Category: Emergency Medicine

Categories : Emergency Medicine NeurologyTags :

T Cells could Ease Brain Injury after Cardiac Arrest

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Despite improvements in CPR and ambulance response times, only about one in 10 people ultimately survive after out-of-hospital cardiac arrest (OHCA). Most patients hospitalised with OCHA die of brain injury, and no medications are currently available to prevent this outcome. A team led by researchers from Mass General Brigham found that immune cells may play a key role.

Using samples from patients who have had an OHCA, the team uncovered changes in immune cells just six hours after cardiac arrest that can predict brain recovery 30 days later. They pinpointed a particular population of cells that may provide protection against brain injury and a drug that can activate these cells, which they tested in preclinical models. Their results are published in Science Translational Medicine.

“Cardiac arrest outcomes are grim, but I am optimistic about jumping into this field of study because, theoretically, we can treat a patient at the moment injury happens,” said co-senior and corresponding author Edy Kim, MD, PhD, of the Division of Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital. “Immunology is a super powerful way of providing treatment. Our understanding of immunology has revolutionised cancer treatment, and now we have the opportunity to apply the power of immunology to cardiac arrest.”

As a resident physician in the Brigham’s cardiac intensive care unit, Kim noticed that some cardiac arrest patients would have high levels of inflammation on their first night in the hospital and then rapidly improve. Other patients would continue to decline and eventually die. In order to understand why some patients survive and others do not, Kim and colleagues began to build a biobank – a repository of cryopreserved cells donated by patients with consent from their families just hours after their cardiac arrest.

The researchers used a technique known as single-cell transcriptomics to look at the activity of genes in every cell in these samples. They found that one cell population – known as diverse natural killer T (dNKT) cells – increased in patients who would have a favourable outcome and neurological recovery. The cells appeared to be playing a protective role in preventing brain injury.

To further test this, Kim and colleagues used a mouse model, treating mice after cardiac arrest with sulfatide lipid antigen, a drug that activates the protective NKT cells. They observed that the mice had improved neurological outcomes.

The researchers note that there are many limitations to mouse models, but making observations from human samples first could increase the likelihood of successfully translating their findings into intervention that can help patients. Further studies in preclinical models are needed, but their long-term goal is to continue to clinical trials in people to see if the same drug can offer protection against brain injury if given shortly after cardiac arrest.

“This represents a completely new approach, activating T cells to improve neurological outcomes after cardiac arrest,” said Kim. “And a fresh approach could lead to life-changing outcomes for patients.”

Source: Mass General Brigham

Categories : Emergency MedicineTags :

CPR with Breaths Essential for Cardiac Arrest after Drowning

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Updated guidance reaffirms the recommendation for cardiopulmonary resuscitation (CPR) and highlights the importance of compressions with rescue breaths as a first step in responding to cardiac arrest following drowning, according to a new, focused update to Special Circumstances Guidelines from the American Heart Association and the American Academy of Pediatrics. The recommendations were published simultaneously in Circulation (focusing on adults) and Pediatrics (focusing on children).

Drowning is the third-leading cause of death from unintentional injury worldwide. The World Health Organization estimates there are about 236 000 deaths due to drowning each year globally. According to the CDC, it’s the number one cause of death for children ages 1-4 years old in the US.

“The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned, offering practical guidance for health care professionals, trained rescuers, caregivers and families,” said writing group Co-Chair Tracy E. McCallin, M.D., FAAP, associate professor of paediatrics in the division of paediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland. “While we work on a daily basis to lower risks of drowning through education and community outreach on drowning prevention, we still need emergency preparedness training that can be used in tragic circumstances if a drowning occurs.”  

Detailed in the new guideline update:

  • Anyone removed from the water without showing signs of normal breathing or consciousness should be presumed to be in cardiac arrest.
  • Rescuers should immediately initiate CPR that includes rescue breathing in addition to chest compressions. Multiple large studies over time show more people with cardiac arrest from non-cardiac causes such as drowning survive when CPR includes rescue breaths compared to Hands-Only CPR (calling 911 [10111 in South Africa] and pushing hard and fast in the centre of the chest).

Drowning generally progresses quickly from initial respiratory arrest (when a person is unable to breathe) to cardiac arrest, meaning that the heart stops beating. As a result, blood cannot circulate properly throughout the body, and it is starved of oxygen.

