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Götzinger F, Lauder L, Sharp ASP, Lang IM, Rosenkranz S, Konstantinides S, Edelman ER, Böhm M, Jaber W, Mahfoud F. Interventional therapies for pulmonary embolism. Nat Rev Cardiol 2023; 20:670-684. [PMID: 37173409 PMCID: PMC10180624 DOI: 10.1038/s41569-023-00876-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.
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Affiliation(s)
- Felix Götzinger
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Lucas Lauder
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Irene M Lang
- Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stephan Rosenkranz
- Department of Cardiology - Internal Medicine III, Cologne University Heart Center, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Böhm
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Felix Mahfoud
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany.
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Makonnen N, Layng T, Hartka T. Comparison of mortality in emergency department patients with immediate versus delayed hypotension. Am J Emerg Med 2023; 72:1-6. [PMID: 37437384 DOI: 10.1016/j.ajem.2023.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Hypotension in the emergency department (ED) is known to be associated with increased mortality, however, the relationship between timing of hypotension and mortality has not been investigated. The objective of the study was to compare the mortality rate of patients presenting with hypotension with those who develop hypotension while in the ED. METHODS This was a retrospective cohort study in a large academic medical center collected from January 2018-December 2021. Patients were included if they were ≥ 18 years old and had at least one recorded systolic blood pressure (SBP) ≤ 90 in the ED. Patients were separated into medical and trauma presentations by chief compliant. The primary outcome was in-hospital mortality, which included any deaths between ED arrival and hospital discharge. Further analysis examined the association of time to the first hypotensive SBP measurement with mortality. RESULTS There were 212,085 adult patients who presented to the ED during the study period, with 4053 (1.9%) patients having at least one hypotensive blood pressure measurement. The mortality rate was 0.8% for all patients and 10.0% for patients with hypotension. There were 676 unique chief complaints, of which 86 (12.7%) were determined to be trauma related. This grouping resulted in 176,947(83.4%) patients classified as medical and 35,138(16.6%) patients as trauma. For patients presenting with medical complaints, there was not a significant difference in mortality for patients who were hypotensive on arrival and those who developed hypotension during their ED stay (RR 1.19 [95% CI:0.97-1.39]). Similarly, there was no difference for patients with trauma (RR 0.6 [95% CI: 0.31-1.24]). However, for all patients, there was a significant trend toward decreased mortality for every hour after arrival until the development of hypotension, and increased mortality with increasing number of hypotensive measurements recorded. CONCLUSION This study demonstrated hypotension in the ED was associated with a very significantly increased risk of in-hospital mortality. However, there was no significant increase in mortality between those patients with hypotension on arrival those who develop hypotension while in the ED. These finding underscore the importance of careful hemodynamic monitoring for patients in the ED throughout their stay.
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Affiliation(s)
- Nardos Makonnen
- International Emergency Medicine and Global Public Health Fellow, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037, United States of America.
| | - Timothy Layng
- Emergency Medicine, University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22903, United States of America
| | - Thomas Hartka
- Emergency Medicine, University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22903, United States of America
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3
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Peach M, Milne J, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Henneberry R, Fraser J, Chandra K, Howlett M, Mekwan J, Ramrattan B, Middleton J, van Hoving N, Taylor L, Dahn T, Hurley S, MacSween K, Richardson L, Stoica G, Hunter S, Olszynski P, Chandra K, Lewis D, Atkinson P. Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators. CAN J EMERG MED 2023; 25:48-56. [PMID: 36577931 DOI: 10.1007/s43678-022-00431-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/30/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension. METHODS This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis. RESULTS Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9-98.5) vs.93.8% (87.7-97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88-97.2) vs 93.6% (87.8-97.2)]. Diagnostic performance measures were similar across sub-categories of shock. CONCLUSION This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.
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Affiliation(s)
- M Peach
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - J Milne
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Fraser Health Authority, Vancouver, BC, Canada
| | - L Diegelmann
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, USA
| | - H Lamprecht
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - M Stander
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - D Lussier
- Department of Emergency Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - C Pham
- Department of Emergency Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - R Henneberry
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - J Fraser
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
| | - K Chandra
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - M Howlett
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - J Mekwan
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - B Ramrattan
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - J Middleton
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - N van Hoving
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - L Taylor
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
| | - T Dahn
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - S Hurley
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - K MacSween
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - L Richardson
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - G Stoica
- Research Services, Horizon Health Network, Saint John, NB, Canada
| | - Samuel Hunter
- Faculty of Science, University of Ottawa, Ottawa, ON, Canada
| | - P Olszynski
- Department of Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada
| | - K Chandra
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - D Lewis
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - P Atkinson
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada.
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada.
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada.
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Quinn E, Su J, Fei L, Liu J, Friedman M, Lobel D, Kabiriti S, Likourezos A, Motov S, Eng D. Perceptions and Barriers to Administering Vasopressors in the Prehospital Setting. Cureus 2022; 14:e29614. [PMID: 36321024 PMCID: PMC9603066 DOI: 10.7759/cureus.29614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Vasopressor administration is a critical medical intervention for patients with hypotension in undifferentiated shock states. Over the years, prehospital care has advanced with protocols and training that allow paramedics in the field to administer a variety of vasopressors. The primary objective of this investigation was to evaluate vasopressor experience among paramedics with regard to preference as well as the barriers to its preparation and administration. Methods A cross-sectional survey of vasopressor use by nationally certified paramedics (NRPs) was performed. A 20-item questionnaire was constructed to capture the prehospital perceptions and barriers of dopamine infusion, norepinephrine infusion, and IV bolus “push-dose” epinephrine (PD-E). Data collection was carried out from June to September 2021. Results A total of 44 responses were obtained (response rate = 44%). All participants had experience using vasopressors and understood their medical indications. Overall, PD-E was the most common vasopressor used in the prehospital setting, and participants felt equally confident in “using” and “preparing” it. Participants felt less confident with “using” and “preparing” vasopressors that required channel setup and maintaining a flow rate. Younger paramedics with less than five years of experience were more eager to use norepinephrine if trucks were stocked with pre-mixed norepinephrine rather than the current formulation that required compounding. Conclusion This study provided preliminary data that evaluated perceptions of vasopressor use in the prehospital setting among paramedics in a large urban environment. Preference and barriers to its preparation and administration were surveyed. Further research is needed to identify the interventions to reduce barriers and allow paramedics to be less limited by logistical considerations when choosing vasopressors in the prehospital setting.
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Bloom JE, Andrew E, Dawson LP, Nehme Z, Stephenson M, Anderson D, Fernando H, Noaman S, Cox S, Milne C, Chan W, Kaye DM, Smith K, Stub D. Incidence and Outcomes of Nontraumatic Shock in Adults Using Emergency Medical Services in Victoria, Australia. JAMA Netw Open 2022; 5:e2145179. [PMID: 35080603 PMCID: PMC8792885 DOI: 10.1001/jamanetworkopen.2021.45179] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Nontraumatic shock is a challenging clinical condition, presenting urgent and unique demands in the prehospital setting. There is a paucity of data assessing its incidence, etiology, and clinical outcomes. OBJECTIVE To assess the incidence, etiology, and clinical outcomes of patients treated by emergency medical services (EMS) with nontraumatic shock using a large population-based sample. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study included consecutive adult patients with shock not related to trauma who received care by EMS between January 1, 2015, and June 30, 2019, in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. During the study period there were 2 485 311 cases attended by EMS, of which 16 827 met the study's inclusion criteria for shock. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day mortality. Secondary outcomes included length of hospital stay, emergency department discharge disposition, rates of coronary angiography and revascularization procedures, and the use of mechanical circulatory support. RESULTS A total of 12 695 patients were successfully linked, with a mean (SD) age of 65.7 (19.1) years; 6411 (50.5%) were men. The overall population-wide incidence of EMS-treated prehospital shock was 76 (95% CI, 75-77) per 100 000 person-years. An increased incidence was observed in men (79 [77-81] per 100 000 person-years), older patients (eg, aged 70-79 years: 177 [171-183] per 100 000 person-years), regional locations (outer regional or remote: 100 [94-107] per 100 000 person-years), and in areas with increased socioeconomic disadvantage (lowest socioeconomic status quintile: 92 [89-95] per 100 000 person-years). Patients with hospital outcome data were stratified into shock etiologies; 3615 (28.5%) had cardiogenic shock: 3998 (31.5%), septic shock; 1457 (11.5%), hypovolemic shock; and 3625 (28.6%), other causes of shock. Nearly one-third of patients (4158 [32.8%]) were deceased at 30 days. In multivariable analyses, increased age (all etiologies: hazard ratio [HR], 1.04; 95% CI, 1.03-1.04), female sex (cardiogenic shock: HR, 1.26; 95% CI, 1.12-1.42), increased initial heart rate (all etiologies: 1.01; 95% CI, 1.00-1.01), prehospital intubation (all etiologies: HR, 3.93; 95% CI, 3.48-4.44), and preexisting comorbidities (eg, chronic kidney disease, all etiologies: HR, 1.25; 95% CI, 1.10-1.42) were independently associated with 30-day mortality, while higher socioeconomic status (all etiologies: HR, 0.96; 95% CI, 0.94-0.98) and increased initial systolic blood pressure (all etiologies: HR, 0.99; 95% CI, 0.99-0.99) were associated with lower risk. CONCLUSIONS AND RELEVANCE This population-level cohort study found that EMS-treated nontraumatic shock was a common condition, with a high risk of morbidity and mortality regardless of etiology. It disproportionately affected men, older patients, patients in regional areas, and those with social disadvantage. Further studies are required to assess how current systems of care can be optimized to improve outcomes.
