Sune Forsberg

Coma and impaired consciousness in the emergency room: characteristics of poisoning versus other causes

Objectives: Unconscious patients represent a diagnostic challenge in the emergency room (ER), but studies on their characteristics are limited. The aim of this study was to investigate the frequency, characteristics and prognosis of different coma aetiologies with special focus on poisoning. Design: An observational study of consecutive adults admitted to the non-surgical ER, with a Glasgow coma scale (GCS) score of 10 or below. The GCS score on admission was prospectively entered into a study protocol, which was complemented with data from the medical record within one month. Results: 938 patients were enrolled. Poisoning caused unconsciousness in 352 cases (38%). In the remaining 586 cases (non-poisoning group) the underlying cause was a focal neurological lesion in 24%, a metabolic or diffuse cerebral disturbance in 21%, epileptogenic in 12%, psychogenic in 1% and was still not clarified at hospital discharge in 4%. Among patients below the age of 40 years, the coma was caused by poisoning in 80%, but among those over 60 years, poisoning was the cause in only 11%. The median GCS score on admission was identical in the two study groups. Hospital mortality rates were 2.8% and 39% in the two groups, respectively. Conclusion: Poisoning was the most common cause of coma and young age was a strong predictor of this condition. The prognosis was favourable among poisoned patients but poor in the rest of the study population as a group.

The implementation of a dual dispatch system in out-of-hospital cardiac arrest is associated with improved short and long term survival.

Aims: To determine the impact of a dual dispatch system, using fire fighters as first responders, in out-of-hospital cardiac arrest (OHCA) on short (30 days) and long term (three years) survival, and, to investigate the potential differences regarding in-hospital factors and interventions between the patient groups, such as the use of therapeutic hypothermia and cardiac catheterization. Methods and results: OHCAs from 2004 (historical controls) and 2006–2009 (intervention period) were included. During the intervention period, fire fighters equipped with automated external defibrillators (AEDs) were dispatched in suspected OHCA. Logistic regression analyses of outcome data included: the intervention with dual dispatch, sex, age, location, aetiology, witnessed status, bystander-cardiopulmonary resuscitation, first rhythm and therapeutic hypothermia. In total, 2581 OHCAs were included (historical controls n=620, intervention period n=1961). Fire fighters initiated cardiopulmonary resuscitation and connected an AED before emergency medical services’ arrival in 41% of the cases. The median time from dispatch to arrival of first responder or emergency medical services shortened from 7.7 in the control period to 6.7 min in the intervention period (p<0.001). The 30-day survival improved from 3.9% to 7.6% (p=0.001), adjusted odds ratio 2.8 (confidence interval 1.6–4.9). Survival to three years increased from 2.4% to 6.5% (p<0.001), adjusted odds ratio 3.8 (confidence interval 1.9–7.6). In the logistic regression analysis including in-hospital factors we found no outcome benefit of therapeutic hypothermia. Conclusions: The implementation of a dual dispatch system using fire fighters in OHCA was associated with increased 30-day and three-year survival. No major differences in the in-hospital treatment were seen between the studied patient groups.

The survival benefit of dual dispatch of EMS and fire-fighters in out-of-hospital cardiac arrest may differ depending on population density – A prospective cohort study

BACKGROUND Outcome after out-of-hospital cardiac arrest (OHCA) varies between contexts. Dual dispatching of fire-fighters or police in addition to emergency medical services (EMS) has the potential to increase survival, but the effect in urban vs. rural areas is unknown. The aim of this study was to determine the effects of dual dispatching on response times and outcome in regions with different population density. METHODS AND RESULTS The study design was a prospective cohort study of EMS-treated OHCAs from 2004 (historical controls, only EMS dispatch) and 2006-2009 (intervention, dual dispatch of EMS and fire-fighters), with data on exact geographical coordinates. Patients were divided into four subgroups depending on population density: rural (<250 persons/km2), suburban (250-2999/km2), urban (3000-5999/km2) and downtown (≥6000/km2). Totally, 2513 OHCAs were included (historical controls, n=571 and intervention, n=1942). Median time to arrival of first unit shortened significantly in all subgroups, ranging from 0.8 to 3.2 min, with the main time gain in the rural area. There were significant differences in 30-day survival between the historical controls vs. the intervention group in the suburban population (3.1% vs. 7.0%, p=0.02) and in downtown (4.1 vs. 14.6, p=0.04). In the urban population the difference was 2.7 vs. 6.9% (p=0.06) and in the rural population (4.7 vs. 5.3, p=0.82). CONCLUSIONS Dual dispatch of fire-fighters and EMS in OHCA significantly reduced response times in all studied regions. The 30-day survival increased significantly in the downtown and suburban populations, while a limited impact was seen in the rural areas.

