Robert E. O'Connor

The Public Access Defibrillation (PAD) trial: study design and rationale.

The PAD Trial is a prospective, multicenter, randomized clinical study testing whether volunteer, non-medical responders can improve survival from out-of-hospital cardiac arrest (OOH-CA) by using automated external defibrillators (AEDs). These lay volunteers, who have no traditional responsibility to respond to a medical emergency as part of their primary job description, will form part of a comprehensive, integrated community approach to the treatment of OOH-CA. The study is being conducted at 24 field centers in the United States and Canada. Approximately 1000 community units (e.g. apartment or office buildings, gated communities, sports facilities, senior centers, shopping malls, etc.) were randomized to treatment by trained laypersons who will provide either cardiopulmonary resuscitation (CPR) alone or CPR plus use of an AED, while awaiting arrival of the communitys emergency medical services responders. The primary endpoint is the number of OOH-CA victims who survive to hospital discharge. Secondary endpoints include neurological status, health-related quality of life (HRQL), cost, and cost-effectiveness. Data collection will last approximately 15 months and is expected to be completed in September 2003.

Vasopressin pressor effects in critically ill children during evaluation for brain death and organ recovery.

BACKGROUNDnVasopressin (VP) shows promise as a pressor agent in animals and adult human cardiac arrest and resuscitation, but has not been studied for pressor effect in critically ill or arrested children. VP infusion is routine treatment for diabetes insipidus during brain death evaluation and organ recovery. We hypothesized that low dose VP infusion during organ recovery in critically ill children exerts a pressor effect, without major organ toxicity.nnnMETHODSn34 VP-treated and 29 age-matched critically ill controls (C) < or =18 years were retrospectively reviewed during brain death evaluation and organ recovery. VP infusion protocol titrated VP dose clinically to urine output, with high variability. Pressor and inotrope management was titrated clinically to BP, cerebral perfusion and central venous pressures (when available) and peripheral perfusion with similar protocol targets for pre-load in VP and C groups. Outcome measures include dose, type and number of pressors and inotropes. Organ function was assessed at recovery and 48 h post-transplant by independent surgeon and transplant program organ function criteria. Analysis by Odds Ratio (OR), and chi-square.nnnRESULTSnVP dose averaged 0.041+/-0.069 U/kg/h. Average baseline mean arterial pressure (MAP) before VP infusion was 79+/-17 mmHg VP and 76+/-14 mm Hg C (P=0.6). Subsequent average MAP were: 82+/-21 mmHgVP after VP infusion versus 71+/-16 mmHg C (P=0.01) and 80+/-14 mmHg VP versus 68+/-22 mmHg C (P=0.01). Ability to wean/stop pressors and inotropes was: dopamine (14/23) 42% VP versus (10/26) 38% C (P=0.75), dobutamine (4/7) 57% VP versus (0/6) 0% C (P=0.026), epinephrine (4/5) 80% VP versus (0/6) 0% C (P=0.006), norepinephrine/phenylephrine (4/4) 100% VP versus (2/5) 40% C (P=0. 057). Alpha agonist pressor dependence was successfully weaned from 7/9 (78%) VP versus 0/9 (0%) C: odds ratio=7.3, (P<0.01). There was no VP induced dysrhythmia, hypertension, anuria or toxicity reported. Good organ recovery function was not significantly different at recovery or 48 h post-transplant for kidney (79% VP versus 69% C, P=0.068), liver (87% VP versus 95% C, P=0.533), or heart (90% VP versus 71% C, P=0.11).nnnCONCLUSIONSnLow dose vasopressin infusion exerts a pressor effect in critically ill children treated for diabetes insipidus during brain death and organ recovery. VP treated patients were 7.3 times more likely to wean from alpha agonists than comparably managed age matched controls, without adverse affect on transplant organ function. We speculate that further prospective assessment of VP safety and efficacy as a pressor adjunct for resuscitation of critically ill children is warranted.

