Tom Silfvast

Outcome from severe accidental hypothermia in Southern Finland—a 10-year review

The charts of all adult patients with accidental hypothermia who were admitted to a single academic hospital during a 10 year period were retrospectively retrieved. The aim was to identify factors associated with survival of those with hypothermic cardiac arrest. Of 75 admitted patients, 44 were found to be haemodynamically stable and not to require invasive rewarming measures. Of the remaining 31 patients, 23 were in refractory cardiac arrest due to primary hypothermia and rewarmed using cardiopulmonary bypass (CPB). The aetiology of hypothermia was immersion in cold water in 48%, exposure to cold environment in 39% and submersion in 13% of these patients. Their median age was 50 years, and 83% were males. The patients received a total of 70 min of conventional CPR before institution of CPB. Fourteen of these patients (61%) survived to discharge from hospital. Factors associated with survival were age (P=0.015), arterial pH (P=0.011), PaCO2 (P=0.003), and serum potassium (P=0.007). Logistic regression analysis showed that of the 23 patients, 22 could be correctly classified as survivor or nonsurvivor based on the level of serum potassium and arterial pCO2. It is concluded that patients with cardiac arrest due to primary hypothermia tolerate long periods of conventional CPR before institution of CPB. The possible predictive role of serum potassium and arterial pCO2 needs further evaluation.

Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units : the FINNRESUSCI study

PurposeWe aimed to evaluate post-resuscitation care, implementation of therapeutic hypothermia (TH) and outcomes of intensive care unit (ICU)-treated out-of-hospital cardiac arrest (OHCA) patients in Finland.MethodsWe included all adult OHCA patients admitted to 21 ICUs in Finland from March 1, 2010 to February 28, 2011 in this prospective observational study. Patients were followed (mortality and neurological outcome evaluated by Cerebral Performance Categories, CPC) within 1xa0year after cardiac arrest.ResultsThis study included 548 patients treated after OHCA. Of those, 311 patients (56.8xa0%) had a shockable initial rhythm (incidence of 7.4/100,000/year) and 237 patients (43.2xa0%) had a non-shockable rhythm (incidence of 5.6/100,000/year). At ICU admission, 504 (92xa0%) patients were unconscious. TH was given to 241/281 (85.8xa0%) unconscious patients resuscitated from shockable rhythms, with unfavourable 1-year neurological outcome (CPC 3–4–5) in 42.0xa0% with TH versus 77.5xa0% without TH (pxa0<xa00.001). TH was given to 70/223 (31.4xa0%) unconscious patients resuscitated from non-shockable rhythms, with 1-year CPC of 3–4–5 in 80.6xa0% (54/70) with TH versus 84.0xa0% (126/153) without TH (pxa0=xa00.56). This lack of difference remained after adjustment for propensity to receive TH in patients with non-shockable rhythms.ConclusionsOne-year unfavourable neurological outcome of patients with shockable rhythms after TH was lower than in previous randomized controlled trials. However, our results do not support use of TH in patients with non-shockable rhythms.

Characteristics of discrepancies between clinical and autopsy diagnoses in the intensive care unit: a 5-year review

AbstractnObjectives. To characterise discrepancies between clinical and autopsy diagnoses in patients who die in the intensive care unit.nDesign. Retrospective chart review.nSetting. Ten-bed closed mixed adult intensive care unit in a tertiary referral teaching hospital.nParticipants. All the clinical notes and autopsy reports of 346 patients who died in the intensive care unit in 1996–2000.nInterventions. Discrepancies between clinical and autopsy diagnoses were reviewed by two intensivists, a specialist in infectious diseases, a pathologist and an anaesthesiologist. New findings which would have changed current therapy in the intensive care unit were categorised as a Class I discrepancy, and those related to death but which would not have altered therapy as a Class II discrepancy.nResults. Of 2370 patients admitted, 388 (16.4%) died. An autopsy was performed in 346 (89%) of the deceased patients. A Class I discrepancy was found in 8 patients (2.3%) and a Class II discrepancy in 11 patients (3.2%). Five of the eight (62%) Class I discrepancies were infections which occurred in patients already treated for another infections.nConclusion. Despite the availability of advanced diagnostic facilities, especially infectious complications seem to remain undiagnosed. Autopsy is a valuable tool with which to monitor diagnostic accuracy in these patients.