Prognosis in Patients Presenting with Non-Traumatic Coma

BACKGROUND Studies of patients presenting with coma are limited, and little is known about the prognosis of these cases. OBJECTIVE The aim of this study was to investigate the acute and long-term prognosis after an episode of non-traumatic coma. METHODS Adults admitted consecutively to an emergency department in Stockholm, Sweden between February 2003 and May 2005 with a Glasgow Coma Scale (GCS) score of 10 or below were enrolled prospectively. All available data were used to explore the cause of the impaired consciousness on admission. Patients surviving hospitalization were followed-up for 2 years regarding survival. RESULTS The final study population of 865 patients had the following eight different coma etiologies: poisoning (n = 329), stroke (n = 213), epilepsy (n = 113), circulatory failure (n = 60), infection (n = 56), metabolic disorder (n = 44), respiratory insufficiency (n = 33), and intracranial malignancy (n = 17). The hospital mortality rate among the 865 patients was 26.5%, varying from 0.9% for epilepsy to 71.7% for circulatory failure. The accumulated total 2-year mortality rate was 43.0%, varying from 13.7% for poisoning to 88.2% for malignancy. The level of consciousness on admission also influenced the prognosis: a GCS score of 3-6 was associated with a significantly higher hospital mortality rate than a GCS score of 7-10. CONCLUSION The prognosis in patients presenting with non-traumatic coma is serious and depends largely on both the level of consciousness on admission and the etiology of the coma. Adding the suspected coma etiology to the routine coma grading of these emergencies may more accurately predict their prognosis.

Hospital mortality among poisoned patients presenting unconscious.

Objectives. The hospital mortality from acute poisoning in the western world is approximately 0.6%. However, this figure is based on series of consecutive cases, including mild intoxications. The aim of this paper was to investigate the mortality among poisoned patients with CNS depression on admission. Design. This report is based on two case series. One observational study of 352 prospectively included cases of poisoning with a Glasgow coma scale (GCS) score ≤ 10 at presentation during the 2-year-period 2003–2005, and one retrospective review of all poisonings admitted to a hospital in Stockholm 2009–2011. Results. The observational study showed a hospital mortality rate of 2.8%. Nine of the 10 fatalities had a GCS score below 7 on admission. The more recent retrospective review consisted of 1314 cases of poisoning of whom 419 (32%) had a GCS score ≤ 10 on admission. The hospital mortality among these 419 cases was 2.4%. All 10 deaths in this cohort had a GCS score below 7 at presentation. The subgroup of patients pooled from both case series with a GCS score of 3–6 (n = 444) had a mortality rate of 4.3%. Conclusions. Based on the findings in this report, and on a literature search, about 30% of hospitalized poisonings have a significant CNS depression on admission. Based on our experience, cases of poisoning with a GCS score of 7–10 on admission do not seem to have a worse prognosis than poisonings in general. However, cases of poisoning presenting with deeper coma (GCS score 3–6) have a mortality rate approximately seven times higher than the overall hospital mortality from acute poisoning.

Metabolic vs structural coma in the ED—an observational study

BACKGROUND Patients presenting unconscious may reasonably be categorized as suffering from a metabolic or structural condition. STUDY OBJECTIVE The objective was to investigate if some routinely recorded clinical features may help to distinguish between these 2 main forms of coma in the emergency department (ED). METHODS Adults admitted to an ED in Stockholm between February 2003 and May 2005 with a Glasgow Coma Scale (GCS) score less than 11 were enrolled prospectively. The GCS score was entered into a protocol that was complemented with available data within 1 month. RESULTS The study population of 875 patients was classified into 2 main groups: one with a metabolic (n = 633; 72%) and one with a structural disorder (n = 242; 28%). Among the clinical features recorded in the ED, 3 were found to be strongly associated with a metabolic disorder, namely, young age, low or normal blood pressure, and absence of focal signs in the neurological examination. Patients younger than 51 years with a systolic blood pressure less than 151 mm Hg who did not display signs of focal pathology had a probability of 96% for having a metabolic coma. The mean GCS score on admission was identical in the groups. Hospital mortality was 14% in the metabolic and 56% in the structural group. CONCLUSIONS These findings indicate that unconscious young adults who present without a traumatic incident with a low or normal blood pressure and without signs of focal pathology most probably suffer from a metabolic disorder, wherefore computed tomography of the brain may be postponed and often avoided.

Successful whole bowel irrigation in self-poisoning with potassium capsules.

