Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital.
(65/2311)
OBJECTIVES: The purpose of this study was to evaluate the efficacy of an alternative cardiopulmonary cerebral resuscitation (CPCR) using emergency cardiopulmonary bypass (CPB), coronary reperfusion therapy and mild hypothermia. BACKGROUND: Good recovery of patients with out-of-hospital cardiac arrest is still inadequate. An alternative therapeutic method for patients who do not respond to conventional CPCR is required. METHODS: A prospective preliminary study was performed in 50 patients with out-of-hospital cardiac arrest meeting the inclusion criteria. Patients were treated with standard CPCR and, if there was no response, by emergency CPB plus intra-aortic balloon pumping. Immediate coronary angiography for coronary reperfusion therapy was performed in patients with suspected acute coronary syndrome. Subsequently, in patients with systolic blood pressure above 90 mm Hg and Glasgow coma scale score of 3 to 5, mild hypothermia (34 C for at least two days) was induced by coil cooling. Neurologic outcome was assessed by cerebral performance categories at hospital discharge. RESULTS: Thirty-six of the 50 patients were treated with emergency CPB, and 30 of 39 patients who underwent angiography suffered acute coronary artery occlusion. Return of spontaneous circulation and successful coronary reperfusion were achieved in 92% and 87%, respectively. Mild hypothermia could be induced in 23 patients, and 12 (52%) of them showed good recovery. Factors related to a good recovery were cardiac index in hypothermia and the presence of serious complications with hypothermia or CPB. CONCLUSIONS: The alternative CPCR demonstrated an improvement in the incidence of good recovery. Based upon these findings, randomized studies of this hypothermia are needed. (+info)
Time to presentation with acute myocardial infarction in the elderly: associations with race, sex, and socioeconomic characteristics.
(66/2311)
BACKGROUND: Although prompt treatment is a cornerstone of the management of acute myocardial infarction (AMI), prior studies have shown that one fourth of AMI patients arrive at the hospital >6 hours after symptom onset. It would be valuable to identify individuals at highest risk for late arrival, but predisposing factors have yet to be fully characterized. METHODS AND RESULTS: Data from the Cooperative Cardiovascular Project, involving Medicare beneficiaries aged >65 years hospitalized between January 1994 and February 1996 with confirmed AMI, were used to identify patients who presented "late" (>/=6 hours after symptom onset). Patient characteristics were tested for associations with late presentation by use of backward stepwise logistic regression. Among 102 339 subjects, 29.4% arrived late. Significant predictors of late arrival (odds ratio, 95% CI) included diabetes (1.11, 1.07 to 1.14) and a history of angina (1.32, 1.28 to 1.35), whereas prior MI (0.82, 0.79 to 0.85), prior angioplasty (0.80, 0.75 to 0.85), prior bypass surgery (0.93, 0.89 to 0.98), and cardiac arrest (0.52, 0.46 to 0. 58) predicted early presentation. Additionally, initial evaluation at an outpatient clinic (2.63, 2.51 to 2.75) and daytime presentation (1.67, 1.59 to 1.72) predicted late arrival. Finally, female sex, black race, and poverty, which were evaluated with an 8-level race-sex-socioeconomic status interaction term, were also risk factors for delay. CONCLUSIONS: Delayed hospital presentation is a common problem among Medicare beneficiaries with AMI. Factors associated with delay include not only clinical and logistical issues but also race, sex, and socioeconomic characteristics. Education efforts designed to hasten AMI treatment should be directed at individuals with risk factors for late arrival. (+info)
Profile and outcomes of patients transported to an accident and emergency department by helicopter: prospective case series.
(67/2311)
OBJECTIVES: To study the profile of airlifted patients and their outcomes after arrival at the hospital, and to evaluate the appropriateness of their prehospital care and the decision to use aeromedical evacuation. DESIGN: Prospective case series. SETTING: Accident and emergency department of a public hospital, Hong Kong. PATIENTS: All patients transported to the department by a helicopter of the Government Flying Service from June 1998 through November 1998. MAIN OUTCOME MEASURES: Demographic data, sources and locations of referral, clinical features, triage category, interventions used, and outcome. RESULTS: A total of 186 patients were transferred by helicopter during the 6-month study period. The 101 patients who had been transferred from a rural hospital or clinic were older (mean age, 50 years versus 35 years), comprised more females (55% versus 26%), had a higher overall mortality rate (19.8% versus 3.6%), and had a higher hospital admission rate (91.1% versus 37.6%) than the 85 patients who had been airlifted from the scene of an emergency. Neurological disorders were the most common presentation among interfacility transfers (21.8%). Among the 85 scene transfers, limb injuries (32.1%) and heat illnesses (24.4%) were the most common reasons for helicopter transport. Most interfacility transfers were appropriate, but 34.1% of patients who had been transferred from the scene of the emergency were later discharged and 21.1% refused consultation. CONCLUSIONS: Scene and interfacility transfers by helicopter have different patient profiles, and a substantial proportion of scene transfers may be inappropriate. Guidelines such as field triage and helicopter dispatch criteria need to be established. (+info)
Prehospital care in Hong Kong.