Therapeutic hypothermia after prolonged cardiac arrest due to non-coronary causes

Mild resuscitative hypothermia has been shown to improve neurological outcome after cardiac arrest presenting with ventricular fibrillation (VF) due to cardiac causes. We describe the experience of inducing mild hypothermia in three patients with non-cardiac causes of arrest and long delays before a return of spontaneous circulation (ROSC). In one patient, extreme metabolic acidosis due to inadvertent oesophageal intubation complicated therapy, and the role of point-of-care diagnostics in the prehospital setting is briefly discussed. All patients survived to discharge from hospital, and neuropsychological examinations revealed good recovery. It is concluded that mild resuscitative hypothermia may be beneficial also in patients with obvious non-coronary causes for cardiac arrest.

The effect of experience of on-site physicians on survival from prehospital cardiac arrest

Outcome from prehospital cardiac arrest was studied 1 year before (Period I) and after (Period II) a reorganisation of the work and the simultaneous change of all physicians participating in the care of prehospital patients in the emergency medical service system in Helsinki. There were 444 patients during Period I and 395 patients during Period II. Resuscitation was initiated in 279 patients during Period I and in 323 patients (P < 0.001) during Period II. The number of patients with ventricular fibrillation who suffered a witnessed cardiac arrest due to presumed heart disease was 120 and 130, respectively. During Period I, 70 of these patients were successfully resuscitated and admitted to hospital, 41 (34%) survived to discharge home from hospital. Corresponding figures during Period II were 79 and 33 (25%, NS). Compared with Period I, a larger proportion of the successfully resuscitated patients either died in hospital or were discharged to an institution during Period II (P < 0.05).

Regional variation and outcome of out-of-hospital cardiac arrest (ohca) in Finland – the Finnresusci study

BackgroundDespite the efforts of the modern Emergency Medical Service Systems (EMS), survival rates for sudden out-of-hospital cardiac arrest (OHCA) have been poor as approximately 10% of OHCA patients survive hospital discharge. Many aspects of OHCA have been studied, but few previous reports on OHCA have documented the variation between different sizes of study areas on a regional scale. The aim of this study was to report the incidence, outcomes and regional variation of OHCA in the Finnish population.MethodsFrom March 1st to August 31st, 2010, data on all OHCA patients in the southern, central and eastern parts of Finland was collected. Data collection was initiated via dispatch centres whenever there was a suspected OHCA case or if a patient developed OHCA before arriving at the hospital. The study area includes 49% of the Finnish population; they are served by eight dispatch centres, two university hospitals and six central hospitals.ResultsThe study period included 1042 cases of OHCA. Resuscitation was attempted on 671 patients (64.4%), an incidence of 51/100,000 inhabitants/year. The initial rhythm was shockable for 211 patients (31.4%). The survival rate at one-year post-OHCA was 13.4%. Of the witnessed OHCA events with a shockable rhythm of presumed cardiac origin (n=140), 64 patients (45.7%) were alive at hospital discharge and 47 (33.6%) were still living one year hence. Surviving until hospital admission was more likely if the OHCA occurred in an urban municipality (41.5%, p=0.001).ConclusionsThe results of this comprehensive regional study of OHCA in Finland seem comparable to those previously reported in other countries. The survival of witnessed OHCA events with shockable initial rhythms has improved in urban Finland in recent decades.

Prehospital thrombolytic treatment of massive pulmonary embolism with reteplase during cardiopulmonary resuscitation

A 52-year-old previously healthy man experienced acute severe dyspnoea after suffering from gastroenteritis for 3 days. After arrival of the ambulance, cardiac arrest with an initial rhythm of electro mechanical dissociation occurred. Circulation was restored after 10 min of cardiopulmonary resuscitation but soon cardiac arrest reoccurred. Based on a strong clinical suspicion of massive pulmonary embolism, thrombolytic treatment with heparin 5000 IU and reteplase 20 U, given as single boluses and heparin was continued as an infusion 1000 IU h(-1). After 7 min of continued resuscitation, circulation was restored and after 40 min the vital functions began to stabilize, thus indicating pulmonary reperfusion. The diagnosis of pulmonary embolism was confirmed by a ventilation-perfusion scan and by spiral computerised tomography. The patient was discharged from intensive care after 2 days with a cerebral performance category I. Based on previous calculations, the annual number of patients who present with massive pulmonary embolism leading to cardiac arrest (and thus who would theoretically be candidates for thrombolytic treatment) was estimated to be 0.7/100000 inhabitants in this emergency medical services system.

