Michael C Kurz

The impact of prehospital activation of the cardiac catheterization team on time to treatment for patients presenting with ST-segment-elevation myocardial infarction.

OBJECTIVE We sought to evaluate the accuracy of emergency medical services (EMS) activation of the cardiac catheterization laboratory (CCL) for patients with ST-elevation myocardial infarction (STEMI) and its impact on treatment intervals from dispatch to reperfusion. METHODS We conducted a before-and-after cohort study of patients presenting via EMS with prehospital electrocardiogram findings consistent with STEMI. Before August 20, 2007, percutaneous coronary intervention was initiated after patient arrival. Afterward, EMS providers could activate the CCL if the prehospital electrocardiogram automated interpretation indicated STEMI. All interval times from EMS dispatch to percutaneous coronary intervention were measured via synchronized timepieces. RESULTS A total of 53 patients, 14 before and 39 after prehospital activation, were included. Emergency medical services CCL activation was 79.6% sensitive (95% confidence interval [CI], 65.2%-89.3%) and 99.7% specific (95% CI, 99.1%-99.9%). Mean door-to-hospital electrocardiogram and mean CCL-to-reperfusion times were unaffected by the intervention. Prehospital activation of the CCL significantly improved mean door-to-balloon (D2B) time by 18.2 minutes (95% CI, 7.69-28.71 minutes; P = .0029) and door-to-CCL by 14.8 minutes (95% CI, 6.20-23.39 minutes; P = .0024). Improvements in D2B were independent of presentation during peak hours (F ratio = 17.02, P < .0001). There were significant time savings reflected in all EMS intervals: 20.7 minutes (95% CI, 9.1-32.3 minutes; P = .0015) in mean dispatch-to-reperfusion time, 22.2 minutes (95% CI, 11.45-32.95 minutes; P = .0003) in mean first medical contact-to-reperfusion time, and 20 minutes (95% CI, 10.95-29.05 minutes; P = .0001) in recognition-to-reperfusion time. CONCLUSIONS Emergency medical service providers can appropriately activate the CCL for patients with STEMI before emergency department arrival, significantly reducing mean D2B time. Significant reduction is demonstrated throughout EMS intervals.

Assessing cardiac arrest beyond hospital discharge--We are only as "Good" as the outcomes we measure.

Defining and measuring outcomes after cardiac arrest have hisorically been a crude proposition.1,2 Limited by relatively few urvivors, early studies focused upon outcomes that were numerus enough to be meaningful: return of spontaneous circulation or urvival to hospital admission. As resuscitation science advanced nd the number of patients achieving a “good” outcome grew, the utcome of interest evolved to survival at hospital discharge. Surival, regardless of the time point, is reliable, valid, and difficult to isclassify – all desirable properties of an outcome measure.3 Howver, using survival as a dichotomous outcome measure captures nly universal endpoints of a complex spectrum involving funcional, cognitive, and psychosocial components. Today, patients ischarged from the hospital alive vary widely in terms of physcal and neurologic disability, illuminating why simple survival etermination is no longer an adequate, meaningful outcome after ardiac arrest. Various ordinal assessment tools for cardiac arrest survivors ave been used, including discharge location and the Glasgow coma cale (range 3-15). The cerebral performance category (CPC) scale as specifically developed to grade cardiac arrest outcomes with ore detail.4 Its use is recommended by Utstein guidelines5 and herefore is the most common measure used for assessing patients ollowing cardiac arrest. CPC grades level of consciousness, ability o work, and reliance on others, resulting in a 5-tier scale incorpoating estimates of impairment, function, and participation. Though his additional information is modest, assignment is typically based n chart review rather than actual patient interview and CPC is outinely condensed back into a binary endpoint. As a result, neuologic outcome after cardiac arrest is reduced to “good” (CPC 1–2) ersus “poor” (CPC 3–5). In this construct conscious patients who ely heavily on others for daily activities (CPC 3) are treated as equal o those who are brain dead (CPC 5), eliminating any benefit from he granularity of the 5-tier CPC scale beyond alive versus dead. While combining CPC 1 and 2 is largely a matter of statistical ragmatism and a result of feasible study resources, distinguishng the individual level of impairment within these groups is nything but simple.6,7 The hospital represents a sheltered environent with intense social support: others prepare food and orient atients to day, time, and daily events; medical questions and conitions can be addressed at the bedside. In contrast, upon arriving ome patients may realize they cannot safely cook, handle peronal hygiene, or manage their affairs. These complex activities f independent living are rarely examined in the in-patient seting. The assessment of CPC at hospital discharge, an administrative