(68/2311)
A quick and efficient prehospital emergency response depends on immediate ambulance dispatch, patient assessment, triage, and transport to hospital. During 1999, the Ambulance Command of the Hong Kong Fire Services Department responded to 484,923 calls, which corresponds to 1329 calls each day. Cooperation between the Fire Services Department and the Hospital Authority exists at the levels of professional training of emergency medical personnel, quality assurance, and a coordinated disaster response. In response to the incident at the Hong Kong International Airport in the summer of 1999, when an aircraft overturned during landing, the pre-set quota system was implemented to send patients to designated accident and emergency departments. Furthermore, the 'first crew at the scene' model has been adopted, whereby the command is established and triage process started by the first ambulance crew members to reach the scene. The development of emergency protocols should be accompanied by good field-to-hospital and interhospital communication, the upgrading of decision-making skills, a good monitoring and auditing structure, and commitment to training and skills maintenance. (+info)
Emergency management of poisoning in Hong Kong.
(69/2311)
The emergency management of poisoning is important in reducing the risk of mortality and morbidity in poisoned patients. This article reviews the Hong Kong system of prehospital and emergency care of poisoning, with reference to recent advances in this field. Administering activated charcoal is recommended for the gastro-intestinal decontamination of most poisons, unless doing so is contra-indicated. Gastric lavage should be considered only in life-threatening cases of poisoning that present within the first hour. Newer antidotes that are available in Hong Kong accident and emergency departments include hydroxocobalamin, stonefish and snake antevenenes, digoxin-specific antibodies, esmolol hydrochloride, and octreotide. The 'golden hour' concept of gastro-intestinal decontamination is advocated and ways to ensure that decontamination is performed within the 'golden hour' are suggested. (+info)
Determinants of use of emergency medical services in a population with stroke symptoms: the Second Delay in Accessing Stroke Healthcare (DASH II) Study.
(70/2311)
BACKGROUND AND PURPOSE: With the advent of time-dependent thrombolytic therapy for ischemic stroke, it has become increasingly important for stroke patients to arrive at the hospital quickly. This study investigates the association between the use of emergency medical services (EMS) and delay time among individuals with stroke symptoms and examines the predictors of EMS use. METHODS: The Second Delay in Accessing Stroke Healthcare Study (DASH II) was a prospective study of 617 individuals arriving at emergency departments in Denver, Colo, Chapel Hill, NC, and Greenville, SC, with stroke symptoms. RESULTS: EMS use was associated with decreased prehospital and in-hospital delay. Those who used EMS had a median prehospital delay time of 2.85 hours compared with 4.03 hours for those who did not use EMS (P:=0.002). Older individuals were more likely to use EMS (odds ratio [OR] 1.21 for each 5-year increase, 95% CI 1.14 to 1.29), as were individuals who expressed a high sense of urgency about their symptoms (OR 1.69, 95% CI 1.09 to 2.62). Knowledge of stroke symptoms was not associated with increased EMS use (OR 0.63, 95% CI 0.40 to 0.98). Patients were more likely to use EMS if someone other than the patient first identified that there was a problem (OR 2.35, 95% CI 1.61 to 3.44). CONCLUSIONS: Interventions aimed at increasing EMS use among stroke patients need to stress the urgency of stroke symptoms and the importance of calling 911 and need to be broad-based, encompassing not only those at high risk for stroke but also their friends and family. (+info)
Outcome of "out of hospital" cardiopulmonary arrest in children admitted to the emergency room.
(71/2311)
BACKGROUND: The outcome of cardiopulmonary arrest in children is poor, with many survivors suffering from severe neurological defects. There are few data on the survival rate following cardiopulmonary arrest in children who arrived at the emergency room without a palpable pulse. OBJECTIVE: To determine the survival rate and epidemiology of cardiopulmonary arrest in children who arrived without a palpable pulse at a pediatric ER in southern Israel. METHODS: We retrospectively reviewed the medical records of all patients with cardiopulmonary arrest who arrived at the ER of the Soroka University Medical Center during the period January 1995 to June 1997. RESULTS: The study group included 35 patients. Resuscitation efforts were attempted on 20, but the remaining 15 showed signs of death and were not resuscitated. None of the patients survived, although one patient survived the resuscitation but succumbed a few hours later. The statistics show that more cardiopulmonary arrests occurred among Bedouins than among Jews (32 vs. 3, P < 0.0001). CONCLUSIONS: The probability of survival from cardiopulmonary arrest in children who arrive at the emergency room without palpable pulse is extremely low. Bedouin children have a much higher risk of suffering from out-of-hospital cardiopulmonary arrest than Jewish children. (+info)
A national census of ambulance response times to emergency calls in Ireland.
(72/2311)
BACKGROUND: Equity of access to appropriate pre-hospital emergency care is a core principle underlying an effective ambulance service. Care must be provided within a timeframe in which it is likely to be effective. A national census of response times to emergency and urgent calls in statutory ambulance services in Ireland was undertaken to assess current service provision. METHODS: A prospective census of response times to all emergency and urgent calls was carried out in the nine ambulance services in the country over a period of one week. The times for call receipt, activation, arrival at and departure from scene and arrival at hospital were analysed. Crew type, location of call and distance from ambulance base were detailed. The type of incident leading to the call was recorded but no further clinical information was gathered. Results-2426 emergency calls were received by the services during the week. Fourteen per cent took five minutes or longer to activate (range 5-33%). Thirty eight per cent of emergencies received a response within nine minutes (range 10-47%). Only 4.5% of emergency calls originating greater than five miles from an ambulance station were responded to within nine minutes (range 0-10%). Median patient care times for "on call" crews were three times longer than "on duty" crews. CONCLUSION: Without prioritized use of available resources, inappropriately delayed responses to critical incidents will continue. Recommendations are made to improve the effectiveness of emergency medical service utilisation. (+info)