Overdose of slow-release (SR) potassium chloride is uncommon, but life-threatening (1– 3). Potassium chloride capsules are radio-opaque (1,4), but effective traditional gastrointestinal (GI) decontamination is difficult to achieve (1). The Position Paper on whole bowel irrigation (WBI) (5) recommended that WBI be considered for toxic ingestions of SR drugs. We present a patient who was admitted on three occasions because of self-poisoning with potassium capsules and was successfully treated twice with WBI. A 28-year-old woman was admitted to the emergency department because of self-poisoning with potassium capsules. Her medical history included pacemaker in situ, borderline personality, and two previous episodes of potassium poisoning. Episode 1. Two years previously, the patient was admitted 3 h after ingesting 100 capsules of SR potassium chloride (Kalium retard, 750 mg, 10 mmol K). Serum potassium level on admission was 7.2 mmol/L. Shortly after refusing treatment, the patient had a cardiac arrest. Cardiopulmonary resuscitation and administration of IV adrenaline resulted in ventricular fibrillation. She was defibrillated, intubated, and transferred to the ICU. The serum potassium level was 9.2 mmol/L 2 h after admission; the ECG demonstrated pacemaker capture. Blood pressure was 90/35 mmHg. No GI decontamination was performed. Despite IV treatment with calcium, sodium bicarbonate, and dextrose-insulin and oral sodium polystyrene sulfonate resin, the serum potassium level remained elevated (9.2 → 6.9 → 7.5 → 9.5 mmol/L) during the following 8 h. Four hours of hemodialysis normalized the serum potassium level. No further treatment was necessary and the patient was transferred to the psychiatric department 2 days later. Episode 2. The second episode occurred 4.5 months later. The patient presented 1 h after ingesting 100 capsules of SR potassium chloride (Kalitabs, 750 mg). Serum potassium level was 5.1 mmol/L. She was transferred to the ICU, where she again refused treatment. ECG displayed pacemaker rhythm and blood pressure was 140/60 mmHg. Despite her refusal, the patient was anesthetized and intubated, and gastric lavage was performed with limited results. Serum potassium level was 6.9 mmol/L 2 h after admission. Treatment with IV dextrose-insulin and sodium bicarbonate and oral sodium polystyrene sulfonate resin was initiated. Chest X-ray, performed 3 h after admission to check the position of a central venous line, showed numerous capsules in the stomach and WBI was initiated. Over the next 12 h, 10 L of polyethylene glycol electrolyte solution was administered by nasogastric tube. This resulted in diarrhea containing large numbers of capsule fragments and some whole capsules. During this period, the serum potassium level never exceeded 6.9 mmol/L (6.2 → 6.8 → 5.7 → 5.3 → 4.4 mmol/L). Twenty-four hours later, the patient was extubated and transferred to the psychiatric clinic. Episode 3. On the third overdose, she presented 2.5 h after ingesting 70 capsules SR potassium chloride (Kalitabs, 750 mg). The serum potassium level was 7.1 mmol/L and serum creatinine 69 μmol/L (0.78 mg/dL). ECG revealed sinus rhythm of 70 beats/minute with prominent peaked T-waves. In the ICU, she vomited once. Four capsules were found in the vomit. She again refused to cooperate but was anesthetized and intubated. Sodium bicarbonate and dextrose-insulin were administered IV. Abdominal X-ray revealed multiple capsules (Fig. 1) and WBI was initiated. Over the next 6 h, 4 L of a polyethylene glycol electrolyte solution was administered by nasogastric tube causing diarrhea that contained numerous capsule fragments and several whole capsules. The serum potassium levels during that period were 6.5 → 3.9 → 4.9 → 5.5 → 4.4 mmol/L. Potassium level remained normal without further treatment. A second abdominal X-ray approximately 11 h after the first showed no capsules in the GI tract (Fig. 2A and B). Eight hours later, the patient was transferred from the ICU. In the first episode, abdominal X-ray and WBI were not performed. The 8-h period of sustained hyperkalemia, despite vigorous potassium-lowering treatment before hemodialysis, was due to continuous absorption. In the second episode, the presence of capsules on chest X-ray prompted the ICU staff to consult the Poisons Center, which recommended WBI. This treatment, combined with traditional potassium-lowering measures, rendered hemodialysis unnecessary. In the third episode, an emergency abdominal X-ray revealed multiple capsules. WBI was immediately started and reduced the need for prolonged potassium-lowering measures and shortened the ICU stay. WBI has been used for many years for gut cleansing prior to radiographic investigations (6). The intervention was introduced as a GI decontamination procedure after poisoning in the late 1980s (7). Volunteer studies indicate that WBI variably reduces drug absorption (8– 10). Several reports of WBI in poisoned patients have been published, but only one involving SR potassium (1). WBI should not be used routinely in poisoned patients, but the clinical courses of these three episodes suggest that it should be considered in massive self-poisoning with SR potassium chloride.

