Current Issue : January - March Volume : 2012 Issue Number : 1 Articles : 8 Articles
Background: Pre-hospital electrocardiogram (ECG) transmission to an expert for interpretation and triage reduces\r\ntime to acute percutaneous coronary intervention (PCI) in patients with ST elevation Myocardial Infarction (STEMI).\r\nIn order to detect all STEMI patients, the ECG should be transmitted in all cases of suspected acute cardiac\r\nischemia. The aim of this study was to examine the ability of an artificial neural network (ANN) to safely reduce the\r\nnumber of ECGs transmitted by identifying patients without STEMI and patients not needing acute PCI.\r\nMethods: Five hundred and sixty ambulance ECGs transmitted to the coronary care unit (CCU) in routine care\r\nwere prospectively collected. The ECG interpretation by the ANN was compared with the diagnosis (STEMI or not)\r\nand the need for an acute PCI (or not) as determined from the Swedish coronary angiography and angioplasty\r\nregister. The CCU physician�s real time ECG interpretation (STEMI or not) and triage decision (acute PCI or not)\r\nwere registered for comparison.\r\nResults: The ANN sensitivity, specificity, positive and negative predictive values for STEMI was 95%, 68%, 18% and\r\n99%, respectively, and for a need of acute PCI it was 97%, 68%, 17% and 100%. The area under the ANN�s receiver\r\noperating characteristics curve for STEMI detection was 0.93 (95% CI 0.89-0.96) and for predicting the need of acute\r\nPCI 0.94 (95% CI 0.90-0.97). If ECGs where the ANN did not identify a STEMI or a need of acute PCI were\r\ntheoretically to be withheld from transmission, the number of ECGs sent to the CCU could have been reduced by\r\n64% without missing any case with STEMI or a need of immediate PCI.\r\nConclusions: Our ANN had an excellent ability to predict STEMI and the need of acute PCI in ambulance ECGs,\r\nand has a potential to safely reduce the number of ECG transmitted to the CCU by almost two thirds....
Introduction: Single-pass, whole-body computed tomography (pan-scan) remains a controversial intervention in\r\nthe early assessment of patients with major trauma. We hypothesized that a liberal pan-scan policy is mainly an\r\nindicator of enhanced process quality of emergency care that may lead to improved survival regardless of the\r\nactual use of the method.\r\nMethods: This retrospective cohort study included consecutive patients with blunt trauma referred to a trauma\r\ncenter prior to (2000 to 2002) and after (2002 to 2007) the introduction of a liberal single-pass pan-scan policy. The\r\noverall mortality between the two periods was compared and stratified according to the availability and actual use\r\nof the pan-scan. Logistic regression analysis was employed to adjust mortality estimates for demographic and\r\ninjury-related independent variables.\r\nResults: The study comprised 313 patients during the pre-pan-scan period, 223 patients after the introduction of\r\nthe pan-scan policy but not undergoing a pan-scan and 608 patients undergoing a pan-scan. The overall mortality\r\nwas 23.3, 14.8 and 7.9% (P < 0.001), respectively. By univariable logistic regression analysis, both the availability\r\n(odds ratio (OR) 0.57, 95% confidence interval (CI): 0.36 to 0.90) and the actual use of the pan-scan (OR 0.28, 95%\r\nCI: 0.19 to 0.42) were associated with a lower mortality. The final model contained the Injury Severity Score, the\r\nGlasgow Coma Scale, age, emergency department time and the use of the pan-scan. 2.7% of the explained\r\nvariance in mortality was attributable to the use of the pan-scan. This contribution increased to 7.1% in the highest\r\ninjury severity quartile.\r\nConclusions: In this study, a liberal pan-scan policy was associated with lower trauma mortality. The causal role of\r\nthe pan-scan itself must be interpreted in the context of improved structural and process quality, is apparently\r\nmoderate and needs further investigation with regard to the diagnostic yield and changes in management\r\ndecisions. (The Pan-Scan for Trauma Resuscitation [PATRES] Study Group, ISRCTN35424832 and ISRCTN41462125)...
