely to have EMS attempted resuscitation (p<0.001). Only patients who had received bystander CPR achieved ROSC (p<0.001). Three patients survived to hospital discharge; two survivors suffered severe neurological injury (Cerebral Performance Category Scale 3-4). CONCLUSION: Non-intentional hanging is rare but deliberate hanging with suicidal intent represents a significant proportion of OHCAs in patients under 18 years of age. A focus on prevention is key, as outcomes are poor, with survivors likely to suffer a severe neurological insult.

Out-of-hospital cardiac arrests in the older age groups in Melbourne, Australia.

BACKGROUND: Controversy exists around CPR in the elderly. The characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in this age group were studied in Melbourne, Australia. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs not witnessed by Emergency Medical Services (EMS) occurring in those aged 65 years and older. RESULTS: Between 2000 and 2009 there were 30,006 OHCAs of which 9703 (32%) were in people 65-79 years of age, 6430 (21%) in octogenarians, 1530 (5%) in nonagenarian and 40 (0.1%) in centenarians. Rates of attempted resuscitation decreased with advancing age: 48% for those aged 65-79 years, 39% for octogenarians, 31% for nonagenarians and 17% for centenarians. Similarly rates of survival to hospital discharge decreased with age: 8% for those aged 65-79 years, 4% for octogenarians, 2% for nonagenarians; for 65-79 year olds, octogenarians and nonagenarians survival if in VF/VT was - 17%, 10% and 4%; asystole - 1%, 1% and 0.5%; and PEA - 6%, 3% and 3%, respectively. Multivariable logistic regression shows that between 2000 and 2009 rates of transportation with return of spontaneous circulation have improved for both shockable and non-shockable rhythms [OR 95% CI 1.07(1.04-1.10) and 1.16(1.12-1.20), respectively] but survival to hospital discharge has improved in the shockable rhythm group only [OR 1.12(1.07-1.16)]. CONCLUSION: Outcomes for OHCA with shockable rhythm have improved over the last 10 years for people aged 65 years and over. Quality of life studies should be performed to help inform the community and EMS on appropriate resuscitative efforts.