Conduct of emergency research in patients unable to give consent—Experiences and perceptions of patients, their consent providing next of kin, and treating physicians following a prehospital resuscitation trial☆

OBJECTIVEnAccording to a directive of the European Parliament, informed consent is required to conduct a clinical trial also in emergencies when the patient is unable to provide consent. In these cases surrogate consent can be obtained from the patients next of kin. There are no reports describing how patients and their next of kin perceive this policy. The perceptions of patients and their spouses involved in an emergency trial conducted under surrogate consent were surveyed.nnnMETHODSnA survey was sent to survivors of prehospital cardiac arrest, to consent providers regardless of patient outcome, and to physicians who had recruited the patients.nnnRESULTSn11 (92%) patients, 17 (68%) consent providers, and all physicians returned the survey. All held a positive attitude towards emergency research and were willing to participate without own consent in a trial approved by an institutional review board (IRB). Opinions among responding groups were similar albeit a significant difference regarding the perceived capability of the consent provider to decide upon patients enrolment. Spouses felt able to provide consent, but physicians were sceptical of this. Patients and their spouses would have appreciated additional information regarding the index trial after the acute phase.nnnCONCLUSIONSnEmergency research was perceived positively by cardiac arrest victims and their spouses previously involved in a resuscitation trial. Possible own participation in an emergency trial without personal consent was considered acceptable. Patients and their spouses would prefer additional research information after enrolment.

Feasibility of written instructions in airway management training of laryngeal tube

BackgroundAirway management is of essential importance in emergency care. Training and skill retention of endotracheal intubation (ETI) - the technique considered as the gold standard -, poses a problem especially among care providers experiencing a low frequency of airway management situations. Therefore, alternative airway devices such as the laryngeal tube (LT) with potentially steeper learning curves have been developed and studied. Our aim was to evaluate in a manikin model the use of LT after no other training than written instructions only.MethodsTo evaluate the amount of training required to use the LT in a scenario of airway compromise, we assessed the feasibility of providing written instructions and pictures showing its use to 67 out- and in-hospital emergency care providers attending an Emergency Care conference. The majority of the participants were either nurses or firemen with a median of 5 years history of work in emergency care.ResultsIn this study 55% of all participants inserted the LT on the first attempt without additional instructions. An additional 42% required verbal instructions before successful insertion. Overall, 97% of the participants successfully inserted the LT with two attempts.In logistic regression analysis, no relationship was detected between background variables (basic education, experience of emergency work, frequency of bag-valve-mask ventilation (BVM) and frequency of ETI) and successful insertion of the LT in less than 30 seconds, ability to maintain normoventilation (7 l/min) and need for further instructions during the test.ConclusionsWe found that in this pilot study majority of emergency care providers could insert LT with one or two attempts with written instructions, pictures and verbal instruction. This may provide an option to simplify the training of airway management with LT.

Can Untrained Laypersons Use a Defibrillator with Dispatcher Assistance

OBJECTIVESnAutomated external defibrillators (AEDs) provide an opportunity to improve survival in out-of-hospital cardiac arrest by enabling laypersons not trained in rhythm recognition to deliver lifesaving therapy. This study was performed to examine whether untrained laypersons could safely and effectively use these AEDs with telephone-guided instructions and if this action would compromise the performance of cardiopulmonary resuscitation (CPR) during a simulated ventricular fibrillation out-of-hospital cardiac arrest.nnnMETHODSnFifty-four conscripts without previous medical education were recruited from the Western Command in Finland. For this study, the participants were divided at random to form teams of two persons. The teams were randomized to dispatcher-assisted CPR with or without AED operation during a simulated ventricular fibrillation out-of-hospital cardiac arrest. The time interval from collapse to first shock, hands-off time, and the quality of CPR were compared between the two groups.nnnRESULTSnThe quality of CPR was poor in both groups. The use of an AED did not increase the hands-off time or the time interval to the first compression. Sixty-four percent of the teams in the AED group managed to give the first defibrillatory shock within 5 minutes.nnnCONCLUSIONSnThe quality of dispatcher-assisted CPR is poor. Dispatcher assistance in defibrillation by a layperson not trained to use an AED seems feasible and does not compromise the performance of CPR.