Pre-hospital body surface potential mapping improves early diagnosis of acute coronary artery occlusion in patients with ventricular fibrillation and cardiac arrest

Aims: To determine whether 80-lead body surface potential mapping (BSPM) improves detection of acute coronary artery occlusion in patients presenting with out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF) and who survived to reach hospital. Methods and results: Of 645 consecutive patients with OHCA who were attended by the mobile coronary care unit, VF was the initial rhythm in 168 patients. Eighty patients survived initial resuscitation, 59 of these having had BSPM and 12-lead ECG post-return of spontaneous circulation (ROSC) and in 35 patients (age 69±13 yrs; 60% male) coronary angiography performed within 24. h post-ROSC. Of these, 26 (74%) patients had an acutely occluded coronary artery (TIMI flow grade [TFG] 0/1) at angiography. Twelve-lead ECG criteria showed ST-segment elevation (STE) myocardial infarction (STEMI) using Minnesota 9-2 criteria - sensitivity 19%, specificity 100%; ST-segment depression (STD) =0.05. mV in =2 contiguous leads - sensitivity 23%, specificity 89%; and, combination of STEMI or STD criteria - sensitivity 46%, specificity 100%. BSPM STE occurred in 23 (66%) patients. For the diagnosis of TFG 0/1 in a main coronary artery, BSPM STE had sensitivity 88% and specificity 100% (c-statistic 0.94), with STE occurring most commonly in either the posterior, right ventricular or high right anterior territories. Conclusion: Among OHCA patients presenting with VF and who survived resuscitation to reach hospital, post-resuscitation BSPM STE identifies acute coronary occlusion with sensitivity 88% and specificity 100% (c-statistic 0.94). © 2012 Elsevier Ireland Ltd.

What counts and what is being counted – The social organization of knowledge on the front lines of emergency medical services.

Paramedics are trained to use specialized medical knowledge and a variety of medical procedures and pharmaceutical interventions to “save patients and prevent further damage” in emergency situations, both as members of “health-care teams” in hospital emergency departments (Swanson, 2005: 96) and on the streets – unstandardized contexts “rife with chaotic, dangerous, and often uncontrollable elements” (Campeau, 2008: 3). The paramedic’s unique skill-set and ability to function in diverse situations have resulted in the occupation becoming ever more important to health care systems (Alberta Health and Wellness, 2008: 12).
Today, prehospital emergency services, while varying, exist in every major city and many rural areas throughout North America (Paramedics Association of Canada, 2008) and other countries around the world (Roudsari et al., 2007). Services in North America, for instance, treat and/or transport 2 million Canadians (over 250,000 in Alberta alone ) and between 25 and 30 million Americans annually (Emergency Medical Services Chiefs of Canada, 2006; National EMS Research Agenda, 2001). In Canada, paramedics make up one of the largest groups of health care professionals, with numbers exceeding 20,000 (Pike and Gibbons, 2008; Paramedics Association of Canada, 2008). However, there is little known about the work practices of paramedics, especially in light of recent changes to how their work is organized, making the profession “rich with unexplored opportunities for research on the full range of paramedic work” (Campeau, 2008: 2).

This presentation reports on findings from an institutional ethnography that explored the work of paramedics and different technologies of knowledge and governance that intersect with and organize their work practices. More specifically, my tentative focus of this presentation is on discussing some of the ruling discourses central to many of the technologies used on the front lines of EMS in Alberta and the consequences of such governance practices for both the front line workers and their patients. In doing so, I will demonstrate how IE can be used to answer Rankin and Campbell’s (2006) call for additional research into “the social organization of information in health care and attention to the (often unintended) ways ‘such textual products may accomplish…ruling purposes but otherwise fail people and, moreover, obscure that failure’ (p. 182)” (cited in McCoy, 2008: 709).

Pediatric emergencies admitted in the resuscitation room of a swiss university hospital.