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Affiliation(s)
- Jason E. Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
| | - Emily Andrew
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Luke P. Dawson
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Michael Stephenson
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - David Anderson
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
| | - Shelley Cox
- Ambulance Victoria, Blackburn, Victoria, Australia
| | | | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
| | - David M. Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Western Health, St Albans, Victoria, Australia
- Ambulance Victoria, Blackburn, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Präklinische Bluttransfusion bei lebensbedrohlicher Blutung – erweiterte lebensrettende Therapieoptionen durch das Konzept Medical Intervention Car. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00897-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungDas Medical Intervention Car (MIC) der Klinik für Anästhesiologie des Universitätsklinikums Heidelberg (UKHD) stellt ein neuartiges experimentelles Versorgungskonzept dar, welches zusätzliche Expertise und bisher nur innerklinisch etablierte Interventionen in der Präklinik verfügbar macht. Hierzu zählen die Transfusion von Blutprodukten, die Notfallthorakotomie, die „resuscitative endovascular balloon occlusion of the aorta“ (REBOA) sowie die Möglichkeit zur extrakorporalen kardiopulmonalen Reanimation (eCPR). Anhand der Fallvorstellung eines jungen Patienten, der sich mit einer Kettensäge in der Leiste verletzte und einen hämorrhagisch bedingten Kreislaufstillstand erlitt, wird insbesondere die Möglichkeit der lebensrettenden Transfusion diskutiert. In diesem Einsatz führte ein integratives präklinisches Versorgungskonzept, bestehend aus Rettungswagen, Notarzteinsatzfahrzeug und MIC, zur Wiederherstellung des Spontankreislaufs und einer vollständigen zerebralen Erholung des Patienten.
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Lenz TJ, Phelan MB, Grawey T. Determining a Need for Point-of-Care Ultrasound in Helicopter Emergency Medical Services Transport. Air Med J 2021; 40:175-178. [PMID: 33933221 DOI: 10.1016/j.amj.2021.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/09/2021] [Accepted: 01/22/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Point-of care-ultrasound (PoCUS) is useful in evaluating unstable emergency department patients. The portability of this technology increases its potential use in prehospital settings, including helicopter emergency medical services (HEMS) programs. Identifying useful applications may support implementing a PoCUS program that develops sonography skills for prehospital providers. The aim of this study was to determine the HEMS patient population that would benefit from prehospital PoCUS for hypotension and how commonly the extended focused assessment with sonography in trauma (E-FAST) for trauma patients or the rapid ultrasound in shock (RUSH) for medical patients could be used by HEMS. METHODS A retrospective chart review was performed over a 1-year period of adult patients transported by a midwestern HEMS system. Charts were reviewed for episodes of hypotension. RESULTS The chart review included 216 charts, of which 3 were excluded. Of the 213 cases, 100 were trauma patients, and 113 were medical patients. Of the trauma patients, 51% experienced hypotension, as did 73 of 113 medical patients. CONCLUSION Fifty percent of HEMS patients may benefit from PoCUS to evaluate for hypotension in flight.
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Affiliation(s)
- Timothy J Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
| | - Mary Beth Phelan
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Tom Grawey
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
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Hunley C, Murphy SME, Bershad M, Yapici HO. Utilization of Medical Codes for Hypotension in Shock Patients: A Retrospective Analysis. J Multidiscip Healthc 2021; 14:861-867. [PMID: 33907412 PMCID: PMC8064679 DOI: 10.2147/jmdh.s305985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/19/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose To evaluate the utilization of hypotension diagnosis codes by shock type and year in known hypotensive patients. Patients and Methods Retrospective analysis of the Medicare fee-for-service claims database. Patients with a shock diagnosis code between 2011 and 2017 were identified using the International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM). Based on specific ICD codes corresponding to each shock type, patients were classified into four mutually exclusive cohorts: cardiogenic shock, hypovolemic shock, septic shock, and other/unspecified shock. Annual proportion and counts of cases with at least one hypotension ICD code for each shock cohort were generated to produce 7-year medical code utilization trends. A Cochran-Armitage test for trend was performed to evaluate the statistical significance. Results A total of 2,200,275 shock patients were analyzed, 13.3% (n=292,192) of which received a hypotension code. Hypovolemic shock cases were the most likely to receive a hypotension code (18.02%, n=46,544), while septic shock cases had the lowest rate (11.48%, n=158,348). The proportion of patients with hypotension codes for other cohorts were 18.0% (n=46,544) for hypovolemic shock and 16.9% (n=32,024) for other/unspecified shock. The presence of hypotension codes decreased by 0.9% between 2011 and 2014, but significantly increased from 10.6% in 2014 to 17.9% in 2017 (p <0.0001, Z=−105.05). Conclusion Hypotension codes are remarkably underutilized in known hypotensive patients. Patients, providers, and researchers are likely to benefit from improved hypotension coding practices.
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Affiliation(s)
- Charles Hunley
- Department of Critical Care Medicine, Orlando Regional Medical Center, Orlando, FL, USA
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Oddy C, Allington J, McCaul J, Keeling P, Senn D, Soni N, Morrison H, Mawella R, Samuel T, Dixon J. Inpatient Omission of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Is Associated With Morbidity and Mortality in Coronavirus Disease 2019. Clin Ther 2021; 43:e97-e110. [PMID: 33712270 PMCID: PMC7906507 DOI: 10.1016/j.clinthera.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 12/31/2022]
Abstract
Purpose Due to the affinity of severe acute respiratory syndrome coronavirus 2 for the human angiotensin-converting enzyme 2 (ACE2) receptor, use of ACE inhibitors and angiotensin receptor blockers (ARBs) has been a major concern for clinicians during the 2020 pandemic. Meta-analyses have affirmed that these agents do not worsen clinical outcomes in patients with severe acute respiratory syndrome coronavirus 2 infection. To date, only a limited number of studies have directly evaluated the safety of inpatient prescription of ACE inhibitors/ARBs during acute coronavirus disease 2019 (COVID-19) illness. Methods A retrospective cohort analysis was conducted to investigate the impact of inpatient provision of ACE inhibitors/ARBs on morbidity and mortality in patients admitted to the hospital with COVID-19. Relationships were explored by using linear and logistic regression. Findings A total of 612 adult patients met the inclusion criteria, of whom 151 (24.7%) patients were established on ACE inhibitors/ARBs. Despite correction for known confounders, discontinuation of ACE inhibitors/ARBs was highly predictive of worsened outcomes in COVID-19. The proportion of doses omitted in the hospital was significantly associated with increased mortality (OR, 9.59; 95% CI, 2.55–36.09; P < 0.001), maximum National Early Warning Score 2 (OR, 1.66; 95% CI, 1.27–2.17; P < 0.001), maximum oxygen requirements (OR, 3.00; 95% CI, 1.83–4.91; P < 0.001), and maximum C-reactive protein concentration (OR, 1.83; 95% CI, 1.06–3.17; P = 0.030). Implications Our data show a strong association between missed ACE inhibitor/ARB doses with increased morbidity and mortality. The available evidence supports continuation of currently accepted practice surrounding ACE inhibitor/ARB therapy in acute illness, which is to limit drug omission to established acute contraindications, to actively monitor such decisions, and to restart therapy as soon as it is safe to do so. (Clin Ther. 2021;43:e97–e110) © 2021 Elsevier HS Journals, Inc.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - John Dixon
- St. Helier Hospital, London, United Kingdom
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10
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Atkinson P, Taylor L, Milne J, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Henneberry RJ, Fraser J, Howlett M, Mekwan J, Ramrattan B, Middleton J, Van Hoving DJ, Peach M, Dahn T, Hurley S, MacSween K, Richardson L, Stoica G, Hunter S, Atkinson JP, Olszynski P, Banerjee A, Lewis D. Does Point of Care Ultrasound Improve Resuscitation Markers in Undifferentiated Hypotension? An International Randomized Controlled Trial From The Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Series. Cureus 2020; 12:e9899. [PMID: 32968565 PMCID: PMC7505535 DOI: 10.7759/cureus.9899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for patients with undifferentiated hypotension, yet there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key clinical outcomes. Here we report on resuscitation markers. Methods Adult patients presenting to six emergency departments (ED) in Canada and South Africa with undifferentiated hypotension (systolic blood pressure (SBP) <100mmHg or a Shock Index >1.0) were randomized to receive a PoCUS protocol or standard care (control). Reported physiological markers include shock index (SI), and modified early warning score (MEWS), with biochemical markers including venous bicarbonate and lactate, at baseline and four hours. Results A total of 273 patients were enrolled, with data collected for 270. Baseline characteristics were similar for each group. Improvements in mean values for each marker during initial treatment were similar between groups: Shock Index; mean reduction in Control 0.39, 95% CI 0.34 to 0.44 vs. PoCUS 0.33, 0.29 to 0.38; MEWS, mean reduction in Control 2.56, 2.22 to 2.89 vs. PoCUS 2.91, 2.49 to 3.32; Bicarbonate, mean reduction in Control 2.71 mmol/L, 2.12 to 3.30 mmol/L vs. PoCUS 2.30 mmol/L, 1.75 to 2.84 mmol/L, and venous lactate, mean reduction in Control 1.39 mmol/L, 0.93 to 1.85 mmol/L vs. PoCUS 1.31 mmol/L, 0.88 to 1.74 mmol/L. Conclusion We found no meaningful difference in physiological and biochemical resuscitation markers with or without the use of a PoCUS protocol in the resuscitation of undifferentiated hypotensive ED patients. We are unable to exclude improvements in individual patients or in specific shock types.
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Affiliation(s)
- Paul Atkinson
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN.,Emergency Medicine, Dalhousie University, Saint John, CAN
| | - Luke Taylor
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
| | - James Milne
- Family Medicine, Fraser Valley Health, Vancouver, CAN
| | | | - Hein Lamprecht
- Emergency Medicine, Stellenbosch University, Cape Town, ZAF
| | | | - David Lussier
- Emergency Medicine, University of Manitoba, Winnipeg, CAN
| | - Chau Pham
- Emergency Medicine, University of Manitoba, Winnipeg, CAN
| | | | | | - Michael Howlett
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN.,Emergency Medicine, Dalhousie University, Saint John, CAN
| | - Jay Mekwan
- Emergency Medicine, Horizon Health Network, Saint John, CAN
| | - Brian Ramrattan
- Emergency Medicine, Dalhousie University, Saint John, CAN.,Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
| | - Joanna Middleton
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN.,Emergency Medicine, Dalhousie University, Saint John, CAN
| | | | - Mandy Peach
- Emergency Medicine, Dalhousie University, Saint John, CAN
| | - Tara Dahn
- Emergency Medicine, Dalhousie University, Halifax, CAN
| | - Sean Hurley
- Emergency Medicine, Dalhousie University, Halifax, CAN
| | | | | | - George Stoica
- Research Services, Horizon Health Network, Saint John, CAN
| | - Sam Hunter
- Science, University of Ottawa, Ottawa, CAN
| | | | - Paul Olszynski
- Emergency Medicine, University of Saskatchewan, Saskatoon, CAN
| | | | - David Lewis
- Emergency Medicine, Dalhousie University, Saint John, CAN.,Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
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11
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Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport. Prehosp Disaster Med 2020; 35:495-500. [PMID: 32698933 DOI: 10.1017/s1049023x20000886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency. METHODS This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record. RESULTS Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals. CONCLUSION These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.
