Utilization of thromboelastograms in management of Crotalus adamanteus envenomation.

BACKGROUND: Crotalinae (pit viper) envenomations are frequently encountered in North American emergency departments. Cases can be complicated by ambiguity in initial species identification as well as timing and duration of current antivenin treatment. Recently, thromboelastography (TEG) has emerged as an enhanced real-time monitoring parameter for snake envenomations that may aid in management of venom-induced consumptive coagulopathy. CASE: A 61-year-old snake handler presented with severe coagulopathy and hypofibrinogenemia following envenomation from her pet eastern diamondback rattlesnake (Crotalus adamanteus). Her coagulopathy transiently improved with Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) but would repeatedly rebound following cessation of antivenin over the next 10 days. Serial TEGs were successfully utilized to identify and corroborate fibrinolysis while predicting clot formation prior to routine coagulation studies. DISCUSSION: Traditional coagulation parameters have not always been ideal when treating severe coagulopathy from pit viper envenomations and may not identify active fibrinolysis for several hours. In this case of C. adamanteus envenomation, TEG proved to be useful in demonstrating improvements in clotting function prior to standard laboratory measures, which further guided antivenin therapy.

Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association.

Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.

The AURORA Study: a longitudinal, multimodal library of brain biology and function after traumatic stress exposure.

Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, postconcussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/treatment interventions. Progress in overcoming these limitations has been challenging because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large-scale (n = 5000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for 1 year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.

Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium.

BACKGROUND: Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (ROC). METHODS: Included were consecutive adults OHCA treated by participating emergency medical services (EMS) agencies between June 1, 2011, and June 30, 2015. We defined BLS as receipt of cardiopulmonary resuscitation (CPR) and/or automated defibrillation and ALS as receipt of an advanced airway, manual defibrillation, or intravenous drug therapy. We compared outcomes among patients receiving: 1) BLS-only; 2) BLS + late ALS; 3) BLS + early ALS; and 4) ALS-first care. Using multivariable logistic regression, we evaluated the associations between level of care and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with good functional status, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, EMS response time, CPR quality, and ROC site. RESULTS: Among 35,065 patients with OHCA, characteristics were median age 68 years (IQR 56-80), male 63.9%, witnessed arrest 43.8%, bystander CPR 50.6%, and shockable initial rhythm 24.2%. Care delivered was: 4.0% BLS-only, 31.5% BLS + late ALS, 17.2% BLS + early ALS, and 47.3% ALS-first. ALS care with or without initial BLS care was independently associated with increased adjusted ROSC and survival to hospital discharge unless delivered greater than 6 min after BLS arrival (BLS + late ALS). Regardless of when it was delivered, ALS care was not associated with significantly greater functional outcome. CONCLUSION: ALS care was associated with survival to hospital discharge when provided initially or within six minutes of BLS arrival. ALS care, with or without initial BLS care, was associated with increased ROSC, however it was not associated with functional outcome.

Variations in survival after cardiac arrest among academic medical center-affiliated hospitals.

BACKGROUND: Variation exists in cardiac arrest (CA) survival among institutions. We sought to determine institutional-level characteristics of academic medical centers (AMCs) associated with CA survival. METHODS: We examined discharge data from AMCs participating with Vizient clinical database-resource manager. We identified cases using ICD-9 diagnosis code 427.5 (CA) or procedure code 99.60 (CPR). We estimated hospital-specific risk-standardized survival rates (RSSRs) using mixed effects logistic regression, adjusting for individual mortality risk. Institutional and community characteristics of AMCs with higher than average survival were compared with those with lower survival. RESULTS: We analyzed data on 3,686,296 discharges in 2012, of which 33,700 (0.91%) included a CA diagnosis. Overall survival was 42.3% (95% CI 41.8-42.9) with median institutional RSSR of 42.6% (IQR 35.7-51.0; Min-Max 19.4-101.6). We identified 28 AMCs with above average survival (median RSSR 61.8%) and 20 AMCs with below average survival (median RSSR 26.8%). Compared to AMCs with below average survival, those with high CA survival had higher CA volume (median 262 vs.119 discharges, p = 0.002), total beds (722 vs. 452, p = 0.02), and annual surgical volume (24,939 vs. 13,109, p<0.001), more likely to offer cardiac catheterization (100% vs. 72%, p = 0.007) or cardiac surgery (93% vs. 61%, p = 0.02) and cared for catchment areas with higher household income ($61,922 vs. $49,104, p = 0.004) and lower poverty rates (14.6% vs. 17.3%, p = 0.03). CONCLUSION: Using discharge data from Vizient, we showed AMCs with higher CA and surgical case volume, cardiac catheterization and cardiac surgery facilities, and catchment areas with higher socioeconomic status had higher risk-standardized CA survival.

Association of advanced airway device with chest compression fraction during out-of-hospital cardiopulmonary arrest.