OBJECTIVES: Pediatric resuscitation is an intense, stressful, and challenging process. The aim of this study was to review the life-threatening pediatric (LTP) emergencies admitted in a Swiss university hospital with regards to patients' demographics, reason for admission, diagnosis, treatment, significant events, critical incidents, and outcomes. METHODS: A retrospective observational cohort study of prospectively collected data was conducted, including all LTP emergencies admitted over a period of 2 years in the resuscitation room (RR). Variables, including indication for transfer, mode of prehospital transportation, diagnosis, and time spent in RR, were recorded. RESULTS: Of the 60,939 pediatric emergencies treated in our university hospital over 2 years, a total of 277 LTP emergencies (0.46%) were admitted in the RR. They included 160 boys and 117 girls, aged 6 days to 15.95 years (mean, 6.69 years; median, 5.06). A medical problem was identified in 55.9% (n = 155) of the children. Of the 122 children treated for a surgical problem, 35 (28.3%) went directly from the RR to the operating room. Hemodynamic instability was noted in 19.5% of all LTP emergencies, of which 1.1% benefited from O negative transfusion. Admission to the intensive care unit was necessary for 61.6% of the children transferred from another hospital. The average time spent in the RR was 46 minutes. The overall mortality rate was 7.2%. CONCLUSIONS: The LTP emergencies accounted for a small proportion of all pediatric emergencies. They were more medical than surgical cases and resuscitation measures because of hemodynamic instability were the most frequent treatment.

La perception du rôle et les attitudes de cynisme et de désengagement chez le technicien ambulancier paramédic québécois dans le contexte des interventions non urgentes

Problématique : Le rôle des paramédics se transforme partout dans le monde. Les besoins des aînés et des malades chroniques entraînent une forte proportion d’interventions préhospitalières non urgentes. La confrontation entre la perception et l’expérience du rôle peut entraîner un conflit correspondant à un stress organisationnel modéré et chronique chez ces travailleurs. Pour y faire face, différentes stratégies d’adaptation peuvent être adoptées. Objectifs : Cette étude vise à dépeindre la réalité des interventions préhospitalières non urgentes des paramédics québécois et à explorer son influence sur leur perception du rôle et les manifestations de cynisme et de désengagement. Méthode : Les données qualitatives obtenues en entrevues semi-structurées ont été codifiées et analysées à partir d’un modèle adapté des théories en psychosociologie du travail et d’administration de la santé (n=13, 3 régions, intervenants de - de 3 à + de 20 ans de carrière). Résultats : Les paramédics reconnaissent vivre un conflit de rôle alors que la formation et la définition de leur pratique se rapportent exclusivement à l’urgence, au contraire de leur expérience. Ils manifestent des attitudes de cynisme et de désengagement affectant la qualité des services, précisant qu’il s’agit d’une réalité inhérente à leur expérience professionnelle intimement reliée à l’épuisement professionnel, plus qu’à un manque fondamental de professionnalisme. Conclusion : Les paramédics décrivent différents mécanismes à instaurer qui visent à reconnaître la dualité conflictuelle de leur pratique dont, la mise en valeur de leur aptitude clinique à intervenir en première ligne dans un cadre préhospitalier non urgent ainsi que l’ajustement et le rehaussement des programmes de formation.

Mortalidad por trauma cardiaco penetrante en un hospital de Bogotá, Colombia : análisis de factores asociados

