Ondrej Franek

Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. “Prague OHCA study”

BackgroundOut of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care.MethodsThis paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines.Primary outcome6 months survival with good neurological outcome (Cerebral Performance Category 1–2). Secondary outcomes will include 30 day neurological and cardiac recovery.DiscussionAuthors introduce and offer a protocol of a proposed randomized study comparing a combined “hyperinvasive approach” to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and cathlab teams trained to admit patients with refractory cardiac arrest under ongoing CPR. A prove of concept study will be started soon. The aim of the authors is to establish a net of centers for a multicenter trial initiation in future.Ethics and registrationThe protocol has been approved by an Institutional Review Board, will be supported by a research grant from Internal Grant Agency of the Ministry of Health, Czech Republic NT 13225-4/2012 and has been registered under ClinicalTrials.gov identifier: NCT01511666.

How accurately can the aetiology of cardiac arrest be established in an out-of-hospital setting? Analysis by “Concordance in Diagnosis Crosscheck Tables”

INTRODUCTION Several previous studies have focused on establishing the cause of cardiac arrest (CA) during cardiopulmonary resuscitation (CPR) provided in an out-of-hospital setting. OBJECTIVES To analyze the ability of professional advanced life support providers to correctly establish the aetiology of cardiac arrest during out-of-hospital CPR. STUDY DESIGN A retrospective cohort study analysing 211 cases of out-of-hospital cardiac arrest. METHOD The aetiology assumed by out-of-hospital physicians was compared with the diagnosis that was later established by clinicians or pathologists. RESULTS Cases were sorted into five diagnostic groups and the overall diagnostic concordance was 74.4% (157 of 211 cases). The cardiac aetiology was presumed in 132 out of 211 patients and confirmed in 135 out of 211 patients. However, an analysis of individual cases of the cardiac causes of cardiac arrest revealed diagnostic matches in only 112 cases. Acute myocardial infarction (AMI) or pulmonary embolism (PE), both of which represent cases that can be potentially influenced by thrombolytic therapy, were presumed in 74 (53+21) and confirmed in 97 (77+20) cases, however with individual diagnostic matches in only 55 cases. CONCLUSION This study demonstrates the importance of analysing concordance in presumed and definitive diagnosis of individual cases, since an overall comparison in a cohort of cases may be highly misleading. It introduces the method of the crosscheck table for visualization and comparison of presumed and final diagnoses. The two alternative approaches of inclusion rule for applying the thrombolytic therapy in out-of-hospital care were discussed with regard to the recent TROICA study.

AP074 Process of emergency medical dispatch – An international survey

Background: Peripheral venipuncture in infants and children is technically challenging because their veins are small and located deep in the subcutaneous tissue which makes them difficult to palpate or visualize. In this study, we sought to determine if the use of the VeinViewer (Luminetx Corporation, Memphis, Tenn) in children facilitates peripheral venous access. Materials and Methods: This was a nonblinded, randomized controlled trial of a convenience sample of pediatric patients younger than 20 years old requiring intravenous access in the pediatric ward. Prior to the randomization, the DIVA (difficult intravenous access) score of 4-variable proportionally weighted rule (3 points for prematurity, 3 for younger than 1 year, 1 for 1–2 years of age, 2 for vein not palpable, and 2 for vein not visible) was estimated. We also decided vein categories (easy, intermediate and difficult) according to nurse opinion. Then patients were randomly allocated to undergo VeinViewer-assisted or standard peripheral venous access. Primary end point was the first-attempt success rate. Stepwise logistic regression analysis was used to identify factors associated with the first-attempt success. Results: A total of 111 patients were evaluated: 54 in the VeinViewer group and 57 in the traditional group. Patient demographics and factors related to the success of vein access were similar in both groups. Analysis by vein assessment category yielded a similar rate of successful first-attempt in both groups for easy veins. However, for difficult veins over DIVA score 4, first-attempt success rate increased from 25% in the traditional group to 58.3% in the VeinViewer group (p=0.026). Factors associated with the first-attempt success were patient age and type of delivery. Patient body mass index and the experience of nurse had no significant impact on the first-attempt success. Conclusion: The VeinViewer facilitates the peripheral venous access in pediatric patients with difficult veins enhancing the first-attempt success rate.