Anaesthetics and analgesics; neurocognitive effects, organ protection and cancer reoccurrence an update

Available general and local anaesthetics, third generation inhaled anaesthetics, propofol and amide class local anaesthetics are effective and reassuringly safe. They are all associated to low incidence of toxicology and or adverse-effects. There is however a debate whether anaesthetic drug and technique could exhibit effects beyond the primary effects; fully reversible depression of the central nervous system, dose dependent anaesthesia. Anaesthetics may be involved in the progression of neurocognitive side effects seen especially in the elderly after major surgery, so called Postoperative Cognitive Dysfunction. On the other hand anaesthetics may exhibit organ protective potential, reducing ischemia reperfusion injury and improving survival after cardiac surgery. Anaesthetics and anaesthetic technique may also have effects of cancer reoccurrence and risk for metastasis. The present paper provides an update around the evidence base around anaesthesia potential contributing effect on the occurrence of postoperative cognitive adverse-effects, organ protective properties and influence on cancer re-occurrence/metastasis.

Transversus abdominal plane (TAP) block for postoperative pain management: a review.

Transversus abdominal plane (TAP) block has a long history and there is currently extensive clinical experience around TAP blocks. The aim of this review is to provide a summary of the present evidence on the effects of TAP block and to provide suggestions for further studies. There are several approaches to performing abdominal wall blocks, with the rapid implementation of ultrasound-guided technique facilitating a major difference in TAP block performance. During surgery, an abdominal wall block may also be applied by the surgeon from inside the abdominal cavity. Today, there are more than 11 meta-analyses providing a compiled evidence base around the effects of TAP block. These analyses include different procedures, different techniques of TAP block administration and, importantly, they compare the TAP block with a variety of alternative analgesic regimes. The effects of TAP block during laparoscopic cholecystectomy seem to be equivalent to local infiltration analgesia and also seem to be beneficial during laparoscopic colon resection. The effects of TAP are more pronounced when it is provided prior to surgery and these effects are local anaesthesia dose-dependent. TAP block seems an interesting alternative in patients with, for example, severe obesity where epidural or spinal anaesthesia/analgesia is technically difficult and/or poses a risk. There is an obvious need for further high-quality studies comparing TAP block prior to surgery with local infiltration analgesia, single-shot spinal analgesia, and epidural analgesia. These studies should be procedure-specific and the effects should be evaluated, both regarding short-term pain and analgesic requirement and also including the effects on postoperative nausea and vomiting, recovery of bowel function, ambulation, discharge, and protracted recovery outcomes (assessed by e.g., postoperative quality of recovery scale).

Surviving Two Hours of Ventricular Fibrillation in Accidental Hypothermia

Abstract Background. Cardiac arrest as a consequence of deep accidental hypothermia is associated with high mortality. Standardized prehospital management as well as rewarming with extracorporeal circulation (ECC) are important factors to improve survival. The objective of this case report is to illustrate the importance of effective cardiopulmonary resuscitation (CPR) and ECC in a cardiac arrest following deep accidental hypothermia. Case report. A 42-year-old man was found unresponsive to external stimuli and pulseless at an outdoor temperature of 1°C. CPR was started at the scene by laypersons, and the emergency medical services (EMS) arrived 5 minutes after the emergency call. Resuscitation according to International Liaison Committee on Resuscitation (ILCOR) guidelines was initiated by EMS. The first recorded rhythm was ventricular fibrillation (VF), which persisted, despite repeated defibrillation. The patient showed signs of severe hypothermia and, during ongoing CPR, was transported to hospital where on arrival the patients rectal temperature was measured at 22°C. Resuscitation measures were continued and warming was started at the emergency room. Due to persistent VF and deep hypothermia, the patient was transferred to a cardiothoracic surgical unit for rewarming with ECC. At commencement of ECC, CPR had been going for approximately 130 minutes and a total of 38 defibrillations had been made. During this time interval the patients was pulseless. At a core temperature of 30°C, one defibrillation restored sinus rhythm and subsequently stable circulation was achieved. The patient received a further 24 hours of hypothermia treatment at 32–34°C. He was discharged to rehabilitation facilities after 3 weeks of hospital care. Three months after the cardiac arrest the patient was fully recovered, was back to work, and had resumed normal activities. Conclusions. We demonstrate a case of cardiac arrest due to deep accidental hypothermia that stresses the importance of effective CPR and early-stage consideration of the use of ECC for safe and effective rewarming.