Jason T. McMullan

Midazolam Versus Diazepam for the Treatment of Status Epilepticus in Children and Young Adults: A Meta-Analysis

BACKGROUND Rapid treatment of status epilepticus (SE) is associated with better outcomes. Diazepam and midazolam are commonly used, but the optimal agent and administration route is unclear. OBJECTIVES The objective was to determine by systematic review if nonintravenous (non-IV) midazolam is as effective as diazepam, by any route, in terminating SE seizures in children and adults. Time to seizure cessation and respiratory complications was examined. METHODS We performed a search of PubMed, Web of Knowledge, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, American College of Physicians Journal Club, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, and International Pharmaceutical Abstracts for studies published January 1, 1950, through July 4, 2009. English language quasi-experimental or randomized controlled trials comparing midazolam and diazepam as first-line treatment for SE, and meeting the Consolidated Standards of Reporting Trials (CONSORT)-based quality measures, were eligible. Two reviewers independently screened studies for inclusion and extracted outcomes data. Administration routes were stratified as non-IV (buccal, intranasal, intramuscular, rectal) or IV. Fixed-effects models generated pooled statistics. RESULTS Six studies with 774 subjects were included. For seizure cessation, midazolam, by any route, was superior to diazepam, by any route (relative risk [RR] = 1.52; 95% confidence interval [CI] = 1.27 to 1.82). Non-IV midazolam is as effective as IV diazepam (RR = 0.79; 95% CI = 0.19 to 3.36), and buccal midazolam is superior to rectal diazepam in achieving seizure control (RR = 1.54; 95% CI = 1.29 to 1.85). Midazolam was administered faster than diazepam (mean difference = 2.46 minutes; 95% CI = 1.52 to 3.39 minutes) and had similar times between drug administration and seizure cessation. Respiratory complications requiring intervention were similar, regardless of administration route (RR = 1.49; 95% CI = 0.25 to 8.72). CONCLUSIONS Non-IV midazolam, compared to non-IV or IV diazepam, is safe and effective in treating SE. Comparison to lorazepam, evaluation in adults, and prospective confirmation of safety and efficacy is needed.

Design and Validation of a Prehospital Scale to Predict Stroke Severity: Cincinnati Prehospital Stroke Severity Scale

Background and Purpose— We derived and validated the Cincinnati Prehospital Stroke Severity Scale (CPSSS) to identify patients with severe strokes and large vessel occlusion (LVO). Methods— CPSSS was developed with regression tree analysis, objectivity, anticipated ease in administration by emergency medical services personnel and the presence of cortical signs. We derived and validated the tool using the 2 National Institute of Neurological Disorders and Stroke (NINDS) tissue-type plasminogen activator Stroke Study trials and Interventional Management of Stroke III (IMS III) Trial cohorts, respectively, to predict severe stroke (National Institutes of Health Stroke Scale [NIHSS] ≥15) and LVO. Standard test characteristics were determined and receiver operator curves were generated and summarized by the area under the curve. Results— CPSSS score ranges from 0 to 4; composed and scored by individual NIHSS items: 2 points for presence of conjugate gaze (NIHSS ≥1); 1 point for presence of arm weakness (NIHSS ≥2); and 1 point for presence abnormal level of consciousness commands and questions (NIHSS level of consciousness ≥1 each). In the derivation set, CPSSS had an area under the curve of 0.89; score ≥2 was 89% sensitive and 73% specific in identifying NIHSS ≥15. Validation results were similar with an area under the curve of 0.83; score ≥2 was 92% sensitive, 51% specific, a positive likelihood ratio of 3.3, and a negative likelihood ratio of 0.15 in predicting severe stroke. For 222 of 303 IMS III subjects with LVO, CPSSS had an area under the curve of 0.67; a score ≥2 was 83% sensitive, 40% specific, positive likelihood ratio of 1.4, and negative likelihood ratio of 0.4 in predicting LVO. Conclusions— CPSSS can identify stroke patients with NIHSS ≥15 and LVO. Prospective prehospital validation is warranted.

