Emergency medicine journal : EMJ
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For a significant number of patients suffering out-of-hospital cardiac arrest (OHCA) cardiopulmonary resuscitation (CPR) is likely to be futile and attempting it may be the wrong thing to do. Anticipatory care plans with do-not-attempt cardiopulmonary resuscitation (DNACPR) instructions exist to prevent this. Anecdotally we felt that many patients present to our Emergency Department (ED) with ongoing resuscitation which was not in their best interests. The aim of this study was to establish the proportion of patients arriving in our ED with ongoing CPR who had low, intermediate or high risk of futility. ⋯ Our results suggest that community DNACPR implementation in Edinburgh is suboptimal, with many patients resuscitated and transported to the ED with ongoing resuscitation despite a high likelihood of futility. It is unclear what is required to improve this situation. Possible avenues for improvement may be more anticipatory care planning in the community, better recording of the outcomes of key conversations with patients and carers, or more consistent implementation of these plans by Ambulance Service responders. We plan further work to establish how this system can be changed to serve patients and their families better.
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The benefit of antiplatelet medication in confirmed acute coronary syndrome (ACS) is well established. In the Emergency Department (ED) diagnostic uncertainty may lead to over-treatment, with consequent risks (e.g., bleeding), or under-treatment, compromising clinical outcomes. Clinicians must subjectively balance the anticipated risks and benefits with their perceived probability of ACS in order to decide whether to prescribe these medications. We aimed to construct a clinical model to optimise and personalise recommendations for anti-platelet prescription in this context. ⋯ Systematic review identified three relevant original studies, and three sub-studies. After extracting data, we constructed two separate models, based on clinical outcomes after 30 days and 12 months. Aspirin alone led to greater net utility at probabilities below 7.4%, whereas treatment with ticagrelor led to greater net benefit when the probability of ACS exceeded 8.3% (figures 1 and 2). Sensitivity analyses including 10,000-fold Monte Carlo simulations demonstrated that the models were robust to a wide range of assumptions (figure 3).emermed;34/12/A870-a/F1F1F1Figure 1Acute coronary syndrome risk thresholds of treatment strategy superiority. (Clopidogrel and ticagrelor treatment strategies included the use of aspirin at ACS treatment)emermed;34/12/A870-a/F2F2F2Figure 2Net expected utility of anti-platelet therapy in 12 months combined outcome modelemermed;34/12/A870-a/F3F3F3Figure 3A monte carlo simulation (n=10,000) - net expected utility of anti-platelet therapy in 12 month combined outcome model - varying risk and utility outcomes CONCLUSION: This work suggests that treatment with ticagrelor yields greater net benefit for patients when the probability of ACS exceeds 8.3%. This has potential to improve clinical outcomes when used alongside a prediction model, such as the Manchester Acute Coronary Syndromes (MACS) decision aid, which calculates each patient's individual probability of ACS. The clinical and cost effectiveness of this novel 'precision Emergency Medicine' approach should now be evaluated in clinical studies.
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Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care. ⋯ The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were under-powered with sample sizes of 1028-1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group.emermed;34/12/A883-a/T1F1T1Table 1 CONCLUSION: Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.
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Sudden cardiac death is one of the leading causes of mortality in the UK. The incidence of out-of-hospital cardiac arrest (OHCA) in the UK is approximately 30 000. The initial cardiac rhythm in these cases is often a ventricular tachyarrhythmia which requires electrical defibrillation. The efficacy of defibrillation is dependent on its timely use, with the odds of survival decreasing by up to 10% for every minute of delay. The use of AEDs has been shown to significantly improve neurologically intact survival in OHCA. Significant progress has been made regarding the provision of AEDs in public places but it is questioned whether sufficient public education has been undertaken in order to support this strategy. This study aims to explore the attitudes of the general public in order to inform public education strategies, increase AED use and ultimately improve survival of OHCA. ⋯ The level of knowledge of AEDs is low amongst the general public. Majority of the study population who knew about AEDs had some degree of resuscitation training. Further research is required to ascertain how to translate knowledge into optimal use of AEDs in practice.
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There are no widely accepted validated clinical decision rules for the use of WBCT in trauma. Given the potential risks and costs, there is a clear need for a clinical decision rule (CDR) to safely guide targeted use of WBCT. We aimed to derive a CDR to guide clinical decisions on WBCT utilisation by detecting patients at high and low risk of multi-region trauma. ⋯ 1608 patients were included in the study. The derived model combined a bespoke physiological score with mechanistic and anatomical factors. The physiological score identified the risk of multi-region injury at various cut-offs of age, systolic blood pressure, GCS, heart rate and respiratory rate. Patients were further categorised according to mechanism of injury and clinical findings, and specific physiological scores were applied to each category to determine which patients in these categories required WBCT. 'High risk' injury mechanisms included high falls and unprotected road traffic collisions. Clinical signs of injury were categorised by body region, including the head, chest, abdomen and pelvis (figure 1). The overall sensitivity of the clinical decision rule for the primary objective was 96.0% (95% CI:94.8 to 97.2) while the specificity was36.1% (95% CI:33.3 to 39.0). The negative likelihood ratio was 0.11. For the secondary objective the sensitivity was 98.5%, the negative likelihood ratio 0.04.emermed;34/12/A861-a/F1F1F1Figure 1 CONCLUSION: This study derived a two stage CDR which was highly sensitive for identifying patients at high risk of multiregion injury. A prospective external validation study is now required to further refine and improve this model. This could provide a useful screening tool in the future.