Objetivó: Caracterizar los pacientes con heridas cardiacas penetrantes grado II a VI, describir las características del trauma, tratamiento quirúrgico, evolución clínica e identificar los factores asociados a un desenlace. Metodología: Se diseñó un estudio de asociación en 308 pacientes que ingresaron a cirugía con diagnóstico de herida penetrante de corazón entre enero de 1999 y octubre de 2009. Se excluyeron 68 casos. La serie analizada incluyó 240 pacientes con heridas cardiacas. Se analizaron variables demográficas, clínicas, quirúrgicas y de evolución, tabulados en EXCEL® y analizados en SPSS 20®. Resultados: El promedio de edad fue 27.8 años, principalmente hombres (96%), lesiones por arma cortopunzante 93% y un 7% por proyectil arma de fuego. El estado hemodinámico al ingreso (según Ivatury) fue normal 44%; Shock profundo 34%; Agónicos 18% y 3% fatales. El 67% (n=161) presentaron taponamiento cardiaco. Los grados de lesión cardiaca según la clasificación OIS-AAST fueron: grado II 33%, grado III 13%, grado IV 29%, grado V 22% y grado VI 3%. La ventana pericárdica fue el método diagnóstico confirmatorio de lesión en 63% y las incisiones de abordaje quirúrgico fueron la esternotomía 63% y la toracotomía anterolateral 35%. La mortalidad fue 15% (n=36). Las diferencias en mortalidad entre el estado hemodinámico al inicio de cirugía, mecanismo de lesión y grado de herida, demostraron ser estadísticamente significativas (valor de p<0.001). Conclusiones: El estado hemodinámico y las heridas por arma de fuego son factores asociados a mortalidad. La ventana pericárdica subxifoidea favorece la preferencia y buenos resultados de la esternotomía como vía de abordaje quirúrgico.

Factores asociados con el tiempo de consulta a urgencias en pacientes con infarto agudo de miocardio

Las enfermedades cardiovasculares son la principal causa de muerte en el mundo, siendo la enfermedad coronaria, la más representativa. Con los avances en tratamientos invasivos, se ha logrado disminuir la morbi-mortalidad global, siendo crucial el tiempo de realización de dichas terapias desde el tiempo de inicio de los síntomas. Por tanto es necesario determinar los factores relacionados con la tardanza en la búsqueda de atención. METODOLOGIA: Estudio observacional analítico transversal, en pacientes hospitalizados por evento coronario agudo en un hospital universitario de tercer nivel en Bogotá durante 6 meses. El tiempo de consulta se dicotomizó entre menor igual y mayor a 6 horas desde el inicio de los síntomas, se realizaron análisis bivariados y de regresión logística para evaluar asociación ente las variables estudiadas con el tiempo de consulta. RESULTADOS: 100 pacientes se incluyeron en el estudio, con edad promedio de 68 años. La mayoría con algún grado de educación, con estado civil casado/unión libre y antecedente de hipertensión arterial (HTA). El tiempo promedio de consulta fue 14 horas, con un 48% antes de 6 horas. Existió una tendencia del estado civil, tipo trasporte, antecedente de HTA y hora de inicio de síntomas con el consultar tempranamente DISCUSION: En esta población se encontró un retraso importante en el tiempo de consulta en paciente con infarto de miocardio, con factores que pueden estar relacionados y serían sujetos de intervención en la atención primaria de estos pacientes. Se requieren estudios con mayor población para validar los resultados acá encontrados.

Resiliencia organizacional y capital psicológico

Desde la noción universal sobre la empresa como un sistema de interacción con un entorno determinado para alcanzar un objetivo, de manera planificada y en función de satisfacer las demandas de un mercado mediante la actividad económica, su viabilidad, sostenibilidad y crecimiento dependerán, por supuesto, de una serie de estrategias adecuadas no solo para tales fines, sino también para enfrentar diversidad de agentes endógenos y exógenos que puedan afectar el normal desempeño de su gestión. Estamos hablando de la importancia de la resiliencia organizacional y del Capital Psicológico. En un escenario tan impredecible como el de la economía mundial, donde la constante son los cambios en su comportamiento —unos propios de su dinámica e interdependencia, naturales de fenómenos como la globalización, y otros derivados de eventos disruptivos— hoy más que nunca es necesario implementar el modelo de la empresa resiliente, que es aquella entidad capaz de adaptarse y recuperarse frente a una perturbación. Al mismo tiempo, más allá de su tamaño, naturaleza u objeto social, es indispensable reconocer básicamente que toda organización está constituida por personas, lo cual implica la trascendencia que para su funcionamiento tiene el factor humano-dependiente, y por lo tanto se crea la necesidad de promover el Capital Psicológico y la resiliencia a nivel de las organizaciones a través de una cultura empresarial.