Airway management and out-of-hospital cardiac arrest outcome in the CARES registry ☆

BACKGROUND Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared OHCA outcomes between patients receiving endotracheal intubation (ETI) versus supraglottic airway (SGA), and between patients receiving [ETI or SGA] and those receiving no advanced airway. METHODS We studied adult OHCA in the Cardiac Arrest Registry to Enhance Survival (CARES). Primary exposures were ETI, SGA, or no advanced prehospital airway placed. Primary outcomes were sustained ROSC, survival to hospital admission, survival to hospital discharge, and neurologically-intact survival to hospital discharge (cerebral performance category 1-2). Propensity scores characterized the probability of receiving ETI, SGA, or no advanced airway. We adjusted for Utstein confounders. Multivariable random effects regression accounted for clustering by EMS agency. We compared outcomes between (1) ETI vs. SGA, and (2) [no advanced airway] vs. [ETI or SGA]. RESULTS Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC (OR 1.35; 95%CI 1.19-1.54), survival to hospital admission (1.36; 1.19-1.55), hospital survival (1.41; 1.14-1.76) and hospital discharge with good neurologic outcome (1.44; 1.10-1.88). Compared with [ETI or SGA], patients receiving no advanced airway attained higher survival to hospital admission (1.31; 1.16-1.49), hospital survival (2.96; 2.50-3.51) and hospital discharge with good neurologic outcome (4.24; 3.46-5.20). CONCLUSION In CARES, survival was higher among OHCA receiving ETI than those receiving SGA, and for patients who received no advanced airway than those receiving ETI or SGA.

Cardiac Arrest Survival Is Rare Without Prehospital Return of Spontaneous Circulation

Abstract Background. Emergency medical services (EMS) are crucial in the management of out-of-hospital cardiac arrest (OHCA). Despite accepted termination-of-resuscitation criteria, many patients are transported to the hospital without achieving field return of spontaneous circulation (ROSC). Objective. We examine field ROSC influence on OHCA survival to hospital discharge in two large urban EMS systems. Methods. A retrospective analysis of prospectively collected data was conducted. Data collection is a component of San Antonio Fire Departments comprehensive quality assurance/quality improvement program and Cincinnati Fire Departments participation in the Cardiac Arrest Registry to Enhance Survival (CARES) project. Attempted resuscitations of medical OHCA and cardiac OHCA for San Antonio and Cincinnati, respectively, from 2008 to 2010 were analyzed by city and in aggregate. Results. A total of 2,483 resuscitation attempts were evaluated. Age and gender distributions were similar between cities, but ethnic profiles differed. Cincinnati had 17% (p = 0.002) more patients with an initial shockable rhythm and was more likely to initiate transport before field ROSC. Overall survival to hospital discharge was 165 of 2,483 (6.6%). More than one-third (894 of 2,483, 36%) achieved field ROSC. Survival with field ROSC was 17.2% (154 of 894) and without field ROSC was 0.69% (11 of 1,589). Of the 11 survivors transported prior to field ROSC, nine received defibrillation by EMS. No asystolic patient survived to hospital discharge without field ROSC. Conclusion. Survival to hospital discharge after OHCA is rare without field ROSC. Resuscitation efforts should focus on achieving field ROSC. Transport should be reserved for patients with field ROSC or a shockable rhythm.

Emergency department volume and acuity as factors in patients leaving without treatment.

Objectives: Patients who leave emergency departments (EDs) without treatment represent potential personal and hospital liability. Many department-dependent factors have been linked to patients who leave without treatment (LWT) in high-volume EDs. The authors studied how department volume and acuity influence LWTs in a small, low-volume, university-affiliated ED. Methods: Through retrospective ED census review, LWTs, department volume, and department acuity were recorded for 12-hour shifts over 1 year. Department acuity is defined as patients requiring resuscitation or admission. Results: Over a 12-month period, 629 of 18,664 patients left the ED. When shift volume exceeded 25 patients, there were significantly more LWTs. When department acuity exceeded four patients per shift, there were also significantly greater numbers of LWTs. More than half of all shifts exceeded one of these thresholds. Conclusions: Thresholds of 25 patients and an acuity of five patients per shift were associated with significant increases in LWTs, suggesting possible per-physician maximum patient loads before an increased risk of LWT patients.