Background: Early intramedullary nailing (IMN) of long bone fractures in severely injured patients has been\r\nevaluated as beneficial, but has also been associated with increased inflammation, multi organ failure (MOF) and\r\nmorbidity. This study was initiated to evaluate the impact of primary femoral IMN on coagulation-, fibrinolysis-,\r\ninflammatory- and cardiopulmonary responses in polytraumatized patients.\r\nMethods: Twelve adult polytraumatized patients with femoral shaft fractures were included. Serial blood samples\r\nwere collected to evaluate coagulation-, fibrinolytic-, and cytokine activation in arterial blood. A flow-directed\r\npulmonary artery (PA) catheter was inserted prior to IMN. Cardiopulmonary function parameters were recorded\r\nperi- and postoperatively. The clinical course of the patients and complications were monitored and recorded daily.\r\nResults: Mean Injury Severity Score (ISS) was 31 �± 2.6. No procedure-related effect of the primary IMN on\r\ncoagulation- and fibrinolysis activation was evident. Tumor necrosis factor alpha (TNF-a) increased significantly\r\nfrom 6 hours post procedure to peak levels on the third postoperative day. Interleukin-6 (IL-6) increased from the\r\nfirst to the third postoperative day. Interleukin-10 (IL-10) peaked on the first postoperative day. A procedure-related\r\ntransient hemodynamic response was observed on indexed pulmonary vascular resistance (PVRI) two hours post\r\nprocedure. 11/12 patients developed systemic inflammatory response syndrome (SIRS), 7/12 pneumonia, 3/12 acute\r\nlung injury (ALI), 3/12 adult respiratory distress syndrome (ARDS), 3/12 sepsis, 0/12 wound infection.\r\nConclusion: In the polytraumatized patients with femoral shaft fractures operated with primary IMN we observed a\r\nsubstantial response related to the initial trauma. We could not demonstrate any major additional IMN-related\r\nimpact on the inflammatory responses or on the cardiopulmonary function parameters. These results have to be\r\ninterpreted carefully due to the relatively few patients included....
Background: On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree\r\nincident in Norway. This article describes the emergency medical service (EMS) response elicited by the two\r\nincidents.\r\nMethods: A retrospective and observational study was conducted based on data from the EMS systems involved\r\nand the public domain. The study was approved by the Data Protection Official and was defined as a quality\r\nimprovement project.\r\nResults: We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response,\r\ntriage and evacuation. The scenes in the Oslo government district and at Ut�¸ya island are described separately.\r\nConclusions: Many EMS units were activated and effectively used despite the occurrence of two geographically\r\nseparate incidents within a short time frame. Important lessons were learned regarding triage and evacuation,\r\npatient flow and communication, the use of and need for emergency equipment and the coordination of\r\nhelicopter EMS....
Background: Most patients with acute poisoning are treated as outpatients worldwide. In Oslo, these patients are\r\ntreated in a physician-led outpatient clinic with limited diagnostic and treatment resources, which reduces both\r\nthe costs and emergency department overcrowding. We describe the poisoning patterns, treatment, mortality,\r\nfactors associated with hospitalization and follow-up at this Emergency Medical Agency (EMA, ââ?¬Å?Oslo Legevaktââ?¬Â), and\r\nwe evaluate the safety of this current practice.\r\nMethods: All acute poisonings in adults (> or = 16 years) treated at the EMA during one year (April 2008 to April\r\n2009) were included consecutively in an observational study design. The treating physicians completed a\r\nstandardized form comprising information needed to address the studyââ?¬â?¢s aims. Multivariate logistic regression\r\nanalysis was used to identify the factors associated with hospitalization.\r\nResults: There were 2348 contacts for 1856 individuals; 1157 (62%) were male, and the median age was 34 years.\r\nThe most frequent main toxic agents were ethanol (43%), opioids (22%) and CO or fire smoke (10%). The\r\nphysicians classified 73% as accidental overdoses with substances of abuse taken for recreational purposes, 15% as\r\nother accidents (self-inflicted or other) and 11% as suicide attempts. Most (91%) patients were treated with\r\nobservation only. The median observation time until discharge was 3.8 hours. No patient developed sequelae or\r\ndied at the EMA. Seventeen per cent were hospitalized. Gamma-hydroxybutyric acid, respiratory depression,\r\nparacetamol, reduced consciousness and suicidal intention were factors associated with hospitalization. Forty-eight\r\nper cent were discharged without referral to follow-up. The one-month mortality was 0.6%. Of the nine deaths, five\r\nwere by new accidental overdose with substances of abuse.\r\nConclusions: More than twice as many patients were treated at the EMA compared with all hospitals in Oslo.\r\nDespite more than a doubling of the annual number of poisoned patients treated at the EMA since 2003, there\r\nwas no mortality or sequelae, indicating that the current practice is safe. Thus, most low- to intermediate-acuity\r\npoisonings can be treated safely without the need to access hospital resources. Although the short-term mortality\r\nwas low, more follow-up of patients with substance abuse should be encouraged....