“CPR for cardiac arrest due to drowning must focus on restoring breathing as well as restoring blood circulation,” said writing group Co-Chair Cameron Dezfulian, MD, FAHA, FAAP, senior faculty in paediatrics and critical care at Baylor College of Medicine in Houston.

“Cardiac arrest following drowning is most often due to severe hypoxia, or low blood oxygen levels,“ Dezfulian said. ”This differs from sudden cardiac arrest from a cardiac cause where the individual generally collapses with fully oxygenated blood.”

The updated guidance advises untrained rescuers and the public to:

  • Provide CPR with breaths and compressions to all people who have a cardiac arrest after drowning. If a person is untrained, unwilling, or unable to give breaths, they can provide chest compressions only until help arrives. 
  • In-water rescue breathing should be given only by rescuers trained in this special skill if it doesn’t compromise their own safety. Trained rescuers should also provide supplemental oxygen if available.
  • The initiation of CPR should always be prioritised and begin as soon as possible as early lay responder CPR has been shown to improve outcomes from drowning.
  • The writing group recommends an automated external defibrillator (AED) should be placed in public facilities where aquatic activities are present such as swimming pools or beaches. They can be used once the person is removed from the water, if available, yet should not delay initiation of CPR. If available, the AED should be connected to the patient to assess for shockable rhythms once CPR is ongoing. Although most cases of cardiac arrest following drowning do not have shockable rhythms, if a primary cardiac event such as a heart attack occurs while in the water, the best outcomes are when defibrillation is done quickly. AED use is safe and feasible in aquatic environments.
  • All individuals requiring any level of resuscitation following drowning, including those who only need rescue breaths, should be transported to a hospital for evaluation, monitoring and treatment.

In addition to the recommendations on drowning resuscitation, the guideline update also highlights the Drowning Chain of Survival, which includes the steps needed to improve chances of survival: prevention, recognition and safe rescue.

Prevention

It has been estimated that more than 90% of all drownings are preventable. Research has found most infants drown in bathtubs, and the majority of preschool-aged children drown in swimming pools. The American Heart Association and the American Academy of Pediatrics recommend being water aware and practicing water safety. See: Prevention of Drowning and other guidelines.  

Recognition

Recognition of drowning may be challenging because someone who is drowning may not be able to verbalise distress or signal for help. Drowning happens quickly. People in distress will rapidly submerge, lose consciousness and may be hidden from anyone not actively seeking them.

Safe Rescue and Removal

The guideline update recommends that appropriately trained rescuers, such as lifeguards, swim instructors or first responders, should provide in-water rescue breathing to an unresponsive person who has drowned if it does not compromise their own safety. Previous studies have proven this leads to more favourable survival outcomes. A drowning person who is unconscious and likely in cardiac arrest should be removed from the water in a near-horizontal position, with the head maintained above body level and airway open. If the drowning individual is conscious, a more vertical position may be preferable to reduce the risk of vomiting.

In summary, “These updated guidelines are based on the latest available evidence and are designed to inform trained rescuers and the public how to proceed in resuscitating people who have drowned. Drowning can be fatal. Our recommendations maximise balancing the need for rapid rescue and resuscitation, while prioritising rescuer safety,” Dezfulian said.

Source: American Heart Association

Categories : Cardiovascular Disease Emergency MedicineTags :

Bystander CPR up to 10 Minutes after Cardiac Arrest may Protect Brain Function

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The sooner a lay rescuer (bystander) starts cardiopulmonary resuscitation (CPR) on a person having a cardiac arrest at home or in public, up to 10 minutes after the arrest, the better the chances of saving the person’s life and protecting their brain function, according to preliminary research to be presented at the American Heart Association’s Resuscitation Science Symposium 2024.

Cardiac arrest, which occurs when the heart malfunctions and abruptly stops beating, is often fatal without quick medical attention such as CPR to increase blood flow to the heart and brain. More than 357 000 out-of-hospital cardiac arrests happen each year in the US, with a 9.3% survival rate. “Our findings reinforce that every second counts when starting bystander CPR and even a few minutes delay can make a big difference,” said first author Evan O’Keefe, MD, a cardiovascular fellow at Saint Luke’s Mid America Heart Institute and the University of Missouri-Kansas City. “If you see someone in need of CPR, don’t dwell on how long they’ve been down, your quick actions could save their life.”