Risperidone versus haloperidol, in combination with lorazepam, in the treatment of acute agitation and psychosis: a pilot, randomized, double-blind, placebo-controlled trial.

Objective. To compare oral risperidone and intramuscular (IM) haloperidol, both in combination with IM lorazepam, in the management of acute agitation and psychosis in the medical emergency department. Methods. In this prospective, randomized, placebo-controlled, double-blind study of 30 patients presenting to the emergency department with acute agitation and/or psychosis, three groups of 10 patients received oral and IM medications: 1) 2 mg oral risperidone and 2 mg IM lorazepam; 2) 5 mg oral haloperidol and 2 mg IM lorazepam; 3) oral placebo and 2 mg IM lorazepam. Each treatment group received both an injection and a tablet to reduce treatment group variability. Patients were evaluated using the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS) before receiving medication and at 30 and 90 minutes after medication was administered. The intergroup mean percent reductions in rating scale scores were compared using ANOVA, chi-square, and Kruskal-Wallis tests. Results. There were no statistically significant differences among the groups at any point. The two groups receiving an antipsychotic plus lorazepam showed a trend towards increased symptom reduction compared with the group receiving lorazepam alone, although this trend was not statistically significant. Conclusions. Lorazepam alone was as effective as lorazepam plus haloperidol or lorazepam plus risperidone in this small trial. While not statistically significant, a trend toward better outcomes with combined treatment warrants further study.

Practice variability among the EMS systems participating in Cardiac Arrest Registry to Enhance Survival (CARES)

STUDY OBJECTIVE To describe the demographic, organizational and provider characteristics of the Emergency Medical Services (EMS) agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES). METHODS A web based survey instrument was developed by the CARES investigators and distributed to the EMS agencies participating in CARES in 2008. Survey questions addressed three domains related to prehospital care: (1) descriptors of the participating EMS agencies, (2) methods of clinical care and clinical protocols used by EMS agencies to deliver out-of-hospital cardiac arrest care and (3) use of resuscitation techniques by EMS agencies. Survey responses were collated and analyzed using descriptive statistics. RESULTS Surveys were received from 21/25 (84%) sites. The EMS agency characteristics including the response areas served by the agencies, organizational structure, medical direction status and deployment status are described. All respondents were non-volunteer agencies with a large number of them being fire-based (43%). Significant variability among the communities was observed with respect to their medical direction status and deployment status. We also observed differences in the management of OHCA among the participating agencies which included implementation of ACLS guideline updates, presence of termination of resuscitation protocol and destination policies for OHCA subjects. Similar variations between agencies were also observed in the use of resuscitation techniques. CONCLUSIONS Differences were observed between the EMS agencies participating in CARES. The clinical impact of these observed differences in agency and provider characteristics on OHCA outcomes deserves study.

Ground Emergency Medical Services Requests for Helicopter Transfer of ST-segment Elevation Myocardial Infarction Patients Decrease Medical Contact to Balloon Times in Rural and Suburban Settings

OBJECTIVES   ST-segment elevation myocardial infarction (STEMI) care is time-dependent. Many STEMI patients require interhospital helicopter transfer for percutaneous coronary intervention (PCI) if ground emergency medical services (EMS) initially transport the patient to a non-PCI center. This investigation models potential time savings of ground EMS requests for helicopter EMS (HEMS) transport of a STEMI patient directly to a PCI center, rather than usual transport to a local hospital with subsequent transfer. METHODS   Data from a multicenter retrospective chart review of STEMI patients transferred for primary PCI by a single HEMS agency over 12 months were used to model medical contact to balloon times (MCTB) for two scenarios: a direct-to-scene HEMS response and hospital rendezvous after ground EMS initiation of transfer. RESULTS   Actual MCTB median time for 36 hospital-initiated transfers was 160 minutes (range = 116 to 321 minutes). Scene response MCTB median time was estimated as 112 minutes (range = 69 to 187 minutes). The difference in medians was 48 minutes (95% confidence interval [CI] = 33 to 62 minutes). Hospital rendezvous MCTB median time was estimated as 113 minutes (range = 74 to 187 minutes). The difference in medians was 47 minutes (95% CI = 32 to 62 minutes). No patient had an actual MCTB time of less than 90 minutes; in the scene response and hospital rendezvous scenarios, 2 of 36 (6%) and 3 of 36 (8%), respectively, would have had MCTB times under 90 minutes. CONCLUSIONS   In this setting, ground EMS initiation of HEMS transfers for STEMI patients has the potential to reduce MCTB time, but most patients will still not achieve MCTB time of less than 90 minutes.

Time-critical neurological emergencies: the unfulfilled role for point-of-care testing

BackgroundNeurological emergencies are common and frequently devastating. Every year, millions of Americans suffer an acute stroke, severe traumatic brain injury, subarachnoid hemorrhage, status epilepticus, or spinal cord injury severe enough to require medical intervention.AimsFull evaluation of the diseases in the acute setting often requires advanced diagnostics, and treatment frequently necessitates transfer to specialized centers. Delays in diagnosis and/or treatment may result in worsened outcomes; therefore, optimization of diagnostics is critical.MethodsPoint-of-care (POC) testing brings advanced diagnostics to the patient’s bedside in an effort to assist medical providers with real-time decisions based on real-time information. POC testing is usually associated with blood tests (blood glucose, troponin, etc.), but can involve imaging, medical devices, or adapting existing technologies for use outside of the hospital. Noticeably missing from the list of current point-of-care technologies are real-time bedside capabilities that address neurological emergencies.ResultsUnfortunately, the lack of these technologies may result in delayed identification of patients of these devastating conditions and contribute to less aggressive therapies than is seen with other disease processes. Development of time-dependent technologies appropriate for use with the neurologically ill patient are needed to improve therapies and outcomes.ConclusionPOC-CENT is designed to support the development of novel ideas focused on improving diagnostic or prognostic capabilities for acute neurological emergencies. Eligible examples include biomarkers of traumatic brain injury, non-invasive measurements of intracranial pressure or cerebral vasospasm, and improved detection of pathological bacteria in suspected meningitis.

Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool

Abstract Background and Purpose: A simple, easily adoptable scale with good performance characteristics is needed for EMS providers to appropriately triage suspected stroke patients to comprehensive stroke centers (CSC). Many existing tools are complex, require substantial training, or have not been prospectively validated in the prehospital setting. We describe the feasibility and effectiveness of prehospital implementation of our previously retrospectively derived and validated Cincinnati Stroke Triage Assessment Tool (C-STAT) to identify subjects with severe stroke (NIHSS ≥15) among all prehospital patients with clinical suspicion of stroke/TIA. Secondarily, we evaluated the tools ability to identify subjects with NIHSS ≥10, large vessel occlusion (LVO), or needing services available only at a CSC. Methods: Without formalized training, Cincinnati Fire Department providers performed standard stroke screening (“face, arm, speech, time;” FAST) and C-STAT as part of their assessment of suspected stroke/TIA patients. Outcomes for patients brought to the regions only CSC or assessed by the regional stroke team were determined through structured chart review by a stroke team nurse. C-STAT test characteristics for each outcome were calculated with 95% confidence intervals. Results: Complete prehospital and outcome data were available for 58 FAST-positive subjects among 158 subjects with prehospital suspicion for stroke/TIA. Subjects were excluded if FAST was negative (n = 22), FAST or C-STAT was incompletely documented (n = 24), if the patient was taken to a non-CSC and did not receive a stroke team consult (n = 48), or if outcome data were missing (n = 6). C-STAT sensitivity and specificity for each outcome were: NIHSS ≥ 15, 77% (95% CI 46–95) and 84% (95% CI 69–93); NIHSS ≥10, 64% (95% CI 41–83) and 91% (95% CI 76–98); LVO, 71% (95% CI 29–96) and 70% (95% CI 55–83); overall CSC need 57% (95% CI 34–78) and 79% (95% CI 61–91). Conclusion: In this pilot prospective evaluation performed in the prehospital setting by EMS providers without formalized training, C-STAT is comparable to other published tools in test characteristics and may inform appropriate CSC triage beyond LVO ascertainment alone.