Colin E. Robertson

Effect of "fast track" admission for acute myocardial infarction on delay to thrombolysis.

OBJECTIVE--To evaluate the impact of a fast track triage system for patients with acute myocardial infarction. DESIGN--Comparison of delays in admission to hospital and in receiving thrombolytic treatment before and after introducing fast track system with delays recorded in 1987-8. Patients fulfilling clinical and electrocardiographic criteria for myocardial infarction were selected for rapid access to the cardiac care team, bypassing evaluation by the medical registrar. SETTING--Major accident and emergency, cardiac and trauma centre. SUBJECTS--359 patients admitted to the cardiac care unit during 1 February to 31 July 1990 with suspected acute infarction. MAIN OUTCOME MEASURES--Accuracy of diagnosis and delay from arrival at hospital to thrombolytic treatment. RESULTS--248 of the 359 patients had myocardial infarction confirmed, of whom 127 received thrombolytic treatment. The fast track system correctly identified 79 out of 127 (62%) patients who subsequently required thrombolytic treatment. 95% (79/83) of patients treated with thrombolysis after fast track admission had the diagnosis confirmed by electrocardiography and enzyme analysis. The median delay from hospital admission to thrombolytic treatment fell from 93 minutes in 1987-8 to 49 minutes in fast track patients (p less than 0.001). Delay in admission to the cardiac care unit was reduced by 47% for fast tract patients (median 60 minutes in 1987-8 v 32 minutes in 1990, p less than 0.001) and by 25% for all patients (60 minutes v 45 minutes, p less than 0.001). CONCLUSION--This fast track system requires no additional staff or equipment, and it halves inhospital delay to thrombolytic treatment without affecting the accuracy of diagnosis among patients requiring thrombolysis.

Paramedics and technicians are equally successful at managing cardiac arrest outside hospital.

Abstract Objective: To examine the effect on survival of treatment by ambulance paramedics and ambulance technicians after cardiac arrest outside hospital. Design: Prospective study over two years from 1 April 1992 to 31 March 1994. Setting: Accident and emergency department of university teaching hospital. Subjects: 502 consecutive adult patients with out of hospital cardiopulmonary arrest of cardiac origin. Interventions: Treatment by ambulance technicians or paramedics both equipped with semi-automatic defibrillators. Main outcome measures: Rate of return of spontaneous circulation, hospital admission, and survival to hospital discharge. Results: Rates of return of spontaneous circulation, hospital admission, and survival to hospital discharge were not significantly different for patients treated by paramedics as opposed to ambulance technicians. Paramedics spent significantly longer at the scene of the arrest than technicians (P<0.0001). Conclusions: The response of ambulance paramedics to patients with cardiopulmonary arrest outside hospital does not provide improved outcome when compared with ambulance technicians using basic techniques and equipped with semi-automatic defibrillators. Key messages Key messages Ambulance paramedics undergo extensive further training in resuscitation techniques No improvement in overall outcome was seen when paramedics attended the patients The government plans to have at least one paramedic in every front line ambulance by the end of 1995 The outcome of patients treated by technicians v paramedics does not justify the governments plans

The time of death after trauma

The pre-eminence of trauma as a cause of death in young adults in the United Kingdom is well established, but little is known about the temporal distribution of these deaths.1 The only complete data are from a frequently quoted paper, in which Trunkey described trauma deaths in San Francisco over two years.2 These data are nearly two decades old and come from a country where the causes of trauma and the system for dealing with it differ from those in the United Kingdom. All patients aged over 12 who died after trauma in the Lothian and Borders regions of Scotland between 1 February 1992 and 31 January 1994 were studied prospectively by the Scottish Trauma Audit Group and …

Field intubation of cardiac arrest patients: a dying art?