Just Missing the Mark: Discharging High-risk Atrial Fibrillation / Flutter without Thromboprophylaxis

Atrial fibrillation and flutter (AF) is a pervasive disease affecting 6.1 million people in the United States.1 Each year it is responsible for more than 750,000 hospitalizations and 130,000 deaths.2,3 In contrast to overall declining death rates for cardiovascular disease,4 AF as the “primary or contributing cause of death has been rising for more than two decades.”3 The annual economic burden of AF is six billion dollars; medical costs per AF patient are about

Characteristics and outcomes of maternal cardiac arrest: A descriptive analysis of Get with the guidelines data

8,707 higher than for non-AF individuals.3 Thrombotic embolism of the cerebral circulation, or stroke, is the principal risk of AF and ranges from less than 2% to greater than 10% annually.5-8 AF is the cause of 100,000-125,000 embolic strokes each year, of which 20% are fatal.9 Anticoagulation to prevent these embolic events is standard of care unless contraindicated.9 However, it is not without risk, as even minor trauma can cause substantial and potentially life-threatening bleeding. Given that AF is the most common arrhythmia among the elderly,1,2,3 balancing these competing risks is challenging. Anticoagulation for AF is most commonly accomplished with a vitamin K antagonist, warfarin. However, its use requires patient education, medication compliance, dietary consistency, and close monitoring. CHA2DS2-VASc, ATRIA, HAS-BLED, ORBIT, and HEMORR2HAGES are just some of the decision-support tools available to objectively weigh the risk of stroke and life-threatening bleeding from therpy.10-15 Newer, novel oral anticoagulant agents (NOAC) provide a benefit/risk profile that may surpass warfarin, especially when considering initiation in the emergency department (ED). 16-18 In this issue of WestJEM, Smith and colleagues present a prospective observational evaluation of anticoagulation prescribing practices in non-valvular AF. Patients presenting to one of seven Northern California EDs with AF at high risk for stroke were eligible unless admitted, not part of Kaiser Permanente of Northern California (KPNC), or already prescribed anticoagulation. During the 14-month study there were no departmental policies governing the initiation of anticoagulation in AF patients. University of Alabama School of Medicine, Department of Emergency Medicine, Birmingham, Alabama

Deconstructing the “Time to Target Temperature” interval: Emphasis on timing rather than depth

BACKGROUND Maternal mortality has risen in the United States in the twenty-first century, yet large cohort data of maternal cardiac arrest (MCA) are limited. OBJECTIVE We sought to describe contemporary characteristics and outcomes of in-hospital MCA. METHODS We queried the American Heart Associations Get with the Guidelines Resuscitation voluntary registry from 2000 to 2016 to identify cases of maternal cardiac arrest. All index cardiac arrests occurring in women aged 18-50 with a patient illness category designated as obstetric or location of arrest occurring in a delivery suite were included. Institutional review deemed that this research was exempt from ethical approval. RESULTS A total of 462 index events met criteria for MCA, with a mean age of 31 ± 7 years and a racial distribution of: 49.4% White, 35.3% Black and 15.3% Other/Unknown. While 32% had no pre-existing conditions or physiologic disorders, respiratory insufficiency (36.1%) and hypotension/hypoperfusion (33.3%) were the most common antecedent conditions. In most cases, the first documented pulseless rhythm was non-shockable; pulseless electrical activity (50.8%) or asystole (25.6%). Only 11.7% presented with a shockable rhythm; ventricular fibrillation (6.5%) or pulseless ventricular tachycardia (5.2%) while the initial pulseless rhythm was unknown in 11.9% of cases. Return of spontaneous circulation occurred in 73.6% but 68 (14.7%) had more than one arrest. The rate of survival to discharge was 40.7% overall; 37.3% with non-shockable rhythms, 33% with shockable rhythms and 64.3% with unknown presenting rhythms. CONCLUSIONS Maternal survival at hospital discharge in this cohort was less than 50%, lower than rates reported in other epidemiological datasets. More research is required in maternal resuscitation science and translational medicine to continue to improve outcomes and understand maternal mortality.

Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac ArrestClinical Perspective: Implications for Prolonging or Terminating Resuscitation

87 Induced hypothermia has long been recognized as a protecant mechanism when initiated prior to an ischemic event. Given he unexpected nature of clinical cardiac arrest, understanding he optimal treatment window for applying targeted temperature anagement (TTM) is important for improving patient outcome. espite controversy surrounding target temperature, TTM remains recommended pillar of comprehensive post-arrest care. Pre-clinical studies in various arrest models have investigated he timing of TTM and its association with outcome. Safar and coleagues pioneered animal work in the 1990s using a dog model, nding that intra-arrest, mild to moderate TTM provided improveent over normothermia1,2 and that even a 15 min delay in TTM nduction post-ROSC tempered its beneficial effect on neurologic utcome.3 Other researchers have demonstrated similar results in oth rat4 and murine5 models, especially with regard to favorable ffects on preserving neuronal integrity.6,7 In contrast, examinaions of delayed TTM initiation have suggested a longer therapeutic indow, up to 8 h from reperfusion, with equal if not enhanced neuoprotection especially when the duration of TTM treatment was rolonged.8–10 Despite the wealth of pre-clinical data evaluating the assoiation between timing of TTM and outcome, few clinical nvestigations have dissected the time to target temperature (T2T) nterval. Several small studies (n < 200 patients) have reported etrimental effects with delays in T2T, including brief delays to TTM nitiation.11–13 However, in a large patient cohort, Haugk et al.14 tudied 588 patients identified in the emergency department and bserved that patients who take longer to reach target temperature measured from ROSC) were more likely to have good neurologic utcome. In a sub-analysis, the time to initiation of cooling in their ohort was not significantly related to outcome. The work of Peran et al.15 is one of few retrospective cohort studies to a-priori reak down the composite T2T interval into its parts: time from OSC to initiation (pre-induction) and time from initiation to target induction). The study population (n = 321) was far more heterogeeous with 53% OHCA, 23% of whom were transfers from outside acilities. Nevertheless, their results echoed those from Haugk and upported the current theory that patients with milder neurologic njury resist TTM.

Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department.

Background: Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest, and case features justifying longer or shorter durations are ill defined. We estimated the impact of resuscitation duration on the probability of favorable functional outcome in out-of-hospital cardiac arrest using a large, multicenter cohort. Methods: This was a secondary analysis of a North American, single-blind, multicenter, cluster-randomized, clinical trial (ROC-PRIMED [Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed]) of consecutive adults with nontraumatic, emergency medical services–treated out-of-hospital cardiac arrest. Primary exposure was duration of resuscitation in minutes (onset of professional resuscitation to return of spontaneous circulation [ROSC] or termination of resuscitation). Primary outcome was survival to hospital discharge with favorable outcome (modified Rankin scale [mRS] score of 0–3). Subjects were additionally classified as survival with unfavorable outcome (mRS score of 4–5), ROSC without survival (mRS score of 6), or without ROSC. Subject accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and subgroups. Adjusted logistic regression models tested the association between resuscitation duration and survival with favorable outcome. Results: The primary cohort included 11 368 subjects (median age, 69 years [interquartile range, 56–81 years]; 7121 men [62.6%]). Of these, 4023 (35.4%) achieved ROSC, 1232 (10.8%) survived to hospital discharge, and 905 (8.0%) had an mRS score of 0 to 3 at discharge. Distribution of cardiopulmonary resuscitation duration differed by outcome (P<0.00001). For cardiopulmonary resuscitation duration up to 37.0 minutes (95% confidence interval, 34.9–40.9 minutes), 99% with an eventual mRS score of 0 to 3 at discharge achieved ROSC. The dynamic probability of an mRS score of 0 to 3 at discharge declined over elapsed resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander cardiopulmonary resuscitation were more likely to survive with favorable outcome after prolonged efforts (30–40 minutes). After adjustment for prehospital (odds ratio, 0.93; 95% confidence interval, 0.92–0.95) and inpatient (odds ratio, 0.97; 95% confidence interval, 0.95–0.99) covariates, resuscitation duration was associated with survival to discharge with an mRS score of 0 to 3. Conclusions: Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes. Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifier: NCT00394706.

The Impact of Emergency Physician–Initiated Primary Percutaneous Coronary Intervention on Mean Door-to-Balloon Time in Patients With ST-Segment-Elevation Myocardial Infarction

Introduction Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. Methods This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. Results A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median

Caution when defining prolonged downtime in out of hospital cardiac arrest as extracorporeal cardiopulmonary resuscitation becomes accessible and feasible.

449.83 vs.

WORKSHEET for Evidence-Based Review of Science for Emergency Cardiac Care

1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6mSv). No patient in either group had a related 30-day revisit. Conclusion Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.