George A Jelinek

Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial

BACKGROUND There is little evidence from clinical trials that the use of adrenaline (epinephrine) in treating cardiac arrest improves survival, despite adrenaline being considered standard of care for many decades. The aim of our study was to determine the effect of adrenaline on patient survival to hospital discharge in out of hospital cardiac arrest. METHODS We conducted a double blind randomised placebo-controlled trial of adrenaline in out-of-hospital cardiac arrest. Identical study vials containing either adrenaline 1:1000 or placebo (sodium chloride 0.9%) were prepared. Patients were randomly allocated to receive 1 ml aliquots of the trial drug according to current advanced life support guidelines. Outcomes assessed included survival to hospital discharge (primary outcome), pre-hospital return of spontaneous circulation (ROSC) and neurological outcome (Cerebral Performance Category Score - CPC). RESULTS A total of 4103 cardiac arrests were screened during the study period of which 601 underwent randomisation. Documentation was available for a total of 534 patients: 262 in the placebo group and 272 in the adrenaline group. Groups were well matched for baseline characteristics including age, gender and receiving bystander CPR. ROSC occurred in 22 (8.4%) of patients receiving placebo and 64 (23.5%) who received adrenaline (OR=3.4; 95% CI 2.0-5.6). Survival to hospital discharge occurred in 5 (1.9%) and 11 (4.0%) patients receiving placebo or adrenaline respectively (OR=2.2; 95% CI 0.7-6.3). All but two patients (both in the adrenaline group) had a CPC score of 1-2. CONCLUSION Patients receiving adrenaline during cardiac arrest had no statistically significant improvement in the primary outcome of survival to hospital discharge although there was a significantly improved likelihood of achieving ROSC.

CPR before defibrillation in out-of-hospital cardiac arrest: A randomized trial

Objective:  Current resuscitation guidelines recommend that defibrillation be undertaken as soon as possible in patients suffering a cardiac arrest where the cardiac rhythm is either ventricular fibrillation (VF) or ventricular tachycardia (VT). Evidence from animal and clinical studies suggests that outcomes may be improved if a period of cardiopulmonary resuscitation (CPR) is given prior to defibrillation. The objective of this study was to determine if 90 seconds of CPR before defibrillation improved survival.

Community attitudes towards performing cardiopulmonary resuscitation in Western Australia

OBJECTIVE to determine the attitudes of the Western Australian community towards performing cardiopulmonary resuscitation, and the factors affecting these attitudes. METHODS telephone survey of a randomly selected sample of people from suburban Perth and rural Western Australia; practical assessment of a sub-sample of volunteers from those surveyed, to correlate survey answers with practical skills. RESULTS of 803 people surveyed, the majority (90.7%) definitely would give mouth-to-mouth ventilation to a friend or relative, but less than half (47.2%) would to a stranger. The reluctance was mostly (56%) because of health and safety concerns, particularly related to HIV infection. Higher percentages of people would definitely provide cardiac massage for a friend or relative (91.4%) or stranger (78.1%). People were more likely to give mouth-to-mouth and cardiac massage if they had been trained in cardiopulmonary resuscitation (CPR), trained several times, trained recently, and used their CPR skills in real life. There were no significant differences between city and country people in whether they would provide CPR, but older people were less willing to provide mouth-to-mouth or cardiac massage. On practical assessment of 100 volunteers, there were significant errors and omissions in airway assessment, mouth-to-mouth resuscitation and cardiac massage. Volunteers with better practical scores were more prepared to provide CPR. DISCUSSION our results indicate a significant reluctance of the Western Australia public to perform mouth-to-mouth, except to a friend or relative. Earlier CPR training, practice and use seemed to diminish this reluctance. Practical CPR skills were not well executed. Those with better skills were less reluctant to use them. We recommend increasing CPR training in the community, greater frequency of refresher courses and public education on the risks of CPR to improve rates of bystander CPR.

Complementing police road-crash records with trauma registry data--an initial evaluation.

This paper examines the consistency of hospital and police reporting of outcomes of road traffic crashes using a database of linked police crash reports and trauma registry records. Criteria for inclusion into the trauma registry include trauma-related causes with subsequent stay of more than 24 h or death due to injuries. During the 1997 calendar year there were 497 cases of road-related injuries within the combined trauma registry of Sir Charles Gairdner and Fremantle Hospitals, of which only 82% had matching police records. Linkage rates were associated with gender, injury severity and the number of vehicles involved. Within the road user category, pedestrians were least likely to link. Of the linked records, police classification of injury severity was correct in 78% of cases. Male casualties were more likely to be correctly classified than females, after adjustment for related variables including injury severity. Correct classification of injury by police was also closely related to severity of injury. Identification and targeting of these groups of casualties is vital in refining the road-crash reporting system. Increased crash reporting and availability of data from these two sources will provide road authorities with more reliable measures of injury outcome.

Organophosphate poisoning in Perth, Western Australia, 1987-1996

This study aimed to review the presentation and management of patients with organophosphate poisoning admitted to the four tertiary teaching hospitals in Perth, Western Australia, over a 10-year period. The case notes of all 69 patients admitted with a discharge diagnosis of organophosphate poisoning were reviewed. Twenty-two of 25 patients (88%) attempting suicide were admitted to Intensive Care Units (ICUs), with a mean stay of 7 days (range 1-25 days). All but one were men, and two died. The 44 patients with accidental exposure were mainly children and had a mean stay of 2 days, with only seven going to the ICU. All survived. Complications overall included respiratory failure, convulsions, and aspiration pneumonia. Intubation and ventilation were required in 11 patients (16%), with a mean ventilation duration of 6 days (range 1-25 days). We conclude that deliberate ingestion of organophosphates is considerably more toxic than accidental exposure. Men aged 30-50 years were the most likely to attempt suicide with these agents and had prolonged ICU admissions with significant complications and mortality.

Use of emergency departments by older people from residential care: a population based study

OBJECTIVE to investigate the differences between emergency department (ED) presentations of older people who do and do not live in residential care facilities (RCFs). DESIGN a population-based retrospective cohort study. ED records linked to ambulance and hospital morbidity records. SETTING public EDs in Perth, Western Australia. SUBJECTS all patients 65 years and older who presented to EDs between 1 January 2003 and 31 December 2006 (n = 97,161). MEASUREMENTS patient demographic and clinical characteristics. Logistic regression was used to model the effect of living in RCFs on the likelihood of a particular ED diagnosis, hospital admission and in-hospital death. RESULTS the age-sex standardised rate of ED presentation for those living in RCFs was 1.69 times that of community dwellers. Compared to community dwellers, people from RCFs were older (mean age 84.7 years vs. 76.0 years, P < 0.001) and a lower proportion were male (28.7% vs. 46.7%, P < 0.001). Adjusting for age and sex revealed that people from RCFs were more likely to be diagnosed with pneumonia/influenza [odds ratio (OR) 1.94, 95% confidence interval (CI) = 1.72-2.19], urinary tract infections (OR 1.72, 95% CI 1.49-1.98) or hip fractures (OR 1.16, 95% CI 1.03-1.32); less likely to be diagnosed with circulatory system diseases (OR 0.69, 95% CI 0.64-0.75) or neoplasms (OR 0.47, 95% CI 0.31-0.72); more likely to be admitted (OR 1.13, 95% CI 1.06-1.20) and to die in hospital (OR 1.57, 95% CI 1.40-1.75). CONCLUSION there are different patterns of ED presentations and hospital admissions of older people who do and do not live in RCFs. The appropriateness of these differences is uncertain.

Widow spider envenomation (latrodectism): A worldwide problem

The objective of this study was to review widow spider envenomation on a worldwide basis, with an emphasis on regional variability in management, particularly between the United States and Australia. Data sources were the Medline database (1966-1997) for English language references using as key words widow spider, latrodectism, and red back spider, and Mesh headings. Textbooks of toxinology were also used. Studies involving clinical reports and series were selected. The data indicated that envenomation by widow spiders (latrodectism) is common worldwide. Local pain and sweating predominate, in about 25% of cases becoming generalized or developing in remote sites. The mortality in published series varies from 5% to 10%, although these may be overestimates. Australia may have the highest rate of latrodectism in the world. The literature reveals regional disparities in the treatment and outcome of latrodectism. In Australia, intramuscular antivenin has been used liberally for more than 40 years with a very low rate (0.5% to 0.8%) of allergic reactions and no deaths recorded since its introduction. Antivenin is routinely successful in relieving the effects of latrodectism. In the United States, the antivenin is given intravenously, is usually reserved for very severe cases, and the rate of allergic reaction is high (from 9% up to 80% in those skin testing positive). Deaths have been recorded after antivenin. The literature suggests that antivenin to one species of Latrodectus is likely to be effective against other species. The conclusion drawn was that latrodectism is a common envenomation worldwide. There is a strong case for a comparative trial of Australian vs US antivenin in treating latrodectism due to the black widow spider in the United States.

The association of alcohol consumption and smoking with quality of life, disability and disease activity in an international sample of people with multiple sclerosis

BACKGROUND Modifiable lifestyle factors represent important targets for preventive intervention in multiple sclerosis (MS). We aimed to explore the association of cigarette smoking and alcohol consumption with major MS morbidity outcomes. METHODS We surveyed a large, international sample of people with MS recruited via Web 2.0 platforms about type of MS, relapse rates, disability, disease activity, health-related quality of life (HRQOL), alcohol use and smoking. RESULTS Of 2469 respondents with confirmed MS, 11.7% were current and 40.3% former smokers. Most (61.5%) consumed less than 15 g alcohol weekly; few (0.8%) drank large amounts. Moderate alcohol consumption was associated with increased HRQOL; and after controlling for age and gender, was associated with lower odds of significant disability (41% decrease). After controlling for age, gender and alcohol use, smokers had an increased likelihood of major mobility requirements by 90% compared to never smokers. There was no association between alcohol or smoking and relapse rate or disease activity after controlling for age and gender, however among former smokers, a longer duration of smoking cessation was associated with reduced disease activity. Smokers had significantly lower HRQOL than never smokers and former smokers; heavier smoking was associated with greater decreases in HRQOL. CONCLUSION This cross-sectional study supports previous research showing a link between morbidity indicators in MS and alcohol use and smoking. While people with MS should be advised of the potential risks of smoking, any risks and benefits of alcohol consumption require validation using a prospective cohort of people with MS.

The association of diet with quality of life, disability, and relapse rate in an international sample of people with multiple sclerosis

Abstract Objectives To explore the association between dietary factors including fat, fruit and vegetable intake, dairy and meat consumption, and health-related quality of life (HRQOL), disability and relapse rate in a large international sample of people with multiple sclerosis (MS). Methods Participants with MS were recruited to the study via Web 2.0 platforms and completed a comprehensive survey measuring demographic and clinical characteristics, HRQOL, disability, relapse rate, and the Diet Habits Questionnaire (DHQ). Results Of 2469 participants with confirmed MS, 2087 (84.5%) provided complete data on their dietary habits (DHQ total score). Multivariate regression models demonstrated that every 10-point increase on the DHQ total score was associated with nearly a six-point and five-point increase in physical and mental HRQOL, respectively, and 30.0% reduced likelihood of a higher level of disability. After controlling for age and gender, and the other dietary covariates, ‘healthy’ consumption of fruit and vegetables and dietary fat predicted better quality of life and less likelihood of higher disability when compared to respondents with a ‘poor’ diet. For those with relapsing–remitting MS, the DHQ total significantly predicted a lower relapse rate and reduced odds of increasing disease activity, but the model fit was poor and the predicted change only marginal. Discussion This study supports significant associations of healthy dietary habits with better physical and mental HRQOL and a lower level of disability. Further research is urgently required to explore these associations including randomized controlled trials of dietary modification for people with MS.

Community competence in cardiopulmonary resuscitation

The aim of this study was to determine community application of cardiopulmonary resuscitation (CPR) skills in an emergency, and, thus, assess the value of training programmes in raising community competence. A cross-sectional telephone survey of the Western Australian population was chosen randomly (n = 803). An urban sub-sample (n = 100) performed a practical demonstration of CPR skills using a simulated collapse scenario using a recording manikin as the victim. Performance was assessed by two observers using pre-determined criteria. Of all respondents, 64% had been trained in CPR. Practical and theoretical assessment scores were significantly better in trained versus untrained participants. The number of times a person was trained in CPR was more effective for retention and competence than time since last trained. Degree of training and theoretical competence were less in those aged over 65 years or with heart disease in the household. Theoretical competence poorly reflected practical performance in many tasks. This study provides a comprehensive database of CPR training and performance, and highlights future directions to ensure appropriate and cost-effective training. Specific factors to be addressed include increasing frequency of training, targeting of high-risk groups, simplification in teaching, and emphasising early activation of the emergency medical system.