The study analysed nearly 200 000 cases of witnessed out-of-hospital cardiac arrest to determine whether initiating CPR within different time windows, compared to outcomes with no bystander CPR administered, made a difference in survival and brain function after hospital discharge.

“We found that people who received bystander CPR within the first few minutes of their cardiac arrest were much more likely to survive and have better brain function than those who didn’t,” O’Keefe said. “The longer it took for CPR to start, the less survival benefit one received. However, even when CPR was started up to 10 minutes after cardiac arrest, there was still a significant survival benefit compared to individuals who did not receive CPR from a bystander.”

Results also found: 

  • People who received CPR within two minutes of out-of-hospital cardiac arrest had an 81% higher rate of survival to release from the hospital and 95% higher rate of surviving without significant brain damage compared to people who did not receive bystander CPR.
  • Even people who received bystander CPR up to 10 minutes after cardiac arrest were 19% more likely to survive to hospital discharge and 22% more likely to have a favorable neurological outcome than those who did not receive bystander CPR at all.
  • For those who did not receive bystander CPR, about 12% survived to be released from the hospital, and more than 9% survived without significant brain damage or major disabilities. When bystander CPR was initiated more than 10 minutes after cardiac arrest, bystander CPR, compared to not receiving the lifesaving assistance, was no longer associated with improved survival.

“These results highlight the critical importance of quick action in emergencies. It suggests that we need to focus on teaching more people how to perform CPR, and we also need to emphasise ways to get help to those suffering cardiac arrest faster,” O’Keefe said. “This might include more widespread CPR training programs, as well as better public access to automated external defibrillators (AEDs) and improved dispatch systems.”

O’Keefe noted that future research could explore how technology (like apps that alert nearby trained bystanders or alert dispatchers to likely cardiac arrest) may help to reduce the time to first intervention, information that could be important for emergency dispatchers and policymakers in the development of public interventions for cardiac arrest.

“This study highlights the need for prompt recognition and treatment of cardiac arrest by bystanders. Time is of the essence when a cardiac arrest occurs, and late interventions can be as ineffective as no intervention. Community education and empowerment are critical for us to save lives,” said American Heart Association volunteer expert Anezi Uzendu, MD, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas and a cardiac arrest survivor.

A limitation of the study includes that the average time of arrival for emergency medical technicians (EMTs) to the person having cardiac arrest was roughly 10 minutes. This means that in this study, the people who received bystander CPR 10 minutes after their cardiac arrest were likely being compared to a group receiving professional medical attention.

Study details and background:

  • The study identified 160 822 witnessed out-of-hospital cardiac arrests that occurred from 2013-2022.  Among the people whose data was analysed, the average age was 64 years old and about 34% were women.
  • Researchers used data from the Cardiac Arrest Registry to Enhance Survival (CARES), a national, web-based health registry focused on helping communities improve care for and survival of out-of-hospital cardiac arrest.
  • The research categorized time to initiation of bystander CPR in two-minute intervals and analysed the link between each time interval, compared to the group who did not receive CPR, with survival to hospital discharge and favourable neurological survival, or surviving with minor disabilities.

Source: American Heart Association

Categories : Cardiovascular Disease Emergency MedicineTags :

Defibrillation Using 1/1000th the Energy could be Possible

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Researchers from Sergio Arboleda University in Colombia and the Georgia Institute of Technology in the US used an electrophysiological computer model of the heart’s electrical circuits to examine the effect of the applied voltage field in multiple fibrillation-defibrillation scenarios. Their research, published in the interdisciplinary journal Chaos, discovered that far less energy is needed than is currently used in state-of-the-art defibrillation techniques.

“The results were not at all what we expected. We learned the mechanism for ultra-low-energy defibrillation is not related to synchronisation of the excitation waves like we thought, but is instead related to whether the waves manage to propagate across regions of the tissue which have not had the time to fully recover from a previous excitation,” author Roman Grigoriev said. “Our focus was on finding the optimal variation in time of the applied electric field over an extended time interval. Since the length of the time interval is not known a priori, it was incremented until a defibrillating protocol was found.”