Introduction The most appropriate advanced airway intervention in out-of-hospital cardiac arrest (OHCA) is unproven. This study reviews prehospital advanced airway management and its complications in OHCA patients. Methods A 4-year, observational, retrospective case review. Patients attending the Emergency Department of the Royal Infirmary of Edinburgh, Scotland, with a primary diagnosis of OHCA were identified. Patient demographics, survival to admission, airway management technique and complication rates were identified. Results Seven hundred and ninety-four cases were identified. The aetiology of cardiac arrest was medical in 95.2%, traumatic in 3.9% and unrecorded in 0.9%. Prehospital intubation was attempted in 628 patients. Prehospital intubation was successful in 573 patients. A significant complication (multiple attempts, displaced endotracheal tube or oesophageal intubation) occurred in 55 (8.8%) patients. 165 (20.8%) patients survived to hospital admission, of whom 110 had undergone prehospital intubation. 55 patients who did not undergo prehospital tracheal intubation survived to hospital admission. Conclusion The optimal method of maintaining an airway and ventilating an OHCA patient has yet to be established. Prehospital tracheal intubation for OHCA is associated with significant complications and may reduce survival. The use of tracheal intubation as a routine intervention should be reconsidered. Ambulance services should consider adopting alternative strategies in airway management.

Comparison of two emergency response systems and their effect on survival from out of hospital cardiac arrest

The pre-hospital care provided by emergency response systems will have an effect on the outcome of patients who have sustained an out of hospital cardiac arrest. This study compares the results of resuscitation in two centres, one in the UK (Edinburgh) and the other in the USA (Milwaukee), and examines the demographics in both centres. An overall greater proportion of patients survived to hospital discharge in Edinburgh, 12.4%, compared with 7.2% in Milwaukee (P < 0.01). However patients were more likely to have a witnessed collapse in Edinburgh 65.7%, compared with 25% (P < 0.001) and significantly more of those patients received bystander cardiopulmonary resuscitation (CPR) 42.3%, compared with 27.1% (P < 0.005). When these two effects are accounted for there is no difference in outcome. The importance of early alerting of emergency services and early bystander CPR should not be underestimated.

Esophageal temperature after out-of-hospital cardiac arrest: An observational study

INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is a significant cause of death and severe neurological disability. The only post-return of spontaneous circulation (ROSC) therapy shown to increase survival is mild therapeutic hypothermia (MTH). The relationship between esophageal temperature post OHCA and outcome is still poorly defined. METHODS Prospective observational study of all OHCA patients admitted to a single centre for a 14-month period (1/08/2008 to 31/09/2009). Esophageal temperature was measured in the Emergency Department and Intensive Care Unit (ICU). Selected patients had pre-hospital temperature monitoring. Time taken to reach target temperature after ROSC was recorded, together with time to admission to the Emergency Department and ICU. RESULTS 164 OHCA patients were included in the study. 105 (64.0%) were pronounced dead in the Emergency Department. 59 (36.0%) were admitted to ICU for cooling; 40 (24.4%) died in ICU and 19 (11.6%) survived to hospital discharge. Patients who achieved ROSC and had esophageal temperature measured pre-hospital (n=29) had a mean pre-hospital temperature of 33.9 degrees C (95% CI 33.2-34.5). All patients arriving in the ED post OHCA had a relatively low esophageal temperature (34.3 degrees C, 95% CI 34.1-34.6). Patients surviving to hospital discharge were warmer on admission to ICU than patients who died in hospital (35.7 degrees C vs 34.3 degrees C, p<0.05). Patients surviving to hospital discharge also took longer to reach T(targ) than non-survivors (2h 48min vs 1h 32min, p<0.05). CONCLUSIONS Following OHCA all patients have esophageal temperatures below normal in the pre-hospital phase and on arrival in the Emergency Department. Patients who achieve ROSC following OHCA and survive to hospital discharge are warmer on arrival in ICU and take longer to reach target MTH temperatures compared to patients who die in hospital. The mechanisms of action underlying esophageal temperature and survival from OHCA remain unclear and further research is warranted to clarify this relationship.