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12
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Atkinson P, Hunter S, Banerjee A, Lewis D, Fraser J, Milne J, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Peach M, Taylor L, Henneberry R, Howlett M, Mekwan J, Ramrattan B, Middleton J, Van Hoving DJ, Stoica G, French J, Olszynski P. Does Point-of-care Ultrasonography Change Emergency Department Care Delivered to Hypotensive Patients When Categorized by Shock Type? A Post-Hoc Analysis of an International Randomized Controlled Trial from the SHoC-ED Investigators. Cureus 2019; 11:e6058. [PMID: 31827989 PMCID: PMC6890162 DOI: 10.7759/cureus.6058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Introduction Our previously reported randomized-controlled-trial of point-of-care ultrasound (PoCUS) for patients with undifferentiated hypotension in the emergency department (ED) showed no survival benefit with PoCUS. Here, we examine the data to see if PoCUS led to changes in the care delivered to patients with cardiogenic and non-cardiogenic shock. Methods A post-hoc analysis was completed on a database of 273 hypotensive ED patients randomized to standard care or PoCUS in six centres in Canada and South Africa. Shock categories recorded one hour after the ED presentation were used to define subcategories of shock. We analyzed initial intravenous fluid volumes, as well as rates of inotrope use and procedures. Results 261 patients could be classified as cardiogenic or non-cardiogenic shock types. Although there were expected differences in the mean fluid volume administered between patients with non-cardiogenic and cardiogenic shock (p-value<0.001), there was no difference between the control and PoCUS groups (mean non-cardiogenic control 1881mL (95% CI 1567-2195mL) vs non-cardiogenic PoCUS 1763mL (1525-2001mL); and cardiogenic control 680mL (28.4-1332mL) vs. cardiogenic PoCUS 744mL (370-1117mL; p= 0.67). Likewise, there were no differences in rates of inotrope administration nor procedures for any of the subcategories of shock between the control group and PoCUS group patients. Conclusion Despite differences in care delivered by subcategory of shock, we did not find any difference in key elements of emergency department care delivered between patients receiving PoCUS and those who did not. This may help explain the previously reported lack of outcome differences between groups.
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Affiliation(s)
- Paul Atkinson
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
| | - Sam Hunter
- Science, University of Ottawa, Ottawa, CAN
| | | | - David Lewis
- Emergency Medicine, Dalhousie University, Saint John, CAN
| | | | - James Milne
- Dalhousie University, Sydney, Nova Scotia, CAN
| | | | - Hein Lamprecht
- Emergency Medicine, Stellenbosch University, Cape Town, ZAF
| | | | - David Lussier
- Emergency Medicine, University of Manitoba, Winnipeg, CAN
| | - Chau Pham
- Emergency Medicine, University of Manitoba, Winnipeg, CAN
| | - Mandy Peach
- Emergency Medicine, Dalhousie University, Saint John, CAN
| | | | | | - Michael Howlett
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
| | - Jay Mekwan
- Emergency Medicine, Horizon Health Network, Saint John, CAN
| | - Brian Ramrattan
- Emergency Medicine, Saint John Regional Hospital/, Saint John, CAN
| | - Joanna Middleton
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
| | | | - George Stoica
- Research Services, Horizon Health Network, Saint John, CAN
| | - James French
- Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
| | - Paul Olszynski
- Emergency Medicine, University of Saskatchewan, Saskatoon, CAN
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13
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Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med 2018; 72:478-489. [DOI: 10.1016/j.annemergmed.2018.04.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 03/21/2018] [Accepted: 04/04/2018] [Indexed: 11/22/2022]
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14
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Amnuaypattanapon K, Khansompop S. Characteristics and Factors Associated With the Mortality of Hypotensive Patients Attending the Emergency Department. J Clin Med Res 2018; 10:576-581. [PMID: 29904442 PMCID: PMC5997420 DOI: 10.14740/jocmr3422w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/09/2018] [Indexed: 11/11/2022] Open
Abstract
Background The prevalence of hypotension in emergency departments (EDs) is approximately 1-2%, but is associated with a mortality rate of 8-15%. There has never been a study in Thailand examining the epidemiology or the risk factors for early mortality of patients presenting with hypotension in the ED. Therefore, this study aimed to define the characteristics, mortality rate within 48 h and associated factors of hypotensive patients at ED. Methods Data of patients with hypotension attending the ED of Thammasat University Hospital (TUH) were retrospectively studied. Results Of the 9,000 patients seen in the TUH ED, 233 were hypotensive for a prevalence of 2.5%. Patients were old, with a mean age of 61 ± 20 years. The most common presenting symptom was fever, and sepsis was the most common cause of hypotension. The mean systolic blood pressure (SBP) was 78 ± 8 mm Hg. Isotonic crystalloid volume resuscitation in first hour was 758 mL (interquartile range (IQR), 500 - 1,000) and the total volume to achieve a mean arterial pressure (MAP) ≥ 65 mm Hg was 1,142 mL (IQR, 500 - 1,500). Twenty-seven percent of patients needed vasopressor support. Nineteen patients died ≤ 48 h, giving a case fatality rate of 8.2%. Three independent factors associated with 48-h mortality were initial pulse rate > 100 beats/min (odds ratio (OR), 4.21; 95% confidence interval (CI), 1.05 - 16.88; P = 0.042), diagnosis of shock (OR, 13.74 (1.49 - 126.61); P = 0.021) and recurrent hypotension (OR, 6.91 (1.54 - 30.99); P = 0.012). Conclusions Hypotension in the ED was common and associated with high mortality rate. Better triage, patient monitoring and treatment may improve outcomes in these patients.
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Affiliation(s)
- Kumpol Amnuaypattanapon
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani 12121, Thailand
| | - Suwimon Khansompop
- Department of Emergency Medicine, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani 12121, Thailand
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15
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Sunde GA, Sandberg M, Lyon R, Fredriksen K, Burns B, Hufthammer KO, Røislien J, Soti A, Jäntti H, Lockey D, Heltne JK, Sollid SJM. Hypoxia and hypotension in patients intubated by physician staffed helicopter emergency medical services - a prospective observational multi-centre study. BMC Emerg Med 2017; 17:22. [PMID: 28693491 PMCID: PMC5504565 DOI: 10.1186/s12873-017-0134-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/30/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The effective treatment of airway compromise in trauma and non-trauma patients is important. Hypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be important quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical trauma and non-trauma patients remain the two major groups to which helicopter emergency medical services (HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma patients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the incidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation (TI) by physician-staffed HEMS. METHODS Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway template. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral oxygen saturation and systolic blood pressure before and after definitive airway management. Data were analysed using Cochran-Mantel-Haenszel methods and mixed-effects models. RESULTS Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI were included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared to trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in both groups were still hypoxic at admission. For hypotension, the differences between the groups were less prominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There was no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level of consciousness was the most frequent indication for TI, and was associated with increased survival to hospital (cOR 2.8; 95% CI: 1.4-5.4). CONCLUSIONS Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than trauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but one in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible causes that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival rates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway management in trauma and non-trauma patients. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01502111 . Registered 22 Desember 2011.
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Affiliation(s)
- Geir Arne Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Department of Health Sciences, University of Stavanger, Stavanger, Norway. .,Norwegian Air Ambulance Foundation, Møllendalsveien 34, 5009, Bergen, Norway.
| | - Mårten Sandberg
- Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Richard Lyon
- University of Surrey, Guildford, UK.,Kent, Surrey & Sussex Air Ambulance Trust, Marden, UK
| | - Knut Fredriksen
- UiT - The Arctic University of Norway, Tromsø, Norway.,The University Hospital of North Norway, Tromsø, Norway
| | - Brian Burns
- Sydney HEMS, NSW Ambulance, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | | | - Jo Røislien
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Akos Soti
- Hungarian Air Ambulance Nonprofit Ltd, Budaors, Hungary
| | - Helena Jäntti
- Centre for Pre-hospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - David Lockey
- Department of Health Sciences, University of Stavanger, Stavanger, Norway.,London's Air Ambulance, Bartshealth NHS Trust, London, UK
| | - Jon-Kenneth Heltne
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Medical Sciences, University of Bergen, Bergen, Norway
| | - Stephen J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway.,Air Ambulance Department, Oslo University Hospital, Oslo, Norway
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16
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Puskarich MA, Nandi U, Long BG, Jones AE. Association between persistent tachycardia and tachypnea and in-hospital mortality among non-hypotensive emergency department patients admitted to the hospital. Clin Exp Emerg Med 2017; 4:2-9. [PMID: 28435896 PMCID: PMC5385508 DOI: 10.15441/ceem.16.144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 11/23/2022] Open
Abstract
Objective Vital sign trends are used in clinical practice to assess treatment response and aid in disposition, yet quantitative data to support this practice are lacking. This study aimed to determine the prognostic value of vital sign normalization. Methods Secondary analysis of a prospective cohort of adult emergency department (ED) patients admitted a single urban tertiary care hospital. A random sample of 182 days was chosen, and a manual review of all admissions was undertaken. Persistent tachycardia or tachypnea was defined as failure to decrease to a normal value in the ED. Elevated upon admission was defined as an abnormal value at the last set of vital signs documented. The primary outcome was in-hospital mortality. Results 4,878 patients were enrolled and 4.5 (±3.8) sets of vital signs were checked per patient. 1,770 patients were tachycardic and 1,499 were tachypneic. Among tachycardic patients, 941 (53%) were persistently tachycardic and 1,074 (61%) were tachycardic upon admission. Among tachypneic patients 639 (42%) were persistently tachypneic and 768 (51%) were tachypneic upon admission. Mortality was higher in patients persistently tachycardic (5.7% vs. 3.1%, P=0.008) or tachycardic upon admission (5.5% vs. 3.0%, P=0.014). Similar results were found in tachypneic patients (8.3% vs. 4.5%, P=0.003; 7.8% vs. 4.4%, P=0.006). Conclusion Persistent tachycardia and tachypnea are associated with an increased risk of mortality in ED patients admitted to the hospital. Further study is necessary to determine if improved recognition or earlier interventions can affect outcomes.
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Affiliation(s)
- Michael A Puskarich
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Utsav Nandi
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ben G Long
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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17
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Ahn JH, Jeon J, Toh HC, Noble VE, Kim JS, Kim YS, Do HH, Ha YR. SEARCH 8Es: A novel point of care ultrasound protocol for patients with chest pain, dyspnea or symptomatic hypotension in the emergency department. PLoS One 2017; 12:e0174581. [PMID: 28355246 PMCID: PMC5371336 DOI: 10.1371/journal.pone.0174581] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/10/2017] [Indexed: 02/06/2023] Open
Abstract
Objective This study was conducted to evaluate a problem-oriented focused torso bedside ultrasound protocol termed “Sonographic Evaluation of Aetiology for Respiratory difficulty, Chest pain, and/or Hypotension” (SEARCH 8Es) for its ability to narrow differential diagnoses and increase physicians’ diagnostic confidence, and its diagnostic accuracy, for patients presenting with dyspnea, chest pain, or symptomatic hypotension. Methods This single-center prospective observational study was conducted over 12 months in an emergency department and included 308 patients (184 men and 124 women; mean age, 67.7 ± 19.1 years) with emergent cardiopulmonary symptoms. The paired t-test was used to compare the number of differential diagnoses and physician’s level of confidence before and after SEARCH 8Es. The overall accuracy of the SEARCH 8Es protocol in differentiating 13 diagnostic entities was evaluated based on concordance (kappa coefficient) with the diagnosis made by the inpatient specialists. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Results SEARCH 8Es narrows the number of differential diagnoses (2.5 ± 1.5 vs. 1.4 ± 0.7; p < 0.001) and improves physicians’ diagnostic confidence (2.8 ± 0.8 vs. 4.3 ± 0.9; p < 0.001) significantly. The overall kappa coefficient value was 0.870 (p < 0.001), with the overall sensitivity, specificity, positive predictive value, and negative predictive value at 90.9%, 99.0%, 89.7%, and 99.0%, respectively. Conclusion The SEARCH 8Es protocol helps emergency physicians to narrow the differential diagnoses, increase diagnostic confidence and provide accurate assessment of patients with dyspnea, chest pain, or symptomatic hypotension.
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Affiliation(s)
- Jung Hwan Ahn
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jin Jeon
- Department of Emergency Medicine, Bundang Jesaeng General Hospital, Sungnam, Republic of Korea
| | - Hong-Chuen Toh
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Vicki Elizabeth Noble
- Department of Emergency Medicine, University Hospital-Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - Jun Su Kim
- Department of Emergency Medicine, Bundang Jesaeng General Hospital, Sungnam, Republic of Korea
| | - Young Sik Kim
- Department of Emergency Medicine, Bundang Jesaeng General Hospital, Sungnam, Republic of Korea
| | - Han Ho Do
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Graduate School of Medicine, Dongguk University, Goyang, Republic of Korea
| | - Young Rock Ha
- Department of Emergency Medicine, Bundang Jesaeng General Hospital, Sungnam, Republic of Korea
- * E-mail:
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18
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Holler JG, Henriksen DP, Mikkelsen S, Rasmussen LM, Pedersen C, Lassen AT. Shock in the emergency department; a 12 year population based cohort study. Scand J Trauma Resusc Emerg Med 2016; 24:87. [PMID: 27364493 PMCID: PMC4929750 DOI: 10.1186/s13049-016-0280-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 06/21/2016] [Indexed: 11/10/2022] Open
Abstract
Background The knowledge of the frequency and associated mortality of shock in the emergency department (ED) is limited. The aim of this study was to describe the incidence, all-cause mortality and factors associated with death among patients suffering shock in the ED. Methods Population-based cohort study at an University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. All patients aged ≥18 years living in the hospital catchment area with a first time ED presentation with shock (n = 1646) defined as hypotension (systolic blood pressure (SBP) ≤100 mmHg)) and ≥1 organ failures. Outcomes were annual incidence per 100,000 person-years at risk (pyar), all-cause mortality at 0–7, and 8–90 days and risk factors associated with death. Results We identified 1646 of 438,191 (0.4 %) ED patients with shock at arrival. Incidence of shock increased from 53.8 to 80.6 cases per 100,000 pyar. The 7-day, and 90-day mortality was 23.1 % (95 % CI: 21.1–25.1) and 40.7 % (95 % CI: 38.3–43.1), respectively. Independent predictors of 7-day mortality were: age (adjusted HR 1.03 (95 % CI: 1.03–1.04), and number of organ failures (≥3 organ failures; adjusted HR 3.13 95 % CI: 2.28–4.30). Age, comorbidity level and number of organ failure were associated with 90-day mortality. Conclusion Shock is a frequent and critical finding in the ED, carrying a 7- and, 90- day mortality of 23.1 and 40.7 %, respectively. Age and number of organ failures are independent prognostic factors for death within 7 days, whereas age, comorbidity and organ failures are of significance within 8–90 days.
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Affiliation(s)
- Jon Gitz Holler
- Department of Emergency Medicine, Odense University Hospital, Sdr Boulevard 29, Entrance 130, 1. Floor 5000, Odense C, Denmark.
| | | | - Søren Mikkelsen
- Department of Anesthesiology and Intensive Care Medicine, Odense University Hospital, Odense C, Denmark
| | - Lars Melholt Rasmussen
- Centre for Individualized Medicine in Arterial Diseases (CIMA) Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, Odense C, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Odense University Hospital, Sdr Boulevard 29, Entrance 130, 1. Floor 5000, Odense C, Denmark
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Gunaydin YK, Çağlar A, Kokulu K, Yıldız CG, Dündar ZD, Akilli NB, Koylu R, Cander B. Triage using the Emergency Severity Index (ESI) and seven versus three vital signs. Notf Rett Med 2016. [DOI: 10.1007/s10049-015-0119-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Holler JG, Henriksen DP, Mikkelsen S, Pedersen C, Lassen AT. Increasing incidence of hypotension in the emergency department; a 12 year population-based cohort study. Scand J Trauma Resusc Emerg Med 2016; 24:20. [PMID: 26936190 PMCID: PMC4776382 DOI: 10.1186/s13049-016-0209-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 02/06/2016] [Indexed: 12/03/2022] Open
Abstract
Background The epidemiology of hypotension as presenting symptom among patients in the Emergency Department (ED) is not clarified. The aim of this study was to describe the incidence, etiology, and overall mortality of hypotensive patients in the ED. Methods Population-based cohort study at an University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. Patients aged ≥18 years living in the hospital catchment area with a first time presentation to the ED with hypotension (systolic blood pressure (SBP) ≤100 mm Hg) were included. Outcomes were annual incidence rates (IRs) per 100,000 person years at risk (pyar) and etiological characteristics by means of the International Classification of Diseases, Tenth Revision (ICD-10), as well as 7-day, 30-day, and 90-day all-cause mortality. Results We identified 3,268 of 438,198 (1 %) cases with a mean overall IR of 125/100,000 pyar (95 % CI: 121–130). The IR increased 28 % during the period (from 113 to 152 cases per 100,000 pyar). Patients ≥65 years had the highest IR compared to age <65 years (rate ratio for men 6.3 (95 % CI: 5.6-7.1) and for women 4.2 (95 % CI: 3.6-4.9)). The etiology was highly diversified with trauma (17 %) and cardiovascular diseases (15 %) as the most common. The overall 7-day, 30-day and 90-day mortality rates were 15 % (95 % CI: 14–16), 22 % (95 % CI: 21–24) and 28 % (95 % CI: 27–30) respectively. Conclusion During 2000–2011 the overall incidence of ED hypotension increased and remained highest among the elderly with a diversified etiology and a 90-day all-cause mortality of 28 %.
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Affiliation(s)
- Jon G Holler
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark.
| | - Daniel P Henriksen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.
| | - Søren Mikkelsen
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark.
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.
| | - Annmarie T Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark.
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McKenzie K, Puskarich MA, Jones AE. What Is the Prognosis of Nontraumatic Hypotension and Shock in the Out-of-Hospital and Emergency Department Setting? Ann Emerg Med 2016; 67:114-6. [DOI: 10.1016/j.annemergmed.2015.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 10/23/2022]
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Postintubation hypotension in intensive care unit patients: A multicenter cohort study. J Crit Care 2015; 30:1055-60. [DOI: 10.1016/j.jcrc.2015.06.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 06/04/2015] [Accepted: 06/05/2015] [Indexed: 11/22/2022]
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Holler JG, Bech CN, Henriksen DP, Mikkelsen S, Pedersen C, Lassen AT. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. PLoS One 2015; 10:e0119331. [PMID: 25789927 PMCID: PMC4366173 DOI: 10.1371/journal.pone.0119331] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 01/26/2015] [Indexed: 12/29/2022] Open
Abstract
Background Acute patients presenting with hypotension in the prehospital or emergency department (ED) setting are in need of focused management and knowledge of the epidemiology characteristics might help the clinician. The aim of this review was to address prevalence, etiology and mortality of nontraumatic hypotension (SBP ≤ 90 mmHg) with or without the presence of shock in the prehospital and ED setting. Methods We performed a systematic literature search up to August 2013, using Medline, Embase, Cinahl, Dare and The Cochrane Library. The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and The Cochrane Collaboration. No restrictions on language, publication date, or status were imposed. We used the Newcastle-Ottawa quality assessment scale (NOS-scale) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE-statement) to assess the quality. Results Six observational studies were considered eligible for analysis based on the evaluation of 11,880 identified papers. Prehospital prevalence of hypotension was 19.5/1000 emergency medicine service (EMS) contacts, and the prevalence of hypotensive shock was 9.5-19/1000 EMS contacts with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 4-13/1000 contacts with a mortality of 12%. Information on mortality, prevalence and etiology of shock in the ED was limited. A meta-analysis was not feasible due to substantial heterogeneity between studies. Conclusion There is inadequate evidence to establish concise estimates of the characteristics of nontraumatic hypotension and shock in the ED or in the prehospital setting. The available studies suggest that 2% of EMS contacts present with nontraumatic hypotension while 1-2% present with shock. The inhospital mortality of prehospital shock is 33-52%. Prevalence of hypotension in the ED is 1% with an inhospital mortality of 12%. Prevalence, etiology and mortality of shock in the ED are not well described.
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Affiliation(s)
- Jon Gitz Holler
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- * E-mail:
| | | | | | - Søren Mikkelsen
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
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Ghane MR, Gharib MH, Ebrahimi A, Samimi K, Rezaee M, Rasouli HR, Kazemi HM. Accuracy of Rapid Ultrasound in Shock (RUSH) Exam for Diagnosis of Shock in Critically Ill Patients. Trauma Mon 2015; 20:e20095. [PMID: 25825696 PMCID: PMC4362031 DOI: 10.5812/traumamon.20095] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/04/2014] [Accepted: 06/12/2014] [Indexed: 01/20/2023] Open
Abstract
Background: Rapid ultrasound in shock (RUSH) is the most recent emergency ultrasound protocol, designed to help clinicians better recognize distinctive shock etiologies in a shorter time frame. Objectives: In this study, we evaluated the accuracy of the RUSH protocol, performed by an emergency physician or radiologist, in predicting the type of shock in critical patients. Patients and Methods: An emergency physician or radiologist performed the RUSH protocol for all patients with shock status at the emergency department. All patients were closely followed to determine their final clinical diagnosis. The agreement between the initial impression provided by RUSH and the final diagnosis was investigated by calculating the Kappa index. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of RUSH for diagnosis of each case. Results: We performed RUSH on 77 patients. Kappa index was 0.71 (P Value = 0.000), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic, cardiogenic and obstructive shock, the protocol had an NPV above 97% yet it had a lower PPV. For shock with distributive or mixed etiology, RUSH showed a PPV of 100% but it had low sensitivity. Subgroup analysis showed a similar Kappa index for the emergency physician and radiologist (0.70 and 0.73, respectively) in performing rush. Conclusions: This study highlights the role of the RUSH exam performed by an emergency physician, to make a rapid and reliable diagnosis of shock etiology, especially in order to rule out obstructive, cardiogenic and hypovolemic shock types in initial exam of shock patients.
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Affiliation(s)
- Mohammad Reza Ghane
- Trauma Research Center, Baqiyatallah University of Medical Science, Tehran, IR Iran
| | - Mohammad Hadi Gharib
- Radiology Department, Iran University of Medical Science, IR Iran
- Corresponding author: Mohammad Hadi Gharib, Radiology Department, Iran University of Medical Science, Tehran, IR Iran. Tel: +98-9127123152, Fax: +98-2122180004, E-mail:
| | - Ali Ebrahimi
- Trauma Research Center, Baqiyatallah University of Medical Science, Tehran, IR Iran
| | - Kaveh Samimi
- Radiology Department, Iran University of Medical Science, IR Iran
| | - Maryam Rezaee
- Trauma Research Center, Baqiyatallah University of Medical Science, Tehran, IR Iran
| | - Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Science, Tehran, IR Iran
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Seymour CW, Kahn JM, Martin-Gill C, Callaway CW, Angus DC, Yealy DM. Creating an infrastructure for comparative effectiveness research in emergency medical services. Acad Emerg Med 2014; 21:599-607. [PMID: 24842512 DOI: 10.1111/acem.12370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 10/30/2013] [Accepted: 11/21/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Emergency medical services (EMS) providers deliver the initial care for millions of people in the United States each year. The Institute of Medicine noted a deficit in research necessary to improve prehospital care, created by the existence of data silos, absence of long-term outcomes, and limited stakeholder engagement in research. This article describes a regional effort to create a high-performing infrastructure in southwestern Pennsylvania addressing these fundamental barriers. METHODS Regional EMS records from 33 agencies in January 2011 were linked to hospital-based electronic health records (EHRs) in a single nine-hospital system, with manual review of matches for accuracy. The use of community stakeholder engagement was included to guide scientific inquiry, as well as 2-year follow up for patient-centered outcomes. RESULTS Local EMS medicine stakeholders emphasized the limits of single-agency EMS research and suggested that studies focus on improving cross-cutting, long-term outcomes. Guided by this input, more than 95% of EMS records (2,675 of 2,800) were linked to hospital-based EHRs. More than 80% of records were linked to 2-year mortality, with more deaths among EMS patients with prehospital hypotension (30.5%) or respiratory distress (19.5%) than chest pain (5.4%) or nonspecific complaints (9.4%). CONCLUSIONS A prehospital comparative effectiveness research infrastructure composed of patient-level EMS data, EHRs at multiple hospitals, long-term outcomes, and community stakeholder perspectives is feasible and may be scalable to larger regions and networks. The lessons learned and barriers identified offer a roadmap to answering community and policy-relevant research questions in prehospital care.
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Affiliation(s)
- Christopher W. Seymour
- The Department of Critical Care and Emergency Medicine; University of Pittsburgh School of Medicine (CWS); Pittsburgh PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; Department of Critical Care; University of Pittsburgh; Pittsburgh PA
| | - Jeremy M. Kahn
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; Department of Critical Care; University of Pittsburgh; Pittsburgh PA
| | | | - Clifton W. Callaway
- The Department of Emergency Medicine; University of Pittsburgh; Pittsburgh PA
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; Department of Critical Care; University of Pittsburgh; Pittsburgh PA
| | - Donald M. Yealy
- The Department of Emergency Medicine; University of Pittsburgh; Pittsburgh PA
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Puskarich MA, Kline JA, Krabill V, Claremont H, Jones AE. Preliminary safety and efficacy of L-carnitine infusion for the treatment of vasopressor-dependent septic shock: a randomized control trial. JPEN J Parenter Enteral Nutr 2013; 38:736-43. [PMID: 23851424 DOI: 10.1177/0148607113495414] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/04/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND Sepsis is characterized by metabolic disturbances, and previous data suggest a relative carnitine deficiency may contribute to metabolic dysfunction. Studies regarding safety and patient-centered efficacy of carnitine during septic shock are lacking. METHODS This was a double-blind randomized control trial of levocarnitine (L-carnitine) infusion vs normal saline for the treatment of vasopressor-dependent septic shock. Patients meeting consensus definition for septic shock with a cumulative vasopressor index ≥ 3 and sequential organ failure assessment (SOFA) score ≥ 5 enrolled within 16 hours of the recognition of septic shock were eligible. The primary safety outcome was difference in serious adverse events (SAEs) per patient between groups. Efficacy outcomes included proportion of patients demonstrating a decrease in SOFA score of 2 or more points at 24 hours and short- and long-term survival. RESULTS Of the 31 patients enrolled, 16 were in the L-carnitine and 15 were in the placebo arm. There was no difference in SAEs between placebo and intervention (2.1 vs 1.8 SAEs per patient, P = .44). There was no difference in the proportion of patients achieving a decrease in SOFA score of 2 or more points at 24 hours between placebo and treatment (53% vs 44%, P = .59). Mortality was significantly lower at 28 days in the L-carnitine group (4/16 vs 9/15, P = .048), with a nonsignificant improved survival at 1 year (P = .06). CONCLUSION L-carnitine infusion appears safe in vasopressor-dependent septic shock. Preliminary efficacy data suggest potential benefit of L-carnitine treatment, and further testing is indicated.
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Affiliation(s)
- Michael A Puskarich
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
| | - Jeffrey A Kline
- Department of Emergency Medicine, University of Indiana School of Medicine, Indianapolis
| | - Virginia Krabill
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | - Heather Claremont
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
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Seymour CW, Cooke CR, Heckbert SR, Copass MK, Yealy DM, Spertus JA, Rea TD. Prehospital systolic blood pressure thresholds: a community-based outcomes study. Acad Emerg Med 2013; 20:597-604. [PMID: 23758307 DOI: 10.1111/acem.12142] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 01/10/2013] [Accepted: 01/11/2013] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Emergency medical services (EMS) personnel commonly use systolic blood pressure (sBP) to triage and treat acutely ill patients. The definition of prehospital hypotension and its associated outcomes are poorly defined. The authors sought to determine the discrimination of prehospital sBP thresholds for 30-day mortality and to compare patient classification by best-performing thresholds to traditional cutoffs. METHODS In a community-based cohort of adult, nontrauma, noncardiac arrest patients transported by EMS between 2002 and 2006, entries to state hospital discharge data and death certificates were linked. Prehospital sBP thresholds between 40 and 140 mm Hg in derivation (n = 132,624) and validation (n = 22,020) cohorts and their discrimination for 30-day mortality, were examined. Cutoffs were evaluated using the 0/1 distance, Youden index, and adjusted Z-statistics from multivariable logistic regression models. RESULTS In the derivation cohort, 1,594 (1.2%) died within 24 hours, 7,404 (6%) were critically ill during hospitalization, and 6,888 (5%) died within 30 days. The area under the receiver operating characteristic (ROC) curve for sBP was 0.60 (95% confidence interval [CI] = 0.59, 0.61) for 30-day mortality and 0.64 (95% CI = 0.62 0.66) for 24-hour mortality. The 0/1 distance, Youden index, and adjusted Z-statistics found best-performing sBP thresholds between 110 and 120 mm Hg. When compared to an sBP ≤ 90 mm Hg, a cutoff of 110 mm Hg would identify 17% (n = 137) more deaths at 30 days, while overtriaging four times as many survivors. CONCLUSIONS Prehospital sBP is a modest discriminator of clinical outcomes, yet no threshold avoids substantial misclassification of 30-day mortality among noninjured patients.
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Affiliation(s)
| | - Colin R. Cooke
- Division of Pulmonary and Critical Care Medicine; Center for Healthcare Outcomes & Policy; University of Michigan; Ann Arbor; MI
| | | | | | - Donald M. Yealy
- Department of Emergency Medicine; University of Pittsburgh; Pittsburgh; PA
| | - John A. Spertus
- Saint Luke's Mid America Heart Institute; University of Missouri-Kansas City; Kansas City; MO
| | - Thomas D. Rea
- Department of General Internal Medicine; King County MedicOne; University of Washington; Seattle; WA
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Considine J, Mohr M, Lourenco R, Cooke R, Aitken M. Characteristics and outcomes of patients requiring unplanned transfer from subacute to acute care. Int J Nurs Pract 2013; 19:186-96. [DOI: 10.1111/ijn.12056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Julie Considine
- School of Nursing and MidwiferyDeakin University Victoria Australia
| | - Marie Mohr
- Broadmeadows Health ServiceNorthern Health Victoria Australia
| | | | - Robynne Cooke
- Medical and Continuing Care ServicesNorthern Health Victoria Australia
| | - Mark Aitken
- Bundoora Extended Care CentreNorthern Health Victoria Australia
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Ødorf K, Day D, Skibsted S, Jessen MK, Duus N, Shapiro NI, Henning D. Lactate levels in emergency department patients across all causes of physiologic instability. Crit Care 2013. [PMCID: PMC3952447 DOI: 10.1186/cc12925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care 2012; 27:587-93. [PMID: 22762924 DOI: 10.1016/j.jcrc.2012.04.022] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 04/24/2012] [Accepted: 04/29/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Arterial hypotension is a recognized complication of emergency intubation that is independently associated with increased morbidity and mortality. Our aim was to identify factors associated with postintubation hypotension after emergency intubation. METHODS Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements below 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with postintubation hypotension (PIH), defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. Multiple logistic regression modeling was used to define predictors of PIH. RESULTS A total 465 patients underwent emergency intubation during the study period, and 300 met inclusion criteria for this study. Postintubation hypotension occurred in 66 (22%) of 300 patients, and these patients experienced significantly higher in-hospital mortality (35% vs 20%; odds ratio [OR] 2.1; 95% confidence interval [CI], 1.2-3.9). Multiple logistic regression analysis demonstrated that preintubation shock index (SI), chronic renal disease, intubation for acute respiratory failure, and age were independently associated with PIH. Of these, SI was the most strongly associated factor (OR, 55; 95% CI, 13-232). Receiver operating characteristic plot showed optimized SI 0.8 or higher predicting PIH with 67% sensitivity and 80% specificity. Rapid sequence intubation paralysis was associated with a lower incidence of PIH (OR, 0.04; 95% CI, 0.003-0.4). CONCLUSIONS Preintubation and peri-intubation factors predict the complication of PIH. Elevated SI strongly and independently forewarned of cardiovascular deterioration after emergency intubation with pre-RSI SI 0.8 or higher as the optimal threshold to identify patients at risk.
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Affiliation(s)
- Alan C Heffner
- Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC 28203, USA.
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Abstract
OBJECTIVE Regionalization of care is a potential strategy for the management of shock. There are no data describing the regional distribution of patients with out-of-hospital shock. We sought to describe the incidence, demographic, clinical, and regional characteristics of patients with traumatic and nontraumatic medical shock treated by out-of-hospital emergency medical services. DESIGN Descriptive study using Pennsylvania statewide emergency medical services patient care data. SETTING Commonwealth of Pennsylvania, 2006-2008. PATIENTS Adult (age ≥ 18 yrs) noncardiac arrest patients with shock, defined as initial systolic blood pressure ≤ 80 mm Hg. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared patient characteristics, demographics, emergency medical services treatment, and regional differences between traumatic and nontraumatic medical shock. Of 3,327,306 adult nonarrest patients, 42,941 (1.29%; 95% confidence interval, 1.28% to 1.30%) had shock in the field, including 39,424 with medical shock and 3,517 with traumatic shock. Patients with medical shock were more likely to be older, female, and treated by rural emergency medical services agencies and experienced longer transport times. County-level annual shock rates varied for medical (median, 99; interquartile range, 44-273; range, 5-1634) and traumatic (median, seven; interquartile range, 3-18; range, 0-300) cases. Per-capita shock rates varied for medical (median, 105 per 100,000 population; interquartile range, 83-128; range, 37-263) and traumatic (median, seven per 100,000 population; interquartile range, 5-10; range, 0-39) cases. The correlation between county-level total annual medical and traumatic shock rates was strong (ρ = .80). CONCLUSIONS While sharing similar regional distributions, key differences exist between emergency medical services patients with traumatic and nontraumatic shock. These differences identify opportunities for and barriers to regionalizing emergency medical services care of patients with shock.
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Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care 2011; 27:417.e9-13. [PMID: 22033053 DOI: 10.1016/j.jcrc.2011.08.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 08/05/2011] [Accepted: 08/09/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Arterial hypotension is a recognized complication of emergency intubation, but the consequence of this event is poorly described. Our aim was to identify the incidence of postintubation hypotension (PIH) after emergency intubation and to determine its association with inhospital mortality. METHODS Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements less than 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with PIH, defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. The primary outcome was inhospital mortality. RESULTS Of 465 patients who underwent emergency intubation, 336 met inclusion criteria and were analyzed. Postintubation hypotension occurred in 79 (23%) of 336 patients. Patients with PIH had significantly higher inhospital mortality (33% vs 21%; 95% confidence interval for 12% difference, 1%-23%) and longer mean intensive care length of stay (LOS) (9.7 vs 5.9 days, P < .01) and hospital LOS (17.0 vs 11.4 days, P < .01). Postintubation hypotension remained a significant predictor of inhospital mortality after adjusting for confounding using multivariable logistic regression analysis (odds ratio, 1.9; 95% confidence interval, 1.1-3.5). CONCLUSION Postintubation hypotension occurs in almost one quarter of normotensive patients undergoing emergency intubation. Postintubation hypotension is independently associated with higher inhospital mortality and longer intensive care unit and hospital LOS.
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Affiliation(s)
- Alan C Heffner
- Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC, USA
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Frederiksen CA, Knudsen L, Juhl-Olsen P, Sloth E. Focus-assessed transthoracic echocardiography in the sitting position: two life-saving cases. Acta Anaesthesiol Scand 2011; 55:126-9. [PMID: 21039360 DOI: 10.1111/j.1399-6576.2010.02330.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Focus-Assessed Transthoracic Echocardiography (FATE) is a point-of-care ultrasound protocol allowing the fast evaluation of the cardio-pulmonary status. It has been well established that patients with an exacerbation of chronic obstructive lung disease and lung oedema benefit from the sitting position. These and other medical emergency situations may prevent patients from attaining the supine position, thus precluding standard echocardiography. Portable ultrasound machines with a wide range of different probes are now available at limited costs. This allows the physician to bring point-of-care ultrasound to the patient in almost any location. We present two cases of severely ill patients where FATE was performed in the sitting position with decisive impact on subsequent therapy.
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Affiliation(s)
- C A Frederiksen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Skejby, Denmark Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
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Seymour CW, Band RA, Cooke CR, Mikkelsen ME, Hylton J, Rea TD, Goss CH, Gaieski DF. Out-of-hospital characteristics and care of patients with severe sepsis: a cohort study. J Crit Care 2010; 25:553-62. [PMID: 20381301 DOI: 10.1016/j.jcrc.2010.02.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 12/16/2009] [Accepted: 02/25/2010] [Indexed: 01/20/2023]
Abstract
PURPOSE Early recognition and treatment in severe sepsis improve outcomes. However, out-of-hospital patient characteristics and emergency medical services (EMS) care in severe sepsis is understudied. Our goals were to describe out-of-hospital characteristics and EMS care in patients with severe sepsis and to evaluate associations between out-of-hospital characteristics and severity of organ dysfunction in the emergency department (ED). MATERIALS AND METHODS We performed a secondary data analysis of existing data from patients with severe sepsis transported by EMS to an academic medical center. We constructed multivariable linear regression models to determine if out-of-hospital factors are associated with serum lactate and sequential organ failure assessment (SOFA) in the ED. RESULTS Two hundred sixteen patients with severe sepsis arrived by EMS. Median serum lactate in the ED was 3.0 mmol/L (interquartile range, 2.0-5.0) and median SOFA score was 4 (interquartile range, 2-6). Sixty-three percent (135) of patients were transported by advanced life support providers and 30% (62) received intravenous fluid. Lower out-of-hospital Glasgow Coma Scale score was independently associated with elevated serum lactate (P < .01). Out-of-hospital hypotension, greater respiratory rate, and lower Glasgow Coma Scale score were associated with greater SOFA (P < .01). CONCLUSIONS Out-of-hospital fluid resuscitation occurred in less than one third of patients with severe sepsis, and routinely measured out-of-hospital variables were associated with greater serum lactate and SOFA in the ED.
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Affiliation(s)
- Christopher W Seymour
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA 98104, USA.
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Jones AE, Trzeciak S, Dellinger RP. Arterial pressure optimization in the treatment of septic shock: a complex puzzle. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:102. [PMID: 20092607 PMCID: PMC2875485 DOI: 10.1186/cc8194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Arterial pressure optimization in septic shock is a critical, yet poorly understood component of resuscitation. New data suggest that, during the routine management of patients with severe sepsis, there is no association between mean arterial pressure achieved and outcome as long as the mean arterial pressure is maintained at or above 70 mmHg. Although these data add important new evidence to our understanding of arterial pressure management, there are still many unanswered questions upon which future investigations should focus.
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Affiliation(s)
- Alan E Jones
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28203, USA
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Abstract
Emergency providers must be experts in the resuscitation and stabilization of critically ill patients, and the rapid recognition of shock is crucial to allow aggressive targeted intervention and reduce morbidity and mortality. This article reviews the physiologic definition of shock, the importance of early intervention, and the clinical and diagnostic signs that emergency department providers can use to identify patients in shock.
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Affiliation(s)
- Matthew C Strehlow
- Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, 701 Welch Road, Palo Alto, CA 94304, USA.
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Puskarich MA, Marchick MR, Kline JA, Steuerwald MT, Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R167. [PMID: 19845956 PMCID: PMC2784398 DOI: 10.1186/cc8138] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 10/01/2009] [Accepted: 10/21/2009] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Early structured resuscitation of severe sepsis has been suggested to improve short term mortality; however, no previous study has examined the long-term effect of this therapy. We sought to determine one year outcomes associated with implementation of early goal directed therapy (EGDT) in the emergency department (ED) care of sepsis. METHODS We performed a longitudinal analysis of a prospective before and after study conducted at a large urban ED. Adult patients were enrolled if they had suspected infection, 2 or more systemic inflammatory response criteria, and either systolic blood pressure (SBP) <90 mmHg after a fluid bolus or lactate >4 mM. Exclusion criteria were: age <18 years, no aggressive care desired, or need for immediate surgery. Clinical and outcomes data were prospectively collected on consecutive eligible patients for 1 year before and 2 years after implementing EGDT. Patients in the pre-implementation phase received non-protocolized care at attending physician discretion. The primary outcome was mortality at one year. RESULTS 285 subjects, 79 in the pre- and 206 in the post-implementation phases, were enrolled. Compared to pre-implementation, post-implementation subjects had a significantly lower ED SBP (72 vs. 85 mm Hg, P < 0.001) and higher sequential organ failure assessment score (7 vs. 5, P = 0.0004). The primary outcome of 1 year mortality was observed in 39/79 (49%) pre-implementation subjects and 77/206 (37%) post-implementation subjects (difference 12%; P = 0.04). CONCLUSIONS Implementation of EGDT for the treatment of ED patients with severe sepsis and septic shock was associated with significantly lower mortality at one year.
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Affiliation(s)
- Michael A Puskarich
- Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, North Carolina 28203, USA.
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Thomas SH, Winsor G, Pang P, Wedel SK, Parry B. NEAR-CONTINUOUS, NONINVASIVE BLOOD PRESSURE MONITORING IN THE OUT-OF-HOSPITAL SETTING. PREHOSP EMERG CARE 2009; 9:68-72. [PMID: 16036831 DOI: 10.1080/10903120590891958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study was conducted to test out-of-hospital performance of a noninvasive radial artery tonometry device to assess blood pressure (BP), providing readings every 10-12 seconds. The primary objective was to determine the correlation between noninvasive BPs calculated with radial artery tonometry and standard oscillometric cuff methods. The secondary objective was to determine whether the difference observed between the two techniques was consistent over the range of BPs measured. METHODS This prospective trial enrolled adults transported by helicopter (n = 9 patients), fixed-wing airplane (n = 1), or ground vehicle (n = 10) of a single transport service. Patients had BP assessed simultaneously, by both standard automatic cuff and radial artery tonometry device, every 5 minutes. Data were assessed with correlation coefficients, and Bland-Altman techniques were utilized to assess for bias over the range of mean arterial pressures (MAPs) encountered. For all tests, p was set at 0.05. RESULTS No major problem with radial artery tonometry device field performance was noted. There were 139 pairs of MAP assessments in 20 patients. The correlation coefficient for the two assessment modalities was 0.96. Bland-Altman bias plot and Pitman's test (p = 0.11) revealed good correlation between the two assessment mechanisms over the entire range of MAPs (42 to 163 mm Hg) encountered in the study. CONCLUSION The radial artery tonometry device provided MAP assessments that were highly correlated with readings from a standard oscillometric device. The radial artery tonometry device performed well in a variety of patient types and in multiple transport vehicles, and there was no sign that its performance was adversely affected by the out-of-hospital setting.
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The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med 2009; 37:1649-54. [PMID: 19325482 DOI: 10.1097/ccm.0b013e31819def97] [Citation(s) in RCA: 407] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Organ failure worsens outcome in sepsis. The Sequential Organ Failure Assessment (SOFA) score numerically quantifies the number and severity of failed organs. We examined the utility of the SOFA score for assessing outcome of patients with severe sepsis with evidence of hypoperfusion at the time of emergency department (ED) presentation. DESIGN Prospective observational study. SETTING Urban, tertiary ED with an annual census of >110,000. PATIENTS ED patients with severe sepsis with evidence of hypoperfusion. INCLUSION CRITERIA suspected infection, two or more criteria of systemic inflammation, and either systolic blood pressure <90 mm Hg after a fluid bolus or lactate >or=4 mmol/L. EXCLUSION CRITERIA age <18 years or need for immediate surgery. INTERVENTIONS SOFA scores were calculated at ED recognition (T0) and 72 hours after intensive care unit admission (T72). The primary outcome was in-hospital mortality. The area under the receiver operating characteristic curve was used to evaluate the predictive ability of SOFA scores at each time point. The relationship between Delta SOFA (change in SOFA from T0 to T72) was examined for linearity. RESULTS A total of 248 subjects aged 57 +/- 16 years, 48% men, were enrolled over 2 years. All patients were treated with a standardized quantitative resuscitation protocol; the in-hospital mortality rate was 21%. The mean SOFA score at T0 was 7.1 +/- 3.6 points and at T72 was 7.4 +/- 4.9 points. The area under the receiver operating characteristic curve of SOFA for predicting in-hospital mortality at T0 was 0.75 (95% confidence interval 0.68-0.83) and at T72 was 0.84 (95% confidence interval 0.77-0.90). The Delta SOFA was found to have a positive relationship with in-hospital mortality. CONCLUSIONS The SOFA score provides potentially valuable prognostic information on in-hospital survival when applied to patients with severe sepsis with evidence of hypoperfusion at the time of ED presentation.
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Marchick MR, Kline JA, Jones AE. The significance of non-sustained hypotension in emergency department patients with sepsis. Intensive Care Med 2009; 35:1261-4. [PMID: 19238354 DOI: 10.1007/s00134-009-1448-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 02/03/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Few studies have documented the incidence and significance of non-sustained hypotension in emergency department (ED) patients with sepsis. We hypothesized that ED non-sustained hypotension increases risk of in-hospital mortality in patients with sepsis. METHODS Secondary analysis of a prospective cohort study. ED patients aged > 17 years admitted to the hospital with explicitly defined sepsis were prospectively identified. INCLUSION CRITERIA Evidence of systemic inflammation (> 1 criteria) and suspicion for infection. Patients with overt shock were excluded. The primary outcome was in-hospital mortality. RESULTS Seven hundred patients with sepsis were enrolled, including 150 (21%) with non-sustained hypotension. The primary outcome of in-hospital mortality was present in 10% (15/150) of patients with non-sustained hypotension compared with 3.6% (20/550) of patients with no hypotension. The presence of non-sustained hypotension resulted in three times the risk of mortality than no hypotension (risk ratio = 2.8, 95% CI 1.5-5.2). Patients with a lowest systolic blood pressure < 80 mmHg had a threefold increase in mortality rate compared with patients with a lowest systolic blood pressure > or = 80 mmHg (5 vs. 16%). In logistic regression analysis, non-sustained hypotension was an independent predictor of in-hospital mortality. CONCLUSION Non-sustained hypotension in the ED confers a significantly increased risk of death during hospitalization in patients admitted with sepsis. These data should impart reluctance to dismiss non-sustained hypotension, including a single measurement, as not clinically significant or meaningful.
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Affiliation(s)
- Michael R Marchick
- Emergency Medicine Research, Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232-2861, USA
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Jansen TC, van Bommel J, Mulder PG, Rommes JH, Schieveld SJM, Bakker J. The prognostic value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R160. [PMID: 19091118 PMCID: PMC2646325 DOI: 10.1186/cc7159] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 12/17/2008] [Indexed: 01/20/2023]
Abstract
INTRODUCTION A limitation of pre-hospital monitoring is that vital signs often do not change until a patient is in a critical stage. Blood lactate levels are suggested as a more sensitive parameter to evaluate a patient's condition. The aim of this pilot study was to find presumptive evidence for a relation between pre-hospital lactate levels and in-hospital mortality, corrected for vital sign abnormalities. METHODS In this prospective observational study (n = 124), patients who required urgent ambulance dispatching and had a systolic blood pressure below 100 mmHg, a respiratory rate less than 10 or more than 29 breaths/minute, or a Glasgow Coma Scale (GCS) below 14 were enrolled. Nurses from Emergency Medical Services measured capillary or venous lactate levels using a hand-held device on arrival at the scene (T1) and just before or on arrival at the emergency department (T2). The primary outcome measured was in-hospital mortality. RESULTS The average (standard deviation) time from T1 to T2 was 27 (10) minutes. Non-survivors (n = 32, 26%) had significantly higher lactate levels than survivors at T1 (5.3 vs 3.7 mmol/L) and at T2 (5.4 vs 3.2 mmol/L). Mortality was significantly higher in patients with lactate levels of 3.5 mmol/L or higher compared with those with lactate levels below 3.5 mmol/L (T1: 41 vs 12% and T2: 47 vs 15%). Also in the absence of hypotension, mortality was higher in those with higher lactate levels. In a multivariable Cox proportional hazard analysis including systolic blood pressure, heart rate, GCS (all at T1) and delta lactate level (from T1 to T2), only delta lactate level (hazard ratio (HR) = 0.20, 95% confidence interval (CI) = 0.05 to 0.76, p = 0.018) and GCS (HR = 0.93, 95% CI = 0.88 to 0.99, p = 0.022) were significant independent predictors of in-hospital mortality. CONCLUSIONS In a cohort of patients that required urgent ambulance dispatching, pre-hospital blood lactate levels were associated with in-hospital mortality and provided prognostic information superior to that provided by the patient's vital signs. There is potential for early detection of occult shock and pre-hospital resuscitation guided by lactate measurement. However, external validation is required before widespread implementation of lactate measurement in the out-of-hospital setting.
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Affiliation(s)
- Tim C Jansen
- Department of Intensive Care, Erasmus MC University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Kilgannon JH, Roberts BW, Reihl LR, Chansky ME, Jones AE, Dellinger RP, Parrillo JE, Trzeciak S. Early arterial hypotension is common in the post-cardiac arrest syndrome and associated with increased in-hospital mortality. Resuscitation 2008; 79:410-6. [PMID: 18990478 PMCID: PMC2746417 DOI: 10.1016/j.resuscitation.2008.07.019] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 07/21/2008] [Accepted: 07/24/2008] [Indexed: 10/21/2022]
Abstract
AIM After return of spontaneous circulation (ROSC) from cardiac arrest, profound myocardial stunning and systemic inflammation may cause hemodynamic alterations; however, the prevalence of post-ROSC hemodynamic instability and the strength of association with outcome have not been established. We tested the hypothesis that exposure to arterial hypotension after ROSC occurs commonly (>50%) and is an independent predictor of death. METHODS Single-center retrospective cohort study of all post-cardiac arrest patients over 1 year. INCLUSION CRITERIA (1) age >17; (2) non-trauma; (3) sustained ROSC after cardiac arrest. Using the Jones criteria, subjects were assigned to one of two groups based on the presence of hypotension within 6h after ROSC: (1) exposures-two or more systolic blood pressures (SBPs) <100mmHg or (2) non-exposures-less than two SBP <100mmHg. The primary outcome was in-hospital mortality. We compared mortality rates between groups and used multivariate logistic regression to determine if post-ROSC hypotension independently predicted death. RESULTS 102 subjects met inclusion criteria. In-hospital mortality was 75%. Exposure to hypotension occurred in 66/102 (65%) and was associated with significantly higher mortality (83%) compared to non-exposures (58%, p=0.01). In a model controlling for common confounding variables (age, pre-arrest functional status, arrest rhythm, and provision of therapeutic hypothermia (HT)), early exposure to hypotension was a strong independent predictor of death (OR 3.5 [95% CI 1.3-9.6]). CONCLUSIONS Early exposure to arterial hypotension after ROSC was common and an independent predictor of death. These data suggest that post-ROSC hypotension could potentially represent a therapeutic target in post-cardiac arrest care.
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Affiliation(s)
- J Hope Kilgannon
- Department of Emergency Medicine, UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, One Cooper Plaza, 114 Kelemen, Camden, NJ 08103, USA
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Meisel ZF, Pollack CV, Mechem CC, Pines JM. Derivation and internal validation of a rule to predict hospital admission in prehospital patients. PREHOSP EMERG CARE 2008; 12:314-9. [PMID: 18584498 DOI: 10.1080/10903120802096647] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To derive and internally validate a simple prediction rule, using routinely collected prehospital patient data, that discriminates between hospital admission and emergency department (ED) discharge for adult patients who arrive by ambulance. METHODS We performed a retrospective cohort study of consecutive adult nontrauma patients transported to two separate EDs over two months by a city-run emergency medical services (EMS) system. We tested whether specific prehospital variables could predict hospital admission using chi-square tests, logistic regression, and receiver-operating characteristic curves. We created a rule to predict the probabilities of hospital admission for individual patients. RESULTS Of 401 patients, the mean age was 47 years; 60% were black and 32% were white; 51% were female; and 33% were admitted to an inpatient service after evaluation in the ED. Independent predictors of admission were dyspnea (adjusted odds ratio [OR] 6.8; awarded 3 points), chest pain (OR 5.2; 3 points), and dizziness, weakness, or syncope (OR 3.5; 2 points). Also predictive were age>or=60 years (OR 5.5; 3 points) and the prehospital identification of a history of diabetes (OR 1.9; 1 point) or cancer (OR 3.9; 2 points). Patients who had a score of 5 or higher had a greater than 69% chance of being admitted to an inpatient unit. CONCLUSION Routinely collected EMS patient information can help predict hospital admission for certain ED patients.
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Affiliation(s)
- Zachary F Meisel
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life support–conformed algorithm. Crit Care Med 2007; 35:S150-61. [PMID: 17446774 DOI: 10.1097/01.ccm.0000260626.23848.fc] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Emergency ultrasound is suggested to be an important tool in critical care medicine. Time-dependent scenarios occur during preresuscitation care, during cardiopulmonary resuscitation, and in postresuscitation care. Suspected myocardial insufficiency due to acute global, left, or right heart failure, pericardial tamponade, and hypovolemia should be identified. These diagnoses cannot be made with standard physical examination or the electrocardiogram. Furthermore, the differential diagnosis of pulseless electrical activity is best elucidated with echocardiography. Therefore, we developed an algorithm of focused echocardiographic evaluation in resuscitation management, a structured process of an advanced life support-conformed transthoracic echocardiography protocol to be applied to point-of-care diagnosis. The new 2005 American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines recommended high-quality cardiopulmonary resuscitation with minimal interruptions to reduce the no-flow intervals. However, they also recommended identification and treatment of reversible causes or complicating factors. Therefore, clinicians must be trained to use echocardiography within the brief interruptions of advanced life support, taking into account practical and theoretical considerations. Focused echocardiographic evaluation in resuscitation management was evaluated by emergency physicians with respect to incorporation into the cardiopulmonary resuscitation process, performance, and physicians' ability to recognize characteristic pathology. The aim of the focused echocardiographic evaluation in resuscitation management examination is to improve the outcomes of cardiopulmonary resuscitation.
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Affiliation(s)
- Raoul Breitkreutz
- Department of Anesthesiology, Intensive Care, and Pain Therapy, Hospital of the Johann-Wolfgang-Goethe University, Frankfurt am Main, Germany.
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Jones AE, Craddock PA, Tayal VS, Kline JA. Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension. Shock 2006; 24:513-7. [PMID: 16317380 DOI: 10.1097/01.shk.0000186931.02852.5f] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The hypothesis of this study states that in emergency department (ED) patients with non-traumatic symptomatic hypotension, the presence of hyperdynamic left ventricular function (LVF) is specific for sepsis as the etiology of shock. We performed a secondary analysis of patients with non-traumatic symptomatic hypotension enrolled in a randomized, clinical diagnostic trial. The study was done in an urban tertiary ED with a census over 100,000 visits per year. Inclusion criteria were non-trauma ED patients aged >17 years, initial vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for one sign and symptom of circulatory shock. All patients underwent focused ED echocardiography (echo) during initial resuscitation. Echos were reviewed post-hoc by a blinded physician and categorized by qualitative LVF as hyperdynamic (ejection fraction [EF] >55%), normal to moderate impairment (EF 30%-55%), and severe impairment (EF <30%). Main outcome was the criterion standard diagnosis of septic shock. Analyses include the diagnostic performance of LVF, Cohen's kappa for interobserver agreement of LVF, and logistic regression for independent predictors of sepsis. There were 103 echos that were adequate for analysis. The mean age was 57+/-16.7 years, 59% were male, and the mean initial systolic blood pressure was 83+/-11.3 mm Hg. A final diagnosis of septic shock was made in 38% (39/103) of patients. Seventeen of 103 (17%) patients had hyperdynamic LVF with an interobserver agreement of kappa=0.8. The sensitivity and specificity of hyperdynamic LVF for predicting sepsis were 33% (95% CI 19%-50%) and 94% (85%-98%), respectively. Hyperdynamic LVF had a positive likelihood ratio of 5.3 for the diagnosis of sepsis and was a strong independent predictor of sepsis as the final diagnosis with an odds ratio of 5.5 (95% CI 1.1-45). Among ED patients with non-traumatic undifferentiated symptomatic hypotension, the presence of hyperdynamic LVF on focused echo is highly specific for sepsis as the etiology of shock.
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Affiliation(s)
- Alan E Jones
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina 28203, USA
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Jones AE, Kline JA. Use of goal-directed therapy for severe sepsis and septic shock in academic emergency departments. Crit Care Med 2005; 33:1888-9; author reply 1889-90. [PMID: 16096485 DOI: 10.1097/01.ccm.0000166872.78449.b1] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Courtney DM, Kline JA. Prospective use of a clinical decision rule to identify pulmonary embolism as likely cause of outpatient cardiac arrest. Resuscitation 2005; 65:57-64. [PMID: 15797276 DOI: 10.1016/j.resuscitation.2004.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2004] [Revised: 07/27/2004] [Accepted: 07/27/2004] [Indexed: 11/20/2022]
Abstract
UNLABELLED A clinical decision rule (CDR) derived retrospectively found that 57% of outpatients aged 65 years or less, with witnessed arrest+PEA had pulmonary embolism (PE) as cause of cardiac arrest. These retrospectively studied patients also had significant frequency of pre-arrest respiratory distress, altered mental status, and shock. OBJECTIVES (1) To test prospectively the feasibility and diagnostic accuracy of this CDR. (2) To test if the pre-arrest clinical triad of respiratory distress, altered mental status and shock predicts the presence of PE. All EMS personnel (N=204) in an urban EMS system and Emergency Department physicians (N=143) at 7 hospitals were included in the CDR and data collection. INCLUSION CRITERIA age 18-70, non-trauma, witnessed arrest, PEA as the first and primary rhythm. Exclusion: defibrillation before or more often than once after PEA. Criterion standards: autopsy or predefined cardiopulmonary imaging for PE. Over 21 months, 44 subjects were enrolled. Thirty-three subjects had a criterion standard (N=20 autopsy, 13-other criteria). 18/33 (54%; 95% CI 36-72%) had PE. Of the PE arrests, 88% were witnessed by EMS (N=8) or ED physicians (N=8), compared with 47% in the non-PE group (N=3 EMS and N=4 ED). Of the PE arrests, 83% had at least two of the three components of the triad versus 33% of the non-PE group (95% CI for difference 20-79). Mortality was 100% in the PE group. Analysis of the EMS cardiac arrest registry indicated that 65% of all patients served by the EMS system, age<or=70 recorded as having pre-hospital PEA arrest were enrolled during the study period. CONCLUSIONS We implemented successfully a CDR in a large, urban prehospital system to detect PE rapidly as most likely cause of cardiac arrest.
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Affiliation(s)
- D Mark Courtney
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Emergency Medicine, 259 E. Erie Suite 100, Chicago, IL 60611, USA.
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Abstract
Arterial hypotension often signifies inadequate systemic perfusion. We hypothesize that in a heterogeneous emergency department (ED) population with clinically suspected circulatory shock, the severity of hypotension on presentation predicts in-hospital outcome. We performed a secondary analysis of patients with nontraumatic shock enrolled in a noninterventional, randomized, controlled trial. The setting was an urban, tertiary ED, census >100,000 visits per year. Patients included nontrauma ED patients, aged >17 years, with initial ED vital signs consistent with shock (systolic blood pressure <100 mmHg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. Measurements included interobserver agreement for signs and symptoms of shock, relationship between the depth and duration of ED hypotension and adverse hospital outcome (in-hospital mortality, need for intensive care unit services, and acute organ failure) and logistic regression analysis for independent predictors of adverse hospital outcome. Of 202 patients who qualified, 190 patients were included; the in-hospital mortality rate was 15%. The sign or symptom of shock with the highest interobserver agreement was "unresponsive" (kappa = 0.74). The adverse hospital outcomes increased with each decile decrease in the lowest ED systolic blood pressure (SBP) from 17% if SBP >89 mmHg versus 50% if SBP < 80 mmHg. Forty percent of patients with an adverse hospital outcome had sustained hypotension (all ED SBP <100 mmHg for > or =60 min). Sustained hypotension was the strongest independent predictor of an adverse hospital outcome (odds ratio 3.1; 95% CI 1.5-7.1). Mortality among patients who present to the ED with undifferentiated shock is high. The depth and duration of systolic blood pressure appears to have a dose-response relationship to adverse hospital outcome.
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Affiliation(s)
- Alan E Jones
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28203, USA
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Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004; 32:1703-8. [PMID: 15286547 DOI: 10.1097/01.ccm.0000133017.34137.82] [Citation(s) in RCA: 334] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension. DESIGN Randomized, controlled trial of immediate vs. delayed ultrasound. SETTING Urban, tertiary emergency department, census >100,000. PATIENTS Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. INTERVENTIONS Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0. MEASUREMENTS AND MAIN RESULTS Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p <.0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70-87%) of group 1 subjects vs. 50% (95% confidence interval, 40-60%) in group 2, difference of 30% (95% confidence interval, 16-42%). CONCLUSIONS Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.
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Affiliation(s)
- Alan E Jones
- Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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