Pulsioximetría de pacientes en hemodiálisis, de la unidad de terapia renal – fundación cardioinfantil, análisis para establecer recomendaciones

Introducción. En Colombia, el 80% de los pacientes con enfermedad renal crónica en hemodiálisis tienen fístula arteriovenosa periférica (FAV) que asegura el flujo de sangre durante la hemodiálisis (1), la variabilidad en el flujo de sangre en el brazo de la FAV hacia la parte distal, puede afectar la lectura de la oximetría de pulso (SpO2) (2), llevando a la toma de decisiones equivocadas por el personal de salud. El objetivo de este estudio es aclarar si existe diferencia entre la SpO2 del brazo de la FAV y el brazo contralateral. Materiales y métodos. Se realizó un estudio de correlación entre los valores de SpO2 del brazo con FAV contra el brazo sin FAV, de 40 pacientes que asistieron a hemodiálisis. La recolección de los datos se llevó a cabo, con un formato que incluyó el resultado de la pulsioximetria y variables asociadas, antes, durante y después de la hemodiálisis. Se comparó la mediana de los deltas de las diferencias con pruebas estadísticas T Student – Mann Whitney, aceptando un valor significativo de p < 0,05. Resultados. No se encontraron diferencias estadísticamente significativas de la SpO2 entre el brazo con FAV y el brazo sin FAV, antes, durante y después de la diálisis, sin embargo si se apreció una correlación positiva estadísticamente significativa. Conclusiones. Se encontró correlación positiva estadísticamente significativa, donde no hubo diferencias en el resultado la pulsioximetría entre el brazo con FAV y brazo sin FAV, por lo tanto es válido tomar la pulsioximetría en cualquiera de los brazos.

Early treatment with intranasal neostigmine reduces mortality in a mouse model of Naja naja (Indian Cobra) envenomation

Objective. Most snakebite deaths occur prior to hospital arrival; yet inexpensive, effective, and easy to administer out-of-hospital treatments do not exist. Acetylcholinesterase inhibitors can be therapeutic in neurotoxic envenomations when administered intravenously, but nasally delivered drugs could facilitate prehospital therapy for these patients. We tested the feasibility of this idea in experimentally envenomed mice. Methods. Mice received intraperitoneal injections of Naja naja venom 2.5 to 10 times the estimated LD50 and then received 5

ARBETSRELATERADE STRESSFAKTORER FÖR SJUKSKÖTERSKOR INOM AKUTSJUKVÅRDEN Litteraturöversikt

Bakgrund: Arbetsrelaterad stress hos sjuksköterskor bidrar till hög andel sjukskrivningar. Inom akutsjukvården så är arbetstempot ofta högre än inom andra delar av sjukvården och omsättningen av patienter är stor. Sjuksköterskor som arbetar inom akutsjukvården är mer utsatta för stress. För att hantera stress så kan copingstrategier användas. Syfte: Syftet är att ta reda på vilka stressfaktorer som påverkar sjuksköterskans hälsa inom akutsjukvården, samt vilka copingstrategier som kan användas för att hantera dessa. Metod: Litteraturöversikt med tolv kvalitativa samt kvantitativa vetenskapliga artiklar som berör sjuksköterskan inom akutsjukvården, arbetsrelaterade stressfaktorer samt copingstrategier. Resultat: Det finns ett antal arbetsrelaterade stressfaktorer som bidrar till ohälsa och lidande för sjuksköterskan inom akutsjukvården. Copingstrategier som stöttning av kollegor, avlastande samtal, genomgång av verksamheten och mindfulness, bidrar till att den arbetsrelaterade stressen blir hanterbar och att hälsa uppnås Slutsats: Stressfaktorer som brist på sjuksköterskor, dödsfall eller sexuella övergrepp på barn, våld och hot från patienter och anhöriga, samt brister i arbetsmiljön bidrar till arbetsrelaterad stress. Copingstrategier kan hjälpa att motverka den stress som uppstår. Men för att copingstrategier ska fungera så är det viktigt att använda sig av de strategier som finns och att tid samt möjlighet finns på arbetsplatsen att utföra dessa.

Avaliação dos parâmetros gasométricos dos traumatizados durante o atendimento pré-hospitalar móvel

OBJECTIVE: To evaluate gasometric differences of severe trauma patients requiring intubation in prehospital care. METHODS: Patients requiring airway management were submitted to collection of arterial blood samples at the beginning of pre-hospital care and at arrival at the Emergency Room. We analyzed: Glasgow Coma Scale, respiratory rate, arterial pH, arterial partial pressure of CO2 (PaCO2), arterial partial pressure of O2 (PaO2), base excess (BE), hemoglobin O2 saturation (SpO2) and the relation of PaO2 and inspired O2 (PaO2/FiO2). RESULTS: There was statistical significance of the mean differences between the data collected at the site of the accident and at the entrance of the ER as for respiratory rate (p = 0.0181), Glasgow Coma Scale (p = 0.0084), PaO2 (p <0.0001) and SpO2 (p = 0.0018). CONCLUSION: tracheal intubation changes the parameters PaO2 and SpO2. There was no difference in metabolic parameters (pH, bicarbonate and base excess). In the analysis of blood gas parameters between survivors and non-survivors there was statistical difference between PaO2, hemoglobin oxygen saturation and base excess.

Time to admission in acute ischemic stroke and transient ischemic attack

BACKGROUND AND PURPOSE: The effect of thrombolysis depends on the time from stroke onset to treatment and therefore also on the time when patients come to the hospital. This study was designed to analyze the variables that influence the time from symptom onset to admission (TTA) to the stroke unit. METHODS: We evaluated the medical records of 615 consecutive stroke or transient ischemic attack (TIA) patients admitted to our neurological department within 48 hours after symptom onset. RESULTS: The median TTA was 180 minutes. Referral by emergency medical services (EMS; P<0.001), high National Institutes of Health Stroke Scale (NIHSS) scores (P<0.001), strokes in the carotid territory (P<0.001), and strokes not attributable to small vessel disease (P<0.001) were associated with shorter prehospital delays. The TTA was adjusted for travel times (adjTTA), and all these variables remained significantly associated with time to admission. In addition, patients with previous experience with stroke or TIA had longer adjTTA (P=0.028). Regression analysis confirmed the independent association between referral by EMS (P=0.010), high NIHSS scores (P<0.001), carotid territory stroke (P<0.001), and first-ever cerebrovascular event (P=0.022) with shorter adjTTA. CONCLUSIONS: Factors such as NIHSS scores and stroke location influence the time to admission but, unlike referral pathways, cannot be modified. Educational programs and stroke campaigns should therefore not only teach typical and less common stroke symptoms and signs but also that EMS provides the fastest means of transportation to a stroke unit and the best chances to get treatment early.

Early resuscitation with polymerized bovine hemoglobin reverses acidosis, but not peripheral tissue oxygenation, in a severe hamster shock model

