Paediatric Retrieval – what's the rush?

Posted on June 5, 2010 by Cliff Reid

The Children’s Acute Transport Service (CATS) in the UK performed 2106 interfacility transports between April 2006 and March 2008. The stabilisation time averaged just over 2 hrs. Stabilisation time was prolonged by the number of major interventions required to stabilise the patient before transfer and differed significantly between various diagnostic groups. The length of time spent by the retrieval team outside the intensive care environment had no independent effect on subsequent patient mortality.

They have shown that stabilisation time can be influenced by a number of patient- and transport team-related factors, and that time spent undertaking intensive care interventions early in the course of patient illness at the referring hospital does not increase patient mortality. In the authors’ words: ‘the “scoop and run” model can be safely abandoned in favor of early goal-directed management during interhospital transport for intensive care.‘

There’s NO rush guys!

Effect of patient- and team-related factors on stabilization time during pediatric intensive care transport
Pediatr Crit Care Med. 2010 May 6

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Pre-hospital intubation experience and outcomes

Posted on June 1, 2010 by Cliff Reid

Hospitals and medical personnel performing high volumes of procedures demonstrate better patient outcomes and fewer adverse events. The relationship between rescuer experience and patient survival for out-of-hospital endotracheal intubation is unknown.

An American study analysing 3 statewide databases with 26,000 records aimed to determine the association between endotracheal intubation experience and patient survival.

In-the-field intubators were EMS paramedics, nurses, and physicians, although paramedics performed more than 94% of out-of-hospital tracheal intubations. Although all air medical rescuers may use neuromuscular- blockade-assisted (rapid sequence) tracheal intubation, select ground EMS units are allowed to use tracheal intubation facilitated by sedatives only; the rest are done ‘cold’.

Patients in cardiac arrest and medical nonarrest experienced increased odds of survival when intubated by rescuers with high procedural experience. In trauma patients, survival was not associated with rescuer experience.

The odds of survival for air medical trauma patients were almost twice that of other patients, which may be related to the use of neuromuscular- blocking agents by air medical crews, or due to more specialised critical care training. The authors suggest that rescuers should perform at least 4 to 12 annual tracheal intubations.

Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes
Ann Emerg Med. 2010 Jun;55(6):527-537

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The myth of ketamine and head injury

Posted on May 12, 2010 by Cliff Reid

A literature review addresses the myth that ketamine is contraindicated in head injured patients. They summarise articles from the 1970’s which identified an association between ketamine and increased ICP in patients with abnormal cerebrospinal fluid pathways (such as those caused by aqueductal stenosis, obstructive hydrocephalus and other mass effects). In more recent studies no statistically significant increase in ICP was observed following the administration of ketamine in patients with head injury; some of the studies showed a net increase in CPP following ketamine administration. They list ketamine’s stable haemodynamic profile and potential neuroprotective effects as further rationale for its use.

The authors boldly summarise:

‘Based on its pharmacological properties, ketamine appears to be the perfect agent for the induction of head-injured patients for intubation.’

Myth: ketamine should not be used as an induction agent for intubation in patients with head injury
CJEM. 2010 Mar;12(2):154-7

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Optimum depth of neonatal chest compressions

Posted on May 11, 2010 by Cliff Reid

A retrospective study of infant chest CT scans using mathematical modelling and a number of assumptions suggests that neonatal CPR according to AAP/AHA guidelines of compressing to one third anteroposterior chest wall diameter should provide a superior ejection fraction to 1/4 depth and should generate less risk for over-compression than 1/2 AP compression depth.
Evaluation of the Neonatal Resuscitation Program’s recommended chest compression depth using computerized tomography imaging
Resuscitation. 2010 May;81(5):544-8

Compare their conclusions with those of the authors of this case series of arterial-line monitored cardiac arrests in infants with a median age of one month

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Hospital bypass for cardiac arrest?

Posted on May 10, 2010 by Cliff Reid

A Japanese study of over 10,000 patients demonstrated improved neurological outcome in out-of-hospital cardiac arrest patients who were taken to hospitals designated as ‘critical care medical centres’, where neurologically favorable 1-month survival was greater [6.7% versus 2.8%, P < 0.001] despite a slightly longer call-hospital arrival interval [30.6 min vs 27.2, p < 0.001]. If return of spontaneous circulation was achieved pre-hospital, there was no difference in survival. It is unclear what factors, such as more interventional cardiology or therapeutic hypothermia, made the difference in the critical care centres.

Impact of transport to critical care medical centers on outcomes after
out-of-hospital cardiac arrest
Resuscitation. 2010 May;81(5):549-54

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Distance to hospital did not affect arrest survival

Posted on May 9, 2010 by Cliff Reid

In a study of over 7500 patients with cardiac arrest transported by EMS in the United States, transport distance was not associated with survival on logistic analysis (OR 1.00; 95% CI 0.99–1.01).
A geospatial assessment of transport distance and survival to discharge in out of
hospital cardiac arrest patients: Implications for resuscitation centers
Resuscitation. 2010 May;81(5):518-23

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Current Controversy in RSI

Posted on April 26, 2010 by Cliff Reid

A review article in Anesthesia and Analgesia provides a summary of the literature surrounding RSI controversies.