The authors applied an adjoint optimization method, which aims to achieve a desired result, defibrillation in this case, by solving the electrophysiologic model for a given voltage input and looping backward through time to determine the correction to the voltage profile that will successfully defibrillate irregular heart activity while reducing the energy the most.

Energy reduction in defibrillation devices is an active area of research. While defibrillators are often successful at ending dangerous arrhythmias in patients, they are painful and cause damage to the cardiac tissue.

“Existing low-energy defibrillation protocols yield only a moderate reduction in tissue damage and pain,” Grigoriev said. “Our study shows these can be completely eliminated. Conventional protocols require substantial power for implantable defibrillators-cardioverters (ICDs), and replacement surgeries carry substantial health risks.”

In a normal rhythm, electrochemical waves triggered by pacemaker cells at the top of the atria propagate through the heart, causing synchronised contractions. During arrhythmias, such as fibrillation, the excitation waves start to quickly rotate instead of propagating through and leaving the tissue, as in normal rhythm.

“Under some conditions, an excitation wave may or may not be able to propagate through the tissue. This is called the ‘vulnerable window,’” Grigoriev said. “The outcome depends on very small changes in the timing of the excitation wave or very small external perturbations.

“The mechanism of ultra-low-energy defibrillation we uncovered exploits this sensitivity. Varying the electrical field profile over a relatively long time interval allows blocking the propagation of the rotating excitation waves through the ‘sensitive’ regions of tissue, successfully terminating the irregular electric activity in the heart.”

Source: American Institute of Physics

Categories : Cardiovascular Disease Emergency MedicineTags :

Two Types of Bloodstream Access in Heart Attacks are Equally Effective

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There is no difference in the effectiveness of the two most commonly used methods for administering medication during out-of-hospital cardiac arrest, according to a large new clinical study published in NEJM.

This is shown in a large new clinical study from Aarhus University and Prehospital Services, Region Midtjylland, which compared two ways of accessing the bloodstream: a standard needle in a vein (venous catheter) and a so-called intraosseous needle, which is inserted into the bone marrow.

“When a person suffers cardiac arrest outside the hospital, it is crucial to quickly access the bloodstream to administer life-saving medication. We investigated which method is best,” explains Lars Wiuff Andersen, professor and physician at the Department of Clinical Medicine, Aarhus University, Prehospital Services, Region Midtjylland, and Aarhus University Hospital.

Venous catheter or intraosseous needle?

Until now, healthcare professionals have preferred using a venous catheter, but it can be difficult to place as veins may collapse during cardiac arrest.

The intraosseous needle, inserted either into the shinbone or upper arm, can be faster and easier to use in an emergency.

Therefore, it’s interesting to investigate the effectiveness of both methods, explains Lars Wiuff Andersen.

The study, based on data from nearly 1500 cardiac arrest patients across Denmark, showed that about 30 percent of patients in both groups had their blood circulation restored.

“The two methods proved to be equally effective in restoring blood circulation and saving lives. There was no difference in the patients’ survival or quality of life,” explains Mikael Fink Vallentin, associate professor at the Department of Clinical Medicine and Prehospital Services, Region Midtjylland, and co-lead author of the study.

May change guidelines

According to the researchers behind the study, the results may impact future guidelines, which previously recommended venous catheters as the first choice.

However, Lars Wiuff Andersen notes that it is too early to say exactly how the guidelines will change.

“Our data must be considered alongside a large clinical trial from the UK, which is being published simultaneously with our study. Combined, these two trials will likely influence guidelines for cardiac arrest treatment, but a thorough review of the results will be needed,” he says.

More unanswered questions

There are still several unanswered questions, especially regarding whether specific groups of cardiac arrest patients benefit more from one method than the other.

The researchers are continuing to analyse and compare their own data with data from the UK trial.

The Danish research team has already planned a new, large clinical trial to investigate which method is best for delivering electric shocks during cardiac arrest.

“We hope to gain even more answers on how to best save lives in cardiac arrest in the future,” says Lars Wiuff Andersen.

Source: Aarhus University

Categories : Allergies Emergency MedicineTags :

Can Adrenaline Auto-injectors Prevent Fatal Anaphylaxis?

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Individuals at risk of anaphylