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Hayes-Bradley C, McCreery M, Delorenzo A, Bendall J, Lewis A, Bowles KA. Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis. Br J Anaesth 2024; 132:918-935. [PMID: 38508943 DOI: 10.1016/j.bja.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/15/2024] [Accepted: 02/01/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Prehospital rapid sequence intubation first pass success rates vary between 59% and 98%. Patient morbidity is associated with repeat intubation attempts. Understanding what influences first pass success can guide improvements in practice. We performed an aetiology and risk systematic review to answer the research question 'what factors are associated with success or failure at first attempt laryngoscopy in prehospital rapid sequence intubation?'. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched on March 3, 2023 for studies examining first pass success rates for rapid sequence intubation of prehospital live patients. Screening was performed via Covidence, and data synthesised by meta-analysis. The review was registered with PROSPERO and performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Reasonable evidence was discovered for predictive and protective factors for failure of first pass intubation. Predictive factors included age younger than 1 yr, the presence of blood or fluid in the airway, restricted jaw or neck movement, trauma patients, nighttime procedures, chronic or acute distortions of normal face/upper airway anatomy, and equipment issues. Protective factors included an experienced intubator, adequate training, use of certain videolaryngoscopes, elevating the patient on a stretcher in an inclined position, use of a bougie, and laryngeal manoeuvres. CONCLUSIONS Managing bloody airways, positioning well, using videolaryngoscopes with bougies, and appropriate training should be further explored as opportunities for prehospital services to increase first pass success. Heterogeneity of studies limits stronger conclusions. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022353609).
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Affiliation(s)
- Clare Hayes-Bradley
- Department of Paramedicine, Monash University, Frankston, VIC, Australia; NSW Ambulance Aeromedical Operations, Sydney, NSW, Australia.
| | | | - Ashleigh Delorenzo
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
| | | | | | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
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Fouche PF, Nichols M, Scott J, Richardson J, Bendall J. Crystalloid Fluid Management of Non-Traumatic Hypotension by New South Wales Ambulance. PREHOSP EMERG CARE 2024:1-8. [PMID: 38436287 DOI: 10.1080/10903127.2024.2306247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/13/2023] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Shock is circulatory insufficiency, inadequate oxygen delivery, and cellular hypoxia. Intravenous fluids are essential for shock management. Despite treatment, patients can face persistent shock with ongoing hypotension, contributing to higher mortality. This analysis aims to quantify hypotensive non-traumatic cases in an Australian ambulance service, determine persistent hypotension prevalence, and assess paramedic-administered intravascular fluids' impact on blood pressure changes. METHODS This study is a retrospective analysis of prehospital fluid resuscitation by New South Wales Ambulance paramedics during 2022. Hypotension is defined as a systolic blood pressure of ≤ 90 mmHg, and persistent hypotension is a systolic blood pressure consistently below 90 mmHg across all observations, with a final blood pressure below 90 mmHg. This study aimed to determine the volume of fluid resuscitation at which a plateau in population-level systolic blood pressure response is observed, by calculating the derivative of the fitted logistic regression model. Moreover, this analysis identified the relative contribution of factors influencing the probability of an attempt at intravenous or intraosseous access using machine learning. RESULTS Among 796,865 attendances, 23,049 (2.9%) involved non-traumatic patients with hypotension. In total 7,388 (32.1%) of the hypotensive cases resulted in persistent hypotension, of which 3,235 (43.8%) received Hartmann's solution and 1,745 (53.9%) received at least 500 ml of fluids but still had hypotension. The model showed that systolic blood pressure tends to stop increasing after 500-600 milliliters of fluid are given. This suggests that, on average, giving more fluid than this may not raise blood pressure further in a prehospital setting, though individual patient needs can differ. The top four factors from the machine learning shows that as initial respiratory rate goes up, the probability of intravascular access rises. Transport times less than 20 min are associated with a smaller chance of access and younger patients are less likely to receive an attempt. Finally, extremes of systolic blood pressure are more likely to receive access attempts. CONCLUSION This study found that three percent of non-traumatic attendances have at least one episode of hypotension, and that more than half of these have persistent hypotension. Only 44% of persistently hypotensive received fluids, and half of persistently hypotensive patients stayed hypotensive despite a reasonable volume of prehospital crystalloids.
