Robert E. O’Connor

In-hospital cardiac arrest: Impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge

CONTEXT In-hospital cardiac arrest is a significant public health problem with a low probability of patient survival to hospital discharge. OBJECTIVE We evaluated the survival rates for adults with in-hospital cardiac arrest based on whether the arrest was witnessed and/or monitored. Our hypothesis is that patients with either a witnessed or monitored arrest had improved survival to hospital discharge with intact neurologic function. DESIGN, SETTING, AND PATIENTS We studied a cohort study of 74,213 patients who suffered in-hospital cardiac arrest from January 1, 2000 through February 1, 2008 at the 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. INTERVENTIONS The primary exposure of interest was whether the arrest was witnessed and/or monitored (i.e. electrocardiography, pulse oximetry, apnea, or bradycardia monitoring) at the time of arrest. Events were classified as being both monitored and witnessed, monitored only, witnessed only, or neither witnessed nor monitored. MAIN OUTCOME MEASURES Survival to hospital discharge and cerebral performance category at time of discharge. RESULTS A total of 73% of patients suffering in-hospital cardiac arrest were witnessed and monitored; 10% were monitored but not witnessed; 9% were witnessed but not monitored; and 8% were neither witnessed nor monitored. Compared with those who were unmonitored/unwitnessed, each of the three groups of patients who were monitored and/or witnessed were over twice as likely to survive to hospital discharge with a cerebral performance category of 1 or 2 (monitored/witnessed OR=2.40, 95% CI: 2.08, 2.76; monitored-only OR=2.12, 95% CI: 1.81, 2.47; witnessed-only OR=2.43, 95% CI: 2.10, 2.83). CONCLUSIONS Patients who are witnessed and/or monitored at the time of cardiac arrest demonstrate a significantly higher rate of survival to hospital discharge compared to those patients who are neither monitored nor witnessed. Monitored and/or witnessed cardiac arrest patients were also more likely to be discharged with favorable neurologic outcome. Cardiac monitoring confers no additional outcome benefit over direct observation of patients suffering in-hospital cardiac arrest.

The Diagnosis and Management of Seizures and Status Epilepticus in the Prehospital Setting

Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public–private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.

Nonurgent Commercial Air Travel After Nonhemorrhagic Cerebrovascular Accident

Nonurgent commercial air travel in patients who have experienced a nonhemorrhagic cerebrovascular accident (CVA) may occur, particularly in the elderly traveling population. A recent CVA, particularly occurring during a persons travel, presents a significant challenge to the patient, companions, family, and health care team. Specific medical recommendation, based on accumulated scientific data and interpreted by medical experts, is needed so that travel health care professionals can appropriately guide the patient. Unfortunately, such recommendations are almost entirely lacking despite the relative frequency of CVA and air travel. This article reviews the existing recommendations with conclusions based on both these limited data and rationale conjecture.

Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children

Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

Importance In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control’s (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. Objective To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. Evidence Review Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. Findings Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. Conclusions and Relevance This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

Air Travel of Patients With Abdominal Aortic Aneurysm: Urgent Air Medical Evacuation and Nonurgent Commercial Air Repatriation

Abdominal aortic aneurysm (AAA) presents across a spectrum of severity. Although some resources suggest a theoretic risk for rupture related to air travel, this claim remains unproven. In fact, there are little data from which to make evidence-based recommendations. Air medical evacuation of a patient with either an AAA at risk of imminent rupture or status post recent rupture can be performed, assuming that local surgical care is not available and that transfer is taking the patient to a higher level of medical intervention. Furthermore, medical opinion suggests that patients with asymptomatic and/or surgically corrected AAA can safely travel by commercial aircraft for nonurgent reasons, assuming that other issues including postoperative needs are appropriately addressed. In this discussion, answers to the following issues are sought: flight safety for urgent evacuation and nonurgent repatriation scenarios, waiting time to fly nonurgently after AAA diagnosis, and the need for medical accompaniment.

Preflight Therapies to Minimize Medical Risk Associated with Commercial Air Travel

Airlines may require a physician to provide medical clearance if they suspect that a passenger is suffering from a condition that would be considered a potential hazard to the safety of the aircraft or adversely affect the welfare and comfort of the other passengers and/or crew. In addition, patients with a variety of medical disorders may be placed at greater risk of adverse health consequences unless preexisting conditions are stabilized prior to departure. The purpose of this chapter is to describe conditions that may place the patient at additional risk during flight, and outline steps to mitigate these risks.

Anticoagulation and Non-urgent Commercial Air Travel: A Review of the Literature

With the increasing number of people traveling by air, it is likely the physician will encounter the need to initiate anticoagulation in an air traveler. Some of the issues that must be considered in the traveling patient are reliability of follow-up, drug interactions, drug dosage, and cost. In this article, we discuss the oral anticoagulant options for these patients, with a focus on issues for the traveling patient. We then discuss 3 scenarios in which this situation could occur with a survey of the current literature and recommendations on the best anticoagulant in each scenario. These scenarios include the traveling patient who experiences deep venous thrombosis, new-onset atrial fibrillation requiring anticoagulation, and significant orthopedic injury. Although there do not appear to be any studies that provide evidence-based recommendations, we extrapolate from the existing literature as to which oral anticoagulant option would be the most appropriate for the patient about to embark on nonurgent air travel. As the population continues to age, so do the number of patients treated with oral anticoagulation. Vitamin K antagonists have been the most commonly used oral anticoagulants worldwide with an extensive list of indications including the treatment/prevention of thromboembolism resulting from prosthetic heart valves, myocardial infarction with impaired left ventricular function, atrial fibrillation, and the treatment/prevention of venous thromboembolism in patients at risk. 1 Between the years of 1998 and 2004, the number of outpatient prescriptions for warfarin in the United States increased from just over 21 million to almost 31 million. 2 This continual increase in the use of warfarin suggests its effectiveness as an anticoagulant; however, its use is not without risk. The drug has both a narrow therapeutic index and a well-recognized risk of hemorrhage. Between 2004 and 2005, warfarin was 1 of 2 drugs most commonly implicated in adverse drug events in US emergency departments. 1 Because of this narrow therapeutic index and related adverse events, the risk of hemorrhage should be determined before the initiation of an oral anticoagulant using the Anticoagulation and Risk Factors in Atrial Fibrillation score, and the drug level must be monitored regularly by checking the international normalized ratio (INR) level. 1