BACKGROUND: Select Emergency Medical Services (EMS) practitioners substitute endotracheal intubation (ETI) with supraglottic airway (SGA) insertion to minimize CPR chest compression interruptions, but the resulting effects upon chest compression fraction (CCF) are unknown. We sought to determine the differences in CCF between adult out-of-hospital cardiac arrest (OHCA) receiving ETI and those receiving SGA. METHODS: We studied adult, non-traumatic OHCA patients enrolled in the Resuscitation Outcomes Consortium (ROC) Prehospital Resuscitation using an Impedance valve and an Early vs. Delayed analysis (PRIMED) trial. Chest compressions were measured using compression or thoracic impedance sensors. We limited the analysis to those receiving ETI or SGA (Combitube, King Laryngeal Tube, or Laryngeal Mask Airway) and >2min of chest compression data before and after airway insertion. We compared CCF between ETI and SGA before and after airway insertion, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, PRIMED trial arm, and regional ROC center. We also compared the change in CCF for each airway technique. RESULTS: Of 14,955 patients enrolled in the ROC PRIMED trial, we analyzed 2767 cases, including 2051 ETI, 671 SGA, and 45 both. Among subjects in this investigation the mean age was 66.4 years with a male predominace, 46% with witnessed event, 37% receiving bystander CPR, and 22% presenting with an initially shockable rhythm. Pre- and post-airway CCF was higher for SGA than ETI (SGA pre-airway CCF 73.2% [95%CI: 71.6-74.7%] vs. ETI 70.6% [95%CI: 69.7-71.5%]; post-airway 76.7% [95%CI: 75.2-78.1%] vs. 72.4% [95%CI: 71.5-73.3%]). After adjusting for potential confounders, these significant changes persisted (pre-airway difference 2.2% favoring SGA, p-value=0.046; post-airway 3.4% favoring SGA, p=0.001). CONCLUSION: In patients with OHCA, we detected a slightly higher rate of CCF in patients for whom a SGA was inserted, both before and after insertion. However, the actual differences were so small, that in the context of this observational, secondary analysis, it is unclear if this represents a clinically significant difference.

External validation of termination of resuscitation guidelines in the setting of intra-arrest cold saline, mechanical CPR, and comprehensive post resuscitation care.

BACKGROUND: The development of advanced life support (ALS) termination of resuscitation (TOR) guidelines for out-of-hospital cardiac arrest (OHCA) seeks to improve the efficiency of scarce pre-hospital resources. However, as pre-hospital treatment for OHCA evolves and survival improves, these TOR guidelines must be reevaluated in the contemporary context of emergency medical services (EMS) providing access to advanced resuscitation care. METHODS: Retrospective review of all adult (>18 years old), non-traumatic, OHCA patients (defined as patients with absence of pulse who received either CPR and/or defibrillation) treated by EMS in Richmond, VA, from January 1, 2009 to December 31, 2010. In addition to standard ALS, intra-arrest cold saline, mechanical CPR, and transportation to a comprehensive post-resuscitation center (CPRC) was provided. Patient treatment and outcomes were recorded via prehospital patient care reports and data were evaluated against previously established criteria for termination of resuscitation in an ALS EMS system. According to the aforementioned previously described criteria for TOR, patients meeting a single criterion for transport are recommended to be transported emergently to a comprehensive post-resuscitation care facility. Conversely, patients failing to meet any of the TOR criteria can be presumed to be expired without exception. Survival at 180 days was presumed when death could not be verified from publically reportable sources. RESULTS: Of the 322 OHCA patients enrolled, the majority were male (59%), unwitnessed (52%), received no bystander CPR (67%), and presented in a non-shockable initial rhythm (79%), with an average age of 62.5 years. Overall survival was 17%, 14%, 12%, and 11% at 7, 14, 30, and 180 days, respectively. Of the 75 patients for which TOR guidelines recommended termination, none survived yielding both 100% specificity (95% CI 100-92.8%) and positive predictive value (95% CI 100-94.1%). However, TOR guidelines recommended transport of 208 of the 283 patients who died within 30 days, resulting in a sensitivity of 26.5% (95% CI 34.5-23.4%). CONCLUSION: The TOR guidelines continue to have a reliable positive predictive value for death even in the setting of advanced EMS resuscitation methods and access to a CPRC. However, as the potential for survival from OHCA improves, the efficiency gained from their use is impacted greatly.

Estimating the impact of off-balancing forces upon cardiopulmonary resuscitation during ambulance transport.

INTRODUCTION: Survival from out-of-hospital cardiac arrest (OOH-CA) remains poor, especially when patients are transported with CPR in progress. Previous investigations suggest that CPR quality erodes during transport due to the austere environment. We sought to determine how frequently ambulance personnel are exposed to off-balancing forces during transport of OOH-CA patients and to estimate the potential impact on CPR and coronary perfusion pressure (CPP). METHODS: An onboard monitoring system was utilized to record acceleration data during the transport of 50 OOH-CA patients. Acceleration vectors were calculated for every second of drive time (speed >0 m/s). A model was constructed to estimate the potential impact of these vectors upon CPR and CPP. These data were then compared to a case-control cohort of 102 matched non-urgent transports. RESULTS: A total of 5.8h of drive time was analyzed in the cardiac arrest cohort. Mean transport time was 8 min 53 s with a mean drive time of 6 min 58 s. Critical acceleration threshold was exceeded 60% of transport time (202.42 min, mean 4.05 min/transport) yielding a potential hands-off ratio of 0.42 with a CPP<15 mmHg 62% of drive time. Ambulance speed was inversely related to the magnitude of off-balancing forces. Comparison to 14.1h of control cohort yielded similar off-balancing forces and relationships despite lower speeds and no "lights and siren" use. CONCLUSION: Critical acceleration forces occur frequently during transport of OOH-CA patients and may directly effect CPR quality and thereby CPP. These force vectors are stronger and more frequent at slower speeds, comprising the majority of ambulance drive time. Reducing speed or transporting OOH-CA patients without lights and sirens does little to mitigate these forces.