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Affiliation(s)
| | - Martin Nichols
- Clinical Systems, New South Wales Ambulance, Rozelle, Sydney, Australia
| | - Justin Scott
- Clinical Systems, New South Wales Ambulance, Rozelle, Sydney, Australia
| | - Jack Richardson
- School of Paramedicine, University of Tasmania, Rozelle, Sydney, Australia
| | - Jason Bendall
- Clinical Systems, New South Wales Ambulance, Rozelle, Sydney, Australia
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Burns B, Marschner I, Eggins R, Buscher H, Morton RL, Bendall J, Keech A, Dennis M. A randomized trial of expedited intra-arrest transfer versus more extended on-scene resuscitation for refractory out of hospital cardiac arrest: Rationale and design of the EVIDENCE trial. Am Heart J 2024; 267:22-32. [PMID: 37871782 DOI: 10.1016/j.ahj.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Refractory Out of Hospital Cardiac Arrest (r-OHCA) is common and the benefit versus harm of intra-arrest transport of patients to hospital is not clear. OBJECTIVE To assess the rate of survival to hospital discharge in adult patients with r-OHCA, initial rhythm pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) or Pulseless Electrical Activity (PEA) treated with 1 of 2 locally accepted standards of care:1 expedited transport from scene; or2 ongoing advanced life support (ALS) resuscitation on-scene. HYPOTHESIS We hypothesize that expedited transport from scene in r-OHCA improves survival with favorable neurological status/outcome. METHODS/DESIGN Phase III, multi-center, partially blinded, prospective, intention-to-treat, safety and efficacy clinical trial with contemporaneous registry of patient ineligible for the clinical trial. Eligible patients for inclusion are adults with witnessed r-OHCA; estimated age 18 to 70, assumed medical cause with immediate bystander cardiopulmonary resuscitation (CPR); initial rhythm of VF/pulseless VT, or PEA; no return of spontaneous circulation following 3 shocks and/or 15 minutes of professional on-scene resuscitation; with mechanical CPR available. Two hundred patients will be randomized in a 1:1 ratio to either expedited transport from scene or ongoing ALS at the scene of cardiac arrest. SETTING Two urban regions in NSW Australia. OUTCOMES Primary: survival to hospital discharge with cerebral performance category (CPC) 1 or 2. Secondary: safety, survival, prognostic factors, use of ECMO supported CPR and functional assessment at hospital discharge and 4 weeks and 6 months, quality of life, healthcare use and cost-effectiveness. CONCLUSIONS The EVIDENCE trial will determine the potential risks and benefits of an expedited transport from scene of cardiac arrest.
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Affiliation(s)
- Brian Burns
- New South Wales Ambulance, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ian Marschner
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | - Renee Eggins
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | - Hergen Buscher
- St. Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Rachael L Morton
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney Australia
| | | | - Anthony Keech
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark Dennis
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia.
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Dinh M, Singh H, Deans C, Pople G, Bendall J, Sarrami P. Prehospital times and outcomes of patients transported using an ambulance trauma transport protocol: A data linkage analysis from New South Wales Australia. Injury 2023; 54:110988. [PMID: 37574381 DOI: 10.1016/j.injury.2023.110988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/13/2023] [Accepted: 08/05/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Prehospital trauma systems are designed to ensure optimal survival from critical injuries by triaging and transporting such patients to the most appropriate hospital in a timely manner. OBJECTIVES We sought to evaluate whether prehospital time and location (metropolitan versus non-metropolitan) were associated with 30-day mortality in a cohort of patients transported by road ambulance using a trauma transport protocol. METHODS Data linkage analysis of routinely collected ambulance and hospital data across all public hospitals in New South Wales (NSW). The data linkage cohort included adult patients (age ≥ 16years) transported by NSW Ambulance, where a T1 Major Trauma Transport Protocol was documented by paramedic crews and transported by road to a public hospital emergency department in NSW for two years between January 2019 and December 2020. The outcomes of interest were prehospital times (response time, scene time and transport time) and 30-day mortality due to injury. RESULTS 9012 cases were identified who were transported to an emergency department with T1 protocol indication. Median prehospital transport times were longer in non-metropolitan road transports [n = 3,071, 98 min (71-126)] compared to metropolitan transports [n = 5,941, 65 min (53-80), p < 0.001]. There was no significant difference in 30-day mortality between the two groups (1.24% vs 1.65%, p = 0.13). In the subgroup of patients with abnormal vital signs, the only predictors of mortality were increasing age, presence of severe injury (OR 24.87, 95%CI 11.02, 56.15, p < 0.001), and arrival at a non-trauma facility (OR 3.01, 95%CI 1.26, 7.20, p < 0.05). Increasing transport times were not found to increase the odds of 30-day mortality. DISCUSSION In the context of an inclusive trauma system and an established prehospital major trauma protocol, increasing prehospital transport times and scene location were not associated with increased mortality.
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Affiliation(s)
- Michael Dinh
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia; Sydney Medical School, the University of Sydney, Australia
| | - Hardeep Singh
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia
| | | | | | | | - Pooria Sarrami
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia; South Western Sydney Clinical School, University of New South Wales, Australia.
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Dinh M, Singh H, Deans C, Pople G, Sarrami P, Sisson G, Newman J, Bendall J. Evaluation of the New South Wales ambulance T1 major trauma transport protocol: A state-wide data linkage study. Injury 2023; 54:110846. [PMID: 37246112 DOI: 10.1016/j.injury.2023.110846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/02/2023] [Accepted: 05/23/2023] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Prehospital triage and transport protocols are critical components of the trauma systems. Still, there have been limited studies evaluating the performance of trauma protocols in New South Wales, such as the NSW ambulance major Trauma transport protocol (T1). OBJECTIVES Determine the performance of a major trauma transport protocol in a cohort of ambulance road transports METHODS: A data-linkage study using routine ambulance and hospital datasets across New South Wales Australia. Adult patients (age > 16 years) where any trauma protocol was indicated by paramedic crews and transported to any emergency department in the state were included. Major injury outcome was defined as an Injury Severity Score >8 based on coded in-patient diagnoses, or admission to intensive care unit or death within 30 days due to injury. Multivariable logistic regression was used to determine ambulance predictors of major injury outcome. RESULTS There were 168,452 linked ambulance transports analysed. Of the 9,012 T1 protocol activations, 2,443 cases had major injury [positive predictive value (PPV) = 27.1%]. There were 16,823 major injuries in total giving a sensitivity of the T1 protocol of 2,443/16,823 (14.5%), specificity of 145,060/151,629 (95.7%) and a negative predictive value (NPV) of 145,060/159,440 (91%). Overtriage rate associated with T1 protocol was 5,697/9,012 (63.2%) and undertriage rate was 5,509/159,440 (3.5%). The most important predictor of major injury was the activation of more than one trauma protocol by ambulance paramedics. DISCUSSION Overall, the T1 was associated with low undertriage and high specificity. The protocol may be improved by considering age and the number of trauma protocols activated by paramedics for any given patient.
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Affiliation(s)
- Michael Dinh
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia; Sydney Medical School, the University of Sydney, Australia
| | - Hardeep Singh
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia
| | | | | | - Pooria Sarrami
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia; South Western Sydney Clinical School, University of New South Wales, Australia.
| | - Glenn Sisson
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia
| | - Jonathon Newman
- NSW Institute for Trauma and Injury Management (ITIM), NSW Agency for Clinical Innovation (ACI), Australia
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Leslie F, Avis SR, Bagnall RD, Bendall J, Briffa T, Brouwer I, Butters A, Figtree GA, La Gerche A, Gray B, Nedkoff L, Page G, Paratz E, Semsarian C, Sy RW, du Toit-Prinsloo L, Yeates L, Sweeting J, Ingles J. The New South Wales Sudden Cardiac Arrest Registry: A Data Linkage Cohort Study. Heart Lung Circ 2023; 32:1069-1075. [PMID: 37419791 DOI: 10.1016/j.hlc.2023.06.573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/04/2023] [Accepted: 06/18/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Sudden cardiac arrest (SCA) in young people aged 1 to 50 years often occurs with no presenting symptoms or risk factors prompting screening for cardiovascular disease prior to their cardiac arrest. Approximately 3,000 young Australians suffer from sudden cardiac death (SCD) each year, making this a major public health issue. However, there is significant variation in the way incidence is estimated resulting in discrepancy across reporting which impacts our ability to understand and prevent these devastating events. We describe the New South Wales (NSW) Sudden Cardiac Arrest Registry: a retrospective, data linkage study which will identify all SCAs in the young in NSW from 2009 through to June 2022. OBJECTIVE To determine the incidence, demographic characteristics and causes of SCA in young people. We will develop an NSW-based registry that will contribute to a greater understanding of SCA including risk factors and outcomes. METHODS The cohort will include all people who experience a SCA in the NSW community aged between 1 to 50 years. Cases will be identified using the following three datasets: the Out of Hospital Cardiac Arrest Register housed at NSW Ambulance, the NSW Emergency Department Data Collection, and the National Coronial Information System. Data from eight datasets will be collected, anonymised and linked for the entire cohort. Analysis will be undertaken and reported using descriptive statistics. CONCLUSIONS The NSW SCA registry will be an important resource for the improved understanding of SCA and inform the widespread impacts it has on individuals, their families and society.
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Affiliation(s)
- Felicity Leslie
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Suzanne R Avis
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia; Tasmanian School of Medicine, University of Tasmania, Hobart, Tas, Australia
| | - Richard D Bagnall
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Jason Bendall
- Clinical Systems, NSW Ambulance, Sydney, NSW, Australia; Department of Rural Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Isabel Brouwer
- Forensic Medicine, Forensic and Analytical Science Service, NSW Health Pathology, Sydney, NSW, Australia
| | - Alexandra Butters
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Belinda Gray
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | | | | | - Christopher Semsarian
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Lorraine du Toit-Prinsloo
- Forensic Medicine, Forensic and Analytical Science Service, NSW Health Pathology, Sydney, NSW, Australia
| | - Laura Yeates
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Joanna Sweeting
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Jodie Ingles
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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Garcia-Esperon C, Ostman C, Walker FR, Chew B, Edwards S, Emery J, Bendall J, Alanati K, Dunkerton S, Starling de Barros R, Amin M, Gangadharan S, Lillicrap T, Parsons M, Levi CR, Spratt NJ. The Hunter-8 scale prehospital triage workflow for identification of large vessel occlusion and brain haemorrhage. PREHOSP EMERG CARE 2022:1-7. [PMID: 36053543 DOI: 10.1080/10903127.2022.2120134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
ObjectiveThe Hunter-8 prehospital stroke scale predicts large vessel occlusion in hyperacute ischemic stroke patients (LVO) at hospital admission. We wished to test its performance in the hands of paramedics as part of a prehospital triage algorithm. We aimed to determine a) the proportion of patients identified by the Hunter-8 algorithm, receiving reperfusion therapies, b) whether a call to stroke team improved this, and c) performance for LVO detection using an expanded LVO definition.MethodsA prehospital workflow combining pre-morbid functional status, time from symptom onset, and the Hunter-8 scale was implemented from July 2019. A telephone call to the stroke team was prompted for potential treatment candidates. Classic LVO was defined as a proximal middle cerebral artery (MCA-M1), terminal internal carotid artery, or tandem occlusion. Extended LVO added proximal MCA-M2 and basilar occlusions.ResultsFrom July 2019 to April 2021, there were 363 Hunter-8 activations, 320 analysed: 181 (56.6%) had confirmed ischemic strokes, 13 (4.1%) transient ischemic attack, 91 (28.5%) stroke mimics, and 35 (10.9%) intracranial haemorrhage. Fifty-two patients (16.3%) received reperfusion therapies, 35 with Hunter-8 ≥ 8. The stroke doctor changed the final destination for 76 patients (23.7%), and five received reperfusion therapies. The AUCs for classic and extended LVO were 0.73 (95% CI 0.66-0.79) and 0.72 (95% CI 0.65-0.77), respectively.ConclusionThe Hunter-8 workflow resulted in 28.7% of confirmed ischemic stroke patients receiving reperfusion therapies, with no secondary transfers to the comprehensive stroke centre. The role of communication with stroke team needs to be further explored.
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Affiliation(s)
- C Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - C Ostman
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia
| | - F R Walker
- College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Bla Chew
- Department of Neurology, John Hunter Hospital, Australia
| | - S Edwards
- New South Wales Ambulance, Rozelle, Australia
| | - J Emery
- New South Wales Ambulance, Rozelle, Australia
| | - J Bendall
- Department of Neurology, John Hunter Hospital, Australia.,New South Wales Ambulance, Rozelle, Australia
| | - K Alanati
- Department of Neurology, John Hunter Hospital, Australia
| | - S Dunkerton
- Department of Neurology, John Hunter Hospital, Australia
| | | | - M Amin
- Department of Neurology, John Hunter Hospital, Australia
| | - S Gangadharan
- Department of Neurology, John Hunter Hospital, Australia
| | - T Lillicrap
- Hunter Medical Research Institute, Newcastle, Australia
| | - M Parsons
- College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, Australia
| | - C R Levi
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - N J Spratt
- Department of Neurology, John Hunter Hospital, Australia.,College of Health, Medicine, and Wellbeing, University of Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
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Djärv T, Douma M, Palmieri T, Meyran D, Berry D, Kloeck D, Bendall J, Morrison LJ, Singletary EM, Zideman D. Duration of cooling with water for thermal burns as a first aid intervention: A systematic review. Burns 2022; 48:251-262. [PMID: 34916091 DOI: 10.1016/j.burns.2021.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/13/2021] [Accepted: 10/18/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cooling thermal burns with running water is a recommended first aid intervention. However, guidance on the ideal duration of cooling remains controversial and inconsistent across organisations. AIM To perform a systematic review of the evidence for the question; Among adults and children with thermal burn, does active cooling using running water as an immediate first aid intervention for 20 min or more, compared with active cooling using running water for any other duration, change the outcomes of burn size, burn depth, pain, adverse outcome (hypothermia) or complications? METHOD We searched Medline, Embase, Cochrane Database of Systematic Reviews and used ROBINS-I to assess for risk of bias. We used Grading of Recommendations, Assessment, Development and Evaluation methodology for determining the certainty of evidence. We included all studies that compared the selected outcomes of the duration of cooling of thermal burns with water in all patient ages. (PROSPERO registration number: CRD42021180665). From 560 screened references, we included four observational studies. In these studies, 48% of burns were cooled for 20 min or more. We found no benefit for a duration of 20 min or more of cooling when compared with less than 20 min of cooling for the outcomes of size and depth of burn, re-epithelialization, or skin grafting. The evidence is of very low certainty owing to limitations in study design, risk of bias and indirectness. CONCLUSION The optimal duration of cooling for thermal burns remains unknown and future prospective research is indicated to better define this treatment recommendation.
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Affiliation(s)
- Therese Djärv
- Department of Medicine Solna, Karolinska Institute and Division of Acute and Reparative Medicine, Karolinska University Hospital, Sweden.
| | - Matthew Douma
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Canada.
| | - Tina Palmieri
- Burn Division, University of California Davis and Shriners Hospital for Children Northern California, Sacramento, CA, USA.
| | - Daniel Meyran
- Bataillon de Marins Pompiers de Marseille, French Red Cross, France.
| | - David Berry
- Department of Kinesiology, Saginaw Valley State University, University Center, MI, USA.
| | - David Kloeck
- Department of Critical Care, University of the Witwatersrand, Johannesburg, South Africa.
| | - Jason Bendall
- Department of Rural Health, University of Newcastle, Newcastle, Australia.
| | - Laurie J Morrison
- Emergency Department, St Michael´s Hospital, Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Eunice M Singletary
- University of Virginia, Department of Emergency Medicine, Charlottesville, VA, USA.
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Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, Aickin R, Bhanji F, Donnino MW, Mancini ME, Wyllie JP, Zideman D, Andersen LW, Atkins DL, Aziz K, Bendall J, Berg KM, Berry DC, Bigham BL, Bingham R, Couto TB, Böttiger BW, Borra V, Bray JE, Breckwoldt J, Brooks SC, Buick J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Couper K, Dainty KN, Dawson JA, de Almeida MF, de Caen AR, Deakin CD, Drennan IR, Duff JP, Epstein JL, Escalante R, Gazmuri RJ, Gilfoyle E, Granfeldt A, Guerguerian AM, Guinsburg R, Hatanaka T, Holmberg MJ, Hood N, Hosono S, Hsieh MJ, Isayama T, Iwami T, Jensen JL, Kapadia V, Kim HS, Kleinman ME, Kudenchuk PJ, Lang E, Lavonas E, Liley H, Lim SH, Lockey A, Lofgren B, Ma MHM, Markenson D, Meaney PA, Meyran D, Mildenhall L, Monsieurs KG, Montgomery W, Morley PT, Morrison LJ, Nadkarni VM, Nation K, Neumar RW, Ng KC, Nicholson T, Nikolaou N, Nishiyama C, Nuthall G, Ohshimo S, Okamoto D, O’Neil B, Yong-Kwang Ong G, Paiva EF, Parr M, Pellegrino JL, Perkins GD, Perlman J, Rabi Y, Reis A, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Schexnayder SM, Scholefield BR, Shimizu N, Skrifvars MB, Smyth MA, Stanton D, Swain J, Szyld E, Tijssen J, Travers A, Trevisanuto D, Vaillancourt C, Van de Voorde P, Velaphi S, Wang TL, Weiner G, Welsford M, Woodin JA, Yeung J, Nolan JP, Fran Hazinski M. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2019; 140:e826-e880. [DOI: 10.1161/cir.0000000000000734] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.
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McNeish I, Moreno V, Jayson G, Roxburgh P, Ginesta MPB, Garcia-Donas J, Torres AA, Michael A, Brown R, Krige D, Bendall J, Di Genova G, McElwaine-Johnn H. OCTAVE: A phase I study of enadenotucirev, an oncolytic group B adenovirus, in combination with weekly paclitaxel in platinum-resistant epithelial ovarian cancer. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz250.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Simpson P, Thomas R, Bendall J, Lord B, Lord S, Close J. 'Popping nana back into bed' - a qualitative exploration of paramedic decision making when caring for older people who have fallen. BMC Health Serv Res 2017; 17:299. [PMID: 28431536 PMCID: PMC5399835 DOI: 10.1186/s12913-017-2243-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older fallers constitute a large proportion of ambulance work, and as many as 25% are not transported to hospital following paramedic assessment. The objective of this study was to explore the decision making process used by paramedics when caring for older fallers. METHODS A qualitative study was conducted using constructivist grounded theory methodology. Purposive sampling was used to recruit paramedics to participate in semi-structured interviews and focus groups. Data analysis commenced with line-by-line coding, developing into formation of theoretical categories. Theoretical sampling was then used to clarify emerging theoretical concepts, with data collection and analysis continuing until theoretical saturation was achieved. RESULTS A total of 33 paramedics participated in 13 interviews and 4 focus groups. When caring for older fallers, paramedic decision making is profoundly affected by 'role perception', in which the individual paramedic's perception of what the role of a paramedic is determines the nature of the decision making process. Transport decisions are heavily influenced by a sense of 'personal protection', or their confidence in the ambulance service supporting their decisions. 'Education and training' impacts on decision making capacity, and the nature of that training subliminally contributes to role perception. Role perception influences the sense of legitimacy a paramedic attaches to cases involving older fallers, impacting on patient assessment routines and the quality of subsequent decisions. CONCLUSIONS Paramedic decision making processes when caring for older people who have fallen appear to be strongly influenced by their perception of what their role should be, and the perceived legitimacy of incidents involving older fallers as constituting 'real' paramedic work.
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Affiliation(s)
- Paul Simpson
- Western Sydney University, Locked Bag 1797, Penrith, 2750, NSW, Australia.
| | - Ric Thomas
- Western Sydney University, Locked Bag 1797, Penrith, 2750, NSW, Australia
| | | | - Bill Lord
- University of Sunshine Coast, Queensland, Australia
| | - Stephen Lord
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, NSW, Australia
| | - Jacqueline Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, NSW, Australia.,Department of Geriatric Medicine, Prince of Wales Clinical School, Sydney, Australia
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Mikolaizak AS, Lord SR, Tiedemann A, Simpson P, Caplan GA, Bendall J, Howard K, Webster L, Payne N, Hamilton S, Lo J, Ramsay E, O'Rourke S, Roylance L, Close JC. A multidisciplinary intervention to prevent subsequent falls and health service use following fall-related paramedic care: a randomised controlled trial. Age Ageing 2017; 46:200-207. [PMID: 28399219 DOI: 10.1093/ageing/afw190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/14/2016] [Indexed: 01/04/2023] Open
Abstract
Background approximately 25% of older people who fall and receive paramedic care are not subsequently transported to an emergency department (ED). These people are at high risk of future falls, unplanned healthcare use and poor health outcomes. Objective to evaluate the impact of a fall-risk assessment and tailored fall prevention interventions among older community-dwellers not transported to ED following a fall on subsequent falls and health service use. Design, setting, participants Randomised controlled trial involving 221 non-transported older fallers from Sydney, Australia. Intervention the intervention targeted identified risk factors and used existing services to implement physiotherapy, occupational therapy, geriatric assessment, optometry and medication management interventions as appropriate. The control group received individualised written fall prevention advice. Measurements primary outcome measures were rates of falls and injurious falls. Secondary outcome measures were ambulance re-attendance, ED presentation, hospitalisation and quality of life over 12 months. Analysis was by intention-to-treat and per-protocol according to self-reported adherence using negative binominal regression and multivariate analysis. Results ITT analysis showed no significant difference between groups in subsequent falls, injurious falls and health service use. The per-protocol analyses revealed that the intervention participants who adhered to the recommended interventions had significantly lower rates of falls compared to non-adherers (IRR: 0.53 (95% CI : 0.32-0.87)). Conclusion a multidisciplinary intervention did not prevent falls in older people who received paramedic care but were not transported to ED. However the intervention was effective in those who adhered to the recommendations. Trial registration the trial is registered at the Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921, 13/05/2011.
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Affiliation(s)
- A Stefanie Mikolaizak
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Stephen R Lord
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Anne Tiedemann
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Paul Simpson
- Western Sydney University, School of Science and Health, Campbelltown, New South Wales, Australia
| | - Gideon A Caplan
- Post Acute Care Services, Prince of Wales Hospital, Randwick, Sydney, New South Wales 2031, Australia
| | - Jason Bendall
- University of the Sunshine Coast, Maroochydore DC, Queensland, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lyndell Webster
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Narelle Payne
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Sarah Hamilton
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Joanne Lo
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Elisabeth Ramsay
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Sandra O'Rourke
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Linda Roylance
- Falls Balance Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - J C Close
- Neuroscience Research Australia, Randwick, New South Wales, Australia
- UNSW Prince of Wales Clinical School, Randwick, New South Wales, Australia
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Lord B, Bendall J, Reinten T. The influence of paramedic and patient gender on the administration of analgesics in the out-of-hospital setting. PREHOSP EMERG CARE 2014; 18:195-200. [PMID: 24401105 DOI: 10.3109/10903127.2013.856502] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine whether analgesic administration in the out-of-hospital setting is influenced by the gender of the patient or the gender of the paramedic. METHODS This retrospective cohort study of patient care records included adult patients (age > 15 years) with moderate to severe pain (verbal numerical rating score 4-10) treated by paramedics between January 1, 2008 and December 31, 2009. Data extracted included patient pain severity score, analgesia provided by paramedics, and gender of the treating paramedic. Data was analyzed by descriptive statistics, χ(2) test, and logistic regression. The primary outcome measures were the effect of patient and paramedic gender on analgesic administration. RESULTS The study population comprised 42,051 patients, median age of 57 years (38-75); 50.4% were female and 51% were administered an analgesic agent. For the outcome of receiving any analgesia, neither patient gender nor paramedic gender was predictive (p = NS). In a multivariate model for the outcome of receiving any analgesia, patient gender, paramedic gender, and the interaction between patient and paramedic gender were all nonsignificant (p = NS). For the outcome of receiving opioid analgesia (i.e., morphine or fentanyl), male patients were at greater odds of receiving an opioid (OR 1.52, 95% CI 1.29-1.79, p < 0.0001). Paramedic gender was not predictive of whether an opioid was given (p = NS). CONCLUSIONS The gender of the paramedic did not appear to influence the odds of analgesic administration. Female patients were less likely to receive opioids. Paramedic gender does not explain this finding.
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Fouche PF, Simpson PM, Bendall J, Thomas RE, Cone DC, Doi SAR. Airways in out-of-hospital cardiac arrest: systematic review and meta-analysis. PREHOSP EMERG CARE 2013; 18:244-56. [PMID: 24111481 DOI: 10.3109/10903127.2013.831509] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine the differences in survival for out-of-hospital advanced airway intervention (AAI) compared with basic airway intervention (BAI) in cardiac arrest. BACKGROUND AAI is commonly utilized in cardiac arrest in the out-of-hospital setting as a means to secure the airway. Observational studies and clinical trials of AAI suggest that AAI is associated with worse outcomes in terms of survival. No controlled trials exist that compares AAI to BAI. METHODS We conducted a bias-adjusted meta-analysis on 17 observational studies. The outcomes were survival, short-term (return of spontaneous circulation and to hospital admission), and longer-term (to discharge, to one month survival). We undertook sensitivity analyses by analyzing patients separately: those who were 16 years and older, nontrauma only, and attempted versus successful AAI. RESULTS This meta-analysis included 388,878 patients. The short-term survival for AAI compared to BAI were overall OR 0.84(95% CI 0.62 to 1.13), for endotracheal intubation (ETI) OR 0.79 (95% CI 0.54 to 1.16), and for supraglottic airways (SGA) OR 0.59 (95% CI 0.39 to 0.89). Long-term survival for AAI were overall OR 0.49 (95% CI 0.37 to 0.65), for ETI OR 0.48 (95% CI 0.36 to 0.64), and for SGA OR 0.35 (95% CI 0.28 to 0.44). Sensitivity analyses shows that limiting analyses to adults, non-trauma victims, and instances where AAI was both attempted and successful did not alter results meaningfully. A third of all studies did not adjust for any other confounding factors that could impact on survival. CONCLUSIONS This meta-analysis shows decreased survival for AAIs used out-of-hospital in cardiac arrest, but are likely biased due to confounding, especially confounding by indication. A properly conducted prospective study or a controlled trial is urgently needed and are possible to do.