Background: Neuron specific enolase (NSE) has repeatedly been evaluated for neurological prognostication in\r\npatients after cardiac arrest. However, it is unclear whether current guidelines for NSE cutoff levels also apply to\r\ncardiac arrest patients treated with hypothermia. Thus, we investigated the prognostic significance of absolute NSE\r\nlevels and NSE kinetics in cardiac arrest patients treated with hypothermia.\r\nMethods: In a prospective study of 35 patients resuscitated from cardiac arrest, NSE was measured daily for four\r\ndays following admission. Outcome was assessed at ICU discharge using the CPC score. All patients received\r\nhypothermia treatment for 24 hours at 33�°C with a surface cooling device according to current guidelines.\r\nResults: The cutoff for absolute NSE levels in patients with unfavourable outcome (CPC 3-5) 72 hours after cardiac\r\narrest was 57 �µg/l with an area under the curve (AUC) of 0.82 (sensitivity 47%, specificity 100%). The cutoff level for\r\nNSE kinetics in patients with unfavourable outcome (CPC 3-5) was an absolute increase of 7.9 �µg/l (AUC 0.78,\r\nsensitivity 63%, specificity 100%) and a relative increase of 33.1% (AUC 0.803, sensitivity 67%, specificity 100%) at 48\r\nhours compared to admission.\r\nConclusion: In cardiac arrest patients treated with hypothermia, prognostication of unfavourable outcome by NSE\r\nkinetics between admission and 48 hours after resuscitation may be superior to prognostication by absolute NSE\r\nlevels....
Background: Gamma-hydroxybutyrate (GHB) and gamma-butyrolactone (GBL) have been profiled as ââ?¬Ë?party drugsââ?¬â?¢\r\nused mainly at dance parties and in nightclubs on weekend nights. The purpose of this study was to examine the\r\nfrequency of injecting drug use among GHB/GBL overdose patients and whether there are temporal differences in\r\nthe occurrence of GHB/GBL overdoses of injecting drug and recreational drug users.\r\nMethods: In this retrospective study, the ambulance and hospital records of suspected GHB- and GBL overdose\r\npatients treated by the Helsinki Emergency Medical Service from January 1st 2006 to December 31st 2007 were\r\nreviewed. According to the temporal occurrence of the overdose, patients were divided in two groups. In group A,\r\nthe overdose occurred on a Friday-Saturday or Saturday-Sunday night between 11 pm-6 am. Group B consisted of\r\noverdoses occurring on outside this time frame.\r\nResults: Group A consisted of 39 patient contacts and the remaining 61 patient contacts were in group B. There\r\nwere statistically significant differences between the two groups in (group A vs. B, respectively): history of injecting\r\ndrug abuse (33% vs. 59%, p = 0.012), reported polydrug and ethanol use (80% vs. 62%, p = 0.028), the location\r\nwhere the patients were encountered (private or public indoors or outdoors, 10%, 41%, 41% vs. 25%, 18%, 53%, p\r\n= 0.019) and how the knowledge of GHB/GBL use was obtained (reported by patient/bystanders or clinical\r\nsuspicion, 72%, 28% vs. 85%, 10%, p = 0.023). Practically all (99%) patients were transported to emergency\r\ndepartment after prehospital care.\r\nConclusion: There appears to be at least two distinct groups of GHB/GBL users. Injecting drug users represent the\r\nmajority of GHB/GBL overdose patients outside weekend nights....
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