Survival from Out-of-Hospital Cardiac Arrest - Comparing the Automated LUCAS-2 Device and Manual CPR.

INTRODUCTION: Competency in and understanding of the factors impacting cardiopulmonary resuscitation (CPR) are key to emergency medicine. The purpose of this study was to assess the impact of the automated LUCAS-2 device on survival to emergency department (ED) compared to manual CPR as part of the EMS response using a large data set collected in a mostly rural U.S. state. METHODS: We conducted a retrospective analysis of South Dakota's electronic Patient Care Reports (ePCR) collected from Jan. 1, 2013 through Dec. 31, 2015. The primary outcome measure was survival to ED. RESULTS: A mechanical piston device (LUCAS-2), was utilized in 260 (15 percent) of 1,781 total cases during this period. The odds for survival to ED were calculated and compared between manual and LUCAS-2-assisted CPR. The odds ratio for survival to ED using compressions alone was 3.94 compared to LUCAS-2 and those results persisted after adjusting for significant covariates. DISCUSSION: Despite hemodynamic benefits associated with the LUCAS-2 device in the laboratory and in other settings, this and other studies indicate that compression-only CPR outperforms automation-assisted CPR during OHCA. However, the data also suggest that enhanced training of emergency providers to improve response times and levels of expertise with the equipment may improve the outcomes associated with the LUCAS-2 and it is recommended that further training should be pursued.

Use of Midazolam for Minimal Sedation in Pediatric Outpatients: A Survey Analysis of Patient Experience and Parent-Guardian Satisfaction.

BACKGROUND: Use of procedural sedation to promote anxiolysis, analgesia, and amnesia enhances both pediatric patient experience and procedural outcomes. Sanford Children's outpatient sedation clinic currently uses oral midazolam for minimal sedation. METHODS: A research survey was designed to evaluate parent/guardian satisfaction with midazolam for pediatric sedation in simple outpatient procedures including, bot linum toxin injections, voiding cystourethrogram (VCUG), and intravenous line placement. Parents'/ guardians' understanding of the sedation and procedural logistics were surveyed and their satisfaction with the child's comfort, recovery time, and overall satisfaction were assessed. Each component was rated on a scale of 1-10, 1 being not satisfied and 10 as extremely satisfied. RESULTS: The study was conducted at a single pediatric outpatient center. Forty-one parents/guardians of patients aged 22 months-17 years were recruited; of these, 41 consented and enrolled in the study. Average age was 6.1 years with 22 females and 19 males. Of the surveys collected, 30 were botulinum toxin injections, eight VCUG, one contrast enema, and two were not recorded. Mean survey results were 8.7 (95 percent CI, 8.2-9.2) for satisfaction of recovery time, 8.0 (95 percent CI, 7.4-8.6) for control of discomfort and 8.4 (95 percent CI, 7.9-8.9) for overall satisfaction. CONCLUSION: When evaluating midazolam as a sedation agent in pediatric procedures, parents/guardians were most satisfied with the duration of recovery and had the lowest satisfaction on control of the patient's discomfort. Overall, it can be concluded that midazolam is a moderately good agent for pediatric patients receiving minimal sedation, with the greatest satisfaction in the duration of recovery.

Using Data Science to Provide Preliminary Estimates of Out-of-Hospital Cardiac Arrest in Rural South Dakota.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is the cessation of electric or mechanical activity of the heart, confirmed by absence of circulation. Survival to hospital dismissal rates have remained low nationwide despite considerable effort to improve treatment. Current initiatives seek systems approaches that optimize care at each point along the "chain of survival." Systems approaches rely on the availability of robust data sets to understand and control variables that can be highly interdependent. The current report seeks to provide a source of reliable data of OHCA for South Dakota. METHODS: Using the "Utstein" guidelines for reviewing and reporting OHCA resuscitations issued by the American Heart Association in 2014, we analyzed the EMS data that were captured by ePCR between January 1, 2013 and December 31, 2015. Inclusion criteria were 911 calls in 2013-2015, where first impression of the call was cardiac arrest. Exclusion criteria were inconsistent and missing data. RESULTS: There were 1,781 OHCA in the ePCR, and 1,280 cases had survival information, with 378 victims surviving to ED. Overall, SD OHCA rates were lower than those reported nationally. Survival was the highest in patients with a shockable rhythm and when victim received bystander CPR. The odds for survival were greater if the arrest took place in an urban setting compared to a rural setting and if the victim received care from an EMS unit that did not have a "hardship" designation. DISCUSSION: Recommendations for future efforts include: (1) Develop and employ quality improvement methodologies for data collection and utilization to minimize the impact of poor or missing data, (2) Assess the educational and training needs of the EMS staff to properly collect, analyze, and develop actionable outputs, (3) Provide public training to include hands-only CPR and PulsePoint.

Kidneys and commonly used medications: how to reduce risk of acute kidney injury in everyday practice?

Medications are a common cause of acute kidney injury (AKI). There are various mechanisms that medications can induce AKI, and a better understanding of this pathophysiology can aid in clinician recognition, treatment and prevention. Hemodynamic-mediated AKI is often associated with drugs that alter renal perfusion and its autoregulation. Acute tubular injury is the result of direct renal tubular cell toxicity. Acute interstitial nephritis is a T-cell mediated immune hypersensitivity reaction to drugs leading to tubule-interstitial inflammation and AKI. Crystalline nephropathy can be caused by medications themselves that crystalize or from the altered urinary chemistries caused by medications. Some medications can cause AKI through uncommon mechanisms such as glomerulonephritis and thrombotic microangiopathy. Notably, some medications may cause a phenomenon called "pseudo-AKI" where serum creatinine is elevated without a true reduction in kidney function. Commonly used medications in clinical practice are reviewed with the focus on mechanisms of injury, diagnosis, treatment, and prevention. Recognizing the common medications that are associated with AKI is an important first step in reducing the risk of AKI. For each medication, understanding general and specific risk factors for AKI allows for early identification and timely discontinuation of offending agents. These measures will help mitigate the risk of AKI and promote renal recovery.