Facilitating EMS Turnaround Intervals at Hospitals in the Face of Receiving Facility Overcrowding

The escalating national problem of oversaturated hospital beds andemergency departments (EDs) has resulted in serious operational impediments within patient-receiving facilities. It has also had a growing impact on the 9-1-1 emergency care system. Beyond the long-standing difficulties arising from ambulance diversion practices, many emergency medical services (EMS) crews are now finding themselves detained in EDs for protracted periods, unable to transfer care of their transported patients to ED staff members. Key factors have included a lack of beds or stretcher space, and, in some cases, EMS personnel are used transiently for ED patient care services. In other circumstances, ED staff members no longer prioritize rapid turnaround of EMS-transported patients because of the increasing volume andacuity of patients already in their care. The resulting detention of EMS crews confounds concurrent ambulance availability problems, creates concrete risks for delayed EMS responses to impending critical cases, andincurs regulatory jeopardy for hospitals. Communities should take appropriate steps to ensure that delivery intervals (time elapsing from entry into the hospital to physical transfer of patient care to ED staff) remain extremely brief (less than a few minutes) andthat they rarely exceed 10 minutes. While recognizing that the root causes of these issues will require far-reaching national health care policy changes, EMS andlocal government officials should still maintain ongoing dialogues with hospital chief administrators to mitigate this mutual crisis of escalating service demands. Federal andstate health officials should also play an active role in monitoring progress andcompliance.

Drug-Assisted Intubation in the Prehospital Setting (Resource Document to NAEMSP Position Statement)

Drug-Assisted Intubation in the Prehospital Setting (Resource Document to NAEMSP Position Statement) Henry E. Wang Assistant Professor a; Daniel P. Davis b; Robert E. OConnor c; Robert M. Domeier d a Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania b Department of Emergency Medicine, University of California, San Diego, San Diego, California c Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware d Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, Michigan

Location of Cardiac Arrests in the Public Access Defibrillation Trial

Background. The Public Access Defibrillation (PAD) Trial found an overall doubling in the number of out-of-hospital cardiac arrest (CA) survivors when a lay responder team was equipped with an automated external defibrillator (AED), compared with cardiopulmonary resuscitation (CPR) alone. Objectives. To describe the types of facilities that participated in the trial andto report the incidence of CA andsurvival in these different types of facilities. Methods. In this post-hoc analysis of PAD Trial data, the physical characteristics of the participating facilities andthe numbers of presumed CAs, treatable CAs, andsurvivors are reported for each category of facilities. Results. There were 625 presumed CAs at 1,260 participating facilities. Just under half (n = 291) of the presumed CAs were classified as treatable CAs. Treatable CAs occurred at a rate of 2.9 per 1,000 person-years of exposure; rates were highest in fitness centers (5.1) andgolf courses (4.8) andlowest in office complexes (0.7) andhotels (0.7). Survival from treatable CA was highest in recreational complexes (0.5), public transportation sites (0.4), andfitness centers (0.4) andlowest in office complexes (0.1) andresidential facilities (0.0). Conclusions. During the PAD Trial, the exposure-adjusted rate of treatable CA was highest in fitness centers andgolf courses, but the incidence per facility was low to moderate. Survival from treatable cardiac arrest was highest in recreational complexes, public transportation facilities, andfitness centers.

Blast-related injuries from terrorism: an international perspective.

Terrorism using conventional weapons andexplosive devices is a likely scenario andoccurs almost daily somewhere in the world. Caring for those injured from explosive devices is a major concern for acute injury care providers. Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. In September 2005, a multidisciplinary meeting of blast-related injury experts was convened including representatives from eight countries with experience responding to terrorist bombings (Australia, Colombia, Iraq, Israel, United Kingdom, Spain, Saudi Arabia, andTurkey). This article describes these experiences andprovides a summary of common findings that can be used by others in preparing for andresponding to civilian casualties resulting from the detonation of explosive devices.

Trauma Triage: Concepts in Prehospital Trauma Care

This report examines the efficacy of current trauma triage rules to determine the exigency of field care andtransport of severely injured patients from a variety of medical populations.

The range of medication storage temperatures in aeromedical emergency medical services.

OBJECTIVESnThe United States Pharmacopoeia (USP) recommends that medication storage temperatures should be maintained between 15 degrees C and 30 degrees C (59 degrees F to 86 degrees F). Concerns have been raised that storage temperatures in EMS may deviate from this optimal range, predisposing drugs to degradation. This study was conducted to determine whether temperatures inside the drug box carried by paramedics aboard a helicopter remained within the range.nnnMETHODSnThe Aviation Section, with a paramedic on board, utilizes two helicopters and conducts approximately 80 patient care flights per month. A dual-display indoor/outdoor thermometer with memory was used to measure the highest and lowest temperatures during each shift. The thermometer was kept with medications in a nylon drug bag, which remained on the helicopter except when needed for patient care. Ambient temperature measurements at the location of the helicopter base were obtained from the National Climatic Data Center. Temperature ranges were recorded during day shift (8 AM to 4 PM) and night shift (4 PM to 12 AM) during the winter from December 1, 1995, to March 13, 1996, and summer from June 17, 1996, to September 14, 1996. Statistical analysis was performed using chi-square and the Bonferroni-adjusted t-test.nnnRESULTSnCompared with the winter day period, the winter night period had lower minimum (13.2 degrees C vs 14.7 degrees C, p = 0.003) and maximum (20.3 degrees C vs 21.2 degrees C, p = 0.02) temperatures. Both were below the USP minimum. The summer day period had higher maximum temperatures than the summer night period (31.2 degrees C vs 27.6 degrees C, p = 5 x 10(-9)). The mean daytime summer maximum exceeded the USP upper limit. Storage temperatures outside of the USP range were observed during 49% of winter days, 62% of winter nights, 56% of summer days, and 27% of summer nights. There was a significant tendency for summer days (p = 8 x 10(-8)) and winter nights (p = 0.009) to be outside of the acceptable range. There was moderate correlation between ambient and drug box temperatures (r2 = 0.49).nnnCONCLUSIONSnMedications stored aboard an EMS helicopter are exposed to extremes of temperature, even inside a drug bag. Measures are needed to attenuate storage temperature fluctuations aboard aeromedical helicopters.

Emergency medical services transport of patients with headache: Mode of arrival may indicate serious etiology

OBJECTIVEnTo determine whether mode of arrival is associated with seriousness of etiology and use of diagnostic testing in patients treated in the emergency department for headache.nnnMETHODSnThis observational, retrospective study was conducted by consecutive review of the records of patients presenting to the emergency department with a chief complaint of headache from December 1994 through May 1995. Patients with altered mental status or seizures were excluded. Mode of arrival was classified as either by EMS or other (e.g., private vehicle). Patients with a final diagnosis of meningitis, intracranial hemorrhage, or central nervous system tumor were classified as having serious causes, whereas those with headache due to migraine, tension headache, or headache that was otherwise unspecified were classified as nonserious. The use of diagnostic studies, such as lumbar puncture or CT scan, and their results, was recorded. Patients were included in the category of patients having serious intracranial pathology even if the diagnosis was delayed. Statistical analysis was performed using the Yates-corrected chi-square test, and by determining odds ratios (ORs) with 95% confidence intervals.nnnRESULTSnFor 967 patients presenting with a chief complaint of headache, 837 charts were included in the analysis. A total of 102 patients arrived by EMS, and 735 arrived by other means. Patients arriving by EMS had a higher rate of serious cause of headache than did those arriving by other means (OR = 18.5, p < 0.0001). EMS patients tended to undergo additional diagnostic testing (OR = 4.4, p < 0.0001), and those tests were more likely to be abnormal than for those arriving by other means (OR = 9.4, p < 0.0001). Males had a somewhat higher rate of serious diagnosis (OR = 2.6, p < 0.05).nnnCONCLUSIONSnIn this EMS system, patients with headache who arrive by EMS are more likely to have serious causes. Mode of arrival may be of use to the clinician in assessing risk of serious illness among patients with headache. Whether this observation represents an element of self-triage or a combination of other factors remains to be determined.

Specialty Coverage at Non-Tertiary Care Centers

The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. Although most injuries are minor or moderate andcan be managed at local community hospitals, a significant minority of injured patients require extensive andexpensive care to survive or minimize injury. Most prehospital trauma triage criteria address a combination of factors to consider, but this approach sometimes fails to identify patients with severe injuries andoften burdens trauma centers with patients suffering minor injuries. It is critical to utilize a method to differentiate those injury victims who need the specialized expertise andresources available in trauma centers from those who can be adequately cared for locally. Although trauma centers assume the leadership role, in a truly inclusive system, all health care providers (prehospital, community hospitals, andtrauma centers) have a defined role in providing care to patients with trauma. All these institutions should establish andmaintain transfer agreements for the transfer of patients meeting system trauma triage criteria. Because prehospital triage criteria are not 100% sensitive, there should be a mechanism in place for the secondary triage of patients. Initial management of patients should continue while efforts are made to transfer the patient.