  • Should a pre-determined dose of induction drug be given or should it be titrated to effect prior to giving suxamethonium?
  • Should fast acting opioids be coadministered to blunt the pressor response?
  • What is the optimal dose of suxamethonium?
  • Should defasciculating doses of neuromuscular blocking drugs be given?
  • What is the ‘priming’ technique with rocuronium and is it necessary?
  • Is it really bad to bag-mask ventilate the patient after induction prior to intubation? Which patients might this benefit?
  • Should patients with full stomachs be anaesthetised sitting up, supine, or head down?
  • Is cricoid pressure a good or a bad thing?

Not surprisingly the jury is still out on these, which is of course why they remain ‘controversies’. The review article provides a readable, interesting, and up to date summary of the evidence to date.

Rapid Sequence Induction and Intubation: Current Controversy
Anesth Analg. 2010 May 110(5):1318-25

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Kids need 'proper' CPR if non-cardiac cause of arrest

Posted on April 16, 2010 by Cliff Reid

The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. These recommendations have new support in a large observational study from Japan examining outcomes in 5170 out-of hospital paediatric arrests over a 3 year period.
For children who had out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander was associated with improved outcomes compared with compression-only CPR (7·2% [45/624] favourable one month neurological outcome vs 1·6% [6/380]; OR 5·54, 2·52–16·99). In children who had arrests of cardiac causes conventional and compression-only CPR were similarly effective. Infants < 1 year had uniformly poor outcomes.

An editorial points out that this is the largest study that has analysed out-of-hospital cardiac arrest in children, and the overall survival of 9% with only 3% of children having a good neurological outcome, is consistent with previous reports.

Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study
Lancet. 2010 Apr 17 345:1347-54

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2000 vs 2005 VF guidelines: RCT

Posted on April 13, 2010 by Cliff Reid

One of the key changes in international resuscitation guidelines between the 2000 and 2005 has been to minimise potentially deleterious hands-off time, so that CPR is interrupted less for pulse checks and DC shocks.

These two approaches have been compared in a randomised controlled trial of 845 patients in France requiring out of hospital defibrillation, in which the control group were shocked using AEDs with prompts based on the 2000 guidelines (3 stacked shocks before CPR resumed, and pulse checks done), and the intervention group were shocked using devices that prompted according to the 2005 guidelines, in which there were fewer and shorter intervals for which the AED required the rescuer to stay clear of the patient (single shocks, no pulse checks).

There was no difference in the primary endpoint of survival to hospital admission (43.2% versus 42.7%; p=0.87), or in survival to hospital discharge (13.3% versus 10.6%; p=0.19). The study was not powered to assess one year survival. In the authors’ words: “our randomized controlled trial now provides more definitive evidence that this combination of Guidelines 2005 CPR protocol changes does not measurably improve outcome. Although the protocol changes accomplish the desired effect of increasing chest compressions, they may also cause other effects, such as earlier refibrillation and more time spent in VF, with as yet unknown consequences.”

Interestingly the Cardio-pump was used in this study to provide chest compressions, which is an active compression-decompression device, potentially limiting the generalisability of the findings to manual compression-only CPR situations. Potential bias was also introduced by the exclusion of patients in whom consent from relatives was not obtained. Nevertheless it’s good to see such rigorous clinical research applied to this area.

DEFI 2005. A Randomized Controlled Trial of the Effect of Automated External Defibrillator Cardiopulmonary Resuscitation Protocol on Outcome From Out-of-Hospital Cardiac Arrest
Circulation. 2010;121:1614-1622

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Battlefield resuscitation

Posted on April 5, 2010 by Cliff Reid

An excellent review of the current British military practice to prevent and treat the acute coagulopathy of trauma shock (ACoTS) describes pathophysiology and treatment options and offers an algorithm for management. Key components of the system (when indicated according to their algorithm) outlined include:

  • Pre-hospital damage control shock resuscitation by a forward medical team, consisting of RSI with reduced dose thio or ketamine with suxamethonium or rocuronium, large bore sublclavian access, and early use of warmed blood products
  • 1:1:1 packed red cells, fresh frozen plasma, and platelets,
  • Cryoprecipitate
  • Tranexamic acid
  • Recombinant activated factor VII
  • Permissive hypotension aiming for a systolic BP of 90 mmHg, using blood products and avoiding vasopressors according to a ‘flow rather than pressure’ philosophy
  • Avoiding hypothermia by giving warmed blood products and employing active patient warming methods
  • Buffering acidosis using Tris-hydroxymethyl aminomethane (THAM), which may be superior to bicarbonate by not affecting minute ventilation or coagulation, and maintaining its efficacy in hypothermic conditions
  • Minimising hypoperfusion with an anaesthetic strategy that provides effective analgesia and vasodilation, using high dose fentanyl and a low concentration volatile agent
  • Using fresh whole blood for resistant coagulopathy

Battlefield resuscitation
Curr Opin Crit Care. 2009 Dec;15(6):527-35

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