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Affiliation(s)
- Pieter F Fouche
- From Paramedics Australasia (PFF), Sydney, New South Wales, Australia; the University of Western Sydney, School of Science and Health (PMS) , Sydney, New South Wales , Australia ; Department of Anaesthesia, Gosford Hospital (JB) , Gosford, New South Wales , Australia ; Australia and New Zealand College of Paramedicine (RET), Sydney , New South Wales , Australia ; Section of EMS, Department of Emergency Medicine, Yale University School of Medicine (DCC) , New Haven , Connecticut ; University of Queensland, School of Population Health (SARD) , Brisbane, Queensland , Australia
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Fan L, Douglas G, Bendall J, McNeill E, Channon K. C Endothelial specific Nox2 over-expression increases susceptibility to angiotensin II induced aortic dissection. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877a.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chew MS, Hawthorne WJ, Bendall J, Whereat S, Huang S, Ting I, Simond D, McLean A. No beneficial effects of levosimendan in acute porcine endotoxaemia. Acta Anaesthesiol Scand 2011; 55:851-61. [PMID: 21574964 DOI: 10.1111/j.1399-6576.2011.02436.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Levosimendan has been proposed as an attractive alternative to adrenergic agents for the treatment of sepsis-induced heart failure and haemodynamic derangements. Its use in this setting is, however, still not well investigated. The aim of this study was to test the hypothesis that levosimendan is able to attenuate endotoxin-induced pulmonary hypertension and improve myocardial function in a porcine model. The secondary aims were to investigate its effect on renal and liver function, and the plasma cytokine response. METHODS Endotoxaemia was induced in 18 pigs, randomized to placebo and Levosimendan groups. All pigs were fluid resuscitated and Noradrenalin infusion was given according to a predefined protocol. Systemic haemodynamics and myocardial function were measured using pulmonary artery catheterization and transthoracic echocardiography. Renal and liver function tests and cytokine concentrations were measured in plasma. RESULTS Levosimendan did not attenuate endotoxin-induced pulmonary hypertension and did not improve myocardial function. There were no differences in renal or liver function. Increases in arterial lactate and decreases in base excess were observed in the Levosimendan group, as well as significant increases in plasma interleukin (IL)-6 and IL-8. CONCLUSIONS Contrary to our hypothesis, levosimendan given in conjunction with a protocolized vasopressor and fluid resuscitation did not improve cardiac, renal or liver function in this model of acute porcine endotoxaemia. Hyperlactataemia, acidosis and increases in plasma pro-inflammatory cytokines were observed, the mechanisms and implications of which remain unclear.
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Affiliation(s)
- Michelle S Chew
- Department of Intensive Care Medicine, Skåne University Hospital Malmö, Lund University, Sweden.
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Eburn M, Bendall J. The provision of Ambulance Services in Australia: a legal argument for the national registration of paramedics. ACTA ACUST UNITED AC 2010. [DOI: 10.33151/ajp.8.4.85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This paper identifies that there is a growing private ambulance sector, notwithstanding legislative prohibitions on the provision of ambulance services that exist in nearly all Australian State and Territories. Notwithstanding these prohibitions, there appears to be no intention to prosecute private ambulance providers and, indeed, governments probably appreciate that these services fill a need and reduce the demand for non-emergency services on state run ambulance services.
The paper will define what is meant by ambulance services and describes what is prohibited in each Australian jurisdiction and then argue that, to ensure that the providers of ambulance services continue to deliver a quality service to the public, there should be a legally sanctioned system to register paramedics and the use of various titles associated with the prehospital sector must be restricted.
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Fan L, Douglas G, Bendall J, Channon K. Targeted endothelial Nox2 over-expression potentiates angiotensin ii induced aortic dissection in mice. Atherosclerosis 2010. [DOI: 10.1016/j.atherosclerosis.2010.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bendall J. Nursing mirror community forum 7. Teaching for all. Nurs Mirror 1983; 157:suppl v-viii. [PMID: 6554763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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