Assessment of the active compression-decompression device (ACD) in cardiopulmonary resuscitation using transoesophageal echocardiography

Transoesophageal echocardiography was used to investigate the haemodynamic profile achieved during active compression-decompression cardiopulmonary resuscitation in humans. The mechanism of antegrade blood flow achieved by ACD-CPR is consistent with the cardiac pump theory. Improved right heart compression, antegrade blood flow patterns and left ventricular filling were observed in some patients during ACD-CPR.

An evaluation of paramedic activities in prehospital trauma care

The object of the study was to identify the effect paramedics have on prehospital trauma care and evaluate their influence on outcome compared to that of ambulance technicians. A prospective review of ambulance and hospital records was conducted over 2 years from 1 August 1993 to 31 July 1995. The setting for the study was the Royal Infirmary of Edinburgh and its primary response catchment area served by the South-East Region of the Scottish Ambulance Service central control room. The study involved 1090 patients brought to hospital by ambulance who met the entry criteria for the Scottish Trauma Audit Group study. The results show that paramedics spend significantly longer at scene than the ambulance technicians; however, there was no difference in total prehospital times between the groups. Paramedics direct a significantly higher proportion of patients to the resuscitation room and significantly more of these patients go to theatre, intensive care or the mortuary. There is no reduction in mortality or length of stay in intensive care in the paramedic group. The authors conclude that paramedics deliver an improved process of care but their activities do not significantly reduce mortality or length of stay in intensive care.

Can the full range of paramedic skills improve survival from out of hospital cardiac arrests

OBJECTIVE: To examine the effect of full implementation of advanced skills by ambulance personnel on the outcome from out of hospital cardiac arrest. SETTING: Patients with cardiac arrest treated at the accident and emergency department of the Royal Infirmary of Edinburgh. METHODS: All cardiorespiratory arrests occurring in the community were studied over a one year period. For patients arresting before the arrival of an ambulance crew, outcome of 92 patients treated by emergency medical technicians equipped with defibrillators was compared with that of 155 treated by paramedic crews. The proportions of patients whose arrest was witnessed by lay persons and those that had bystander cardiopulmonary resuscitation (CPR) were similar in both groups. RESULTS: There was no difference in the presenting rhythm between the two groups. Eight of the 92 patients (8.7%) treated by technicians survived to discharge compared with eight of 155 (5.2%) treated by paramedics (NS). Of those in ventricular fibrillation or pulseless ventricular tachycardia, eight of 43 (18.6%) in the technician group and seven of 80 (8.8%) in the paramedic group survived to hospital discharge (NS). For patients arresting in the presence of an ambulance crew, four of 13 patients treated by technicians compared with seven of 15 by paramedics survived to hospital discharge. Only two patients surviving to hospital discharge received drug treatment before the return of spontaneous circulation. CONCLUSIONS: No improvement in survival was demonstrated with more advanced prehospital care.

Rate, causes and prevention of deaths from injuries in south-east Scotland

Data on all deaths after injuries in Lothian and Borders regions of south-east Scotland were collected prospectively over 2 years. Post-mortems were performed after all deaths and Injury Severity Scores (ISS) calculated. There were 331 deaths at a rate of 20 per 100,000 per year; of those who died 49 per cent were younger than 40 years and most were male; 37 per cent of deaths were caused by road traffic accidents, 16 per cent by falls and 15 per cent by hangings. Two hundred and forty-eight patients (75 per cent) were either dead when found or died instantly with unsurvivable injuries (ISS = 75). A further five patients died in the first hour after injury and before reaching hospital. Nineteen (7 per cent) died between 1 and 4 h after injury, 59 (17 per cent) died more than 4 h after. These results demonstrate the rate, causes and timing of deaths following injuries in one UK region. The pattern of these deaths differs markedly from that previously described in the US. There is no evidence to support the concept of a trimodal distribution of trauma deaths. The greatest potential to reduce the number of trauma deaths lies with prevention.