Awake hamsters equipped with the dorsal window chamber preparation were subjected to hemorrhage of 50% of the estimated blood volume. Initial resuscitation (25% of estimated blood volume) with polymerized bovine hemoglobin (PBH) or 10% hydroxyethyl starch (HES) occurred in concert with an equivolumetric bleeding to simulate the early, prehospital setting (exchange transfusion). Resuscitation (25% of estimated blood volume) without bleeding was performed with PBH, HES, or autologous red blood cells (HES-RBCs). Peripheral microcirculation, tissue oxygenation, and systemic hemodynamic and blood gas parameters were assessed. After exchange transfusion, base deficit was -8.6 +/- 3.7 mmol/L (PBH) and -5.1 +/- 5.3 mmol/L (HES) (not significant). Functional capillary density was 17% +/- 6% of baseline (PBH) and 31% +/- 11% (HES) (P < 0.05) and arteriolar diameter 73% +/- 3% of baseline (PBH) and 90% + 5% (HES) (P < 0.01). At the end, hemoglobin levels were 3.7 +/- 0.3 g/dL with HES, 8.2 +/- 0.6 g/dL with PBH, and 10.4 +/- 0.8 g/dL with HES-RBCs (P < 0.01 HES vs. PBH and HES-RBCs, P < 0.05 PBH vs. HES-RBCs). Base excess was restored to baseline with PBH and HES-RBCs, but not with HES (P < 0.05). Functional capillary density was 46% +/- 5% of baseline (PBH), 62% + 20% (HES-RBCs), and 36% +/- 19% (HES) (P < 0.01 HES-RBCs vs. HES). Peripheral oxygen delivery and consumption was highest with HES-RBCs, followed by PBH (P < 0.05 HES-RBCs vs. PBH, P < 0.01 HES-RBCs and PBH vs. HES). In conclusion, the PBH led to a correction of base deficit comparable to blood transfusion. However, oxygenation of the peripheral tissue was inferior with PBH. This was attributed to its negative impact on the peripheral microcirculation caused by arteriolar vasoconstriction.

Future treatment strategies in ST-segment elevation myocardial infarction

Over the past five decades, management of acute ST-segment elevation myocardial infarction (STEMI) has evolved substantially. Current treatment encompasses a systematic chain of network activation, antithrombotic drugs, and rapid instigation of mechanical reperfusion, although pharmacoinvasive strategies remain relevant. Secondary prevention with drugs and lifestyle modifications completes the contemporary management package. Despite a tangible improvement in outcomes, STEMI remains a frequent cause of morbidity and mortality, justifying the quest to find new therapeutic avenues. Ways to reduce delays in doing coronary angioplasty after STEMI onset include early recognition of symptoms by patients and prehospital diagnosis by paramedics so that the emergency room can be bypassed in favour of direct admission to the catheterisation laboratory. Mechanical reperfusion can be optimised by improvements to stent design, whereas visualisation of infarct size has been improved by developments in cardiac MRI. Novel treatments to modulate the inflammatory component of atherosclerosis and the vulnerable plaque include use of bioresorbable vascular scaffolds and anti-proliferative drugs. Translational efforts to improve patients' outcomes after STEMI in relation to cardioprotection, cardiac remodelling, and regeneration are also being realised. This is the third in a Series of three papers about ST-segment elevation myocardial infarction.

Relationship between onset-to-door time and door-to-thrombolysis time: a pooled analysis of 10 dedicated stroke centers

BACKGROUND AND PURPOSE Inverse relationship between onset-to-door time (ODT) and door-to-needle time (DNT) in stroke thrombolysis was reported from various registries. We analyzed this relationship and other determinants of DNT in dedicated stroke centers. METHODS Prospectively collected data of consecutive ischemic stroke patients from 10 centers who received IV thrombolysis within 4.5 hours from symptom onset were merged (n=7106). DNT was analyzed as a function of demographic and prehospital variables using regression analyses, and change over time was considered. RESULTS In 6348 eligible patients with known treatment delays, median DNT was 42 minutes and kept decreasing steeply every year (P<0.001). Median DNT of 55 minutes was observed in patients with ODT ≤30 minutes, whereas it declined for patients presenting within the last 30 minutes of the 3-hour time window (median, 33 minutes) and of the 4.5-hour time window (20 minutes). For ODT within the first 30 minutes of the extended time window (181-210 minutes), DNT increased to 42 minutes. DNT was stable for ODT for 30 to 150 minutes (40-45 minutes). We found a weak inverse overall correlation between ODT and DNT (R(2)=-0.12; P<0.001), but it was strong in patients treated between 3 and 4.5 hours (R(2)=-0.75; P<0.001). ODT was independently inversely associated with DNT (P<0.001) in regression analysis. Octogenarians and women tended to have longer DNT. CONCLUSIONS DNT was decreasing steeply over the last years in dedicated stroke centers; however, significant oscillations of in-hospital treatment delays occurred at both ends of the time window. This suggests that further improvements can be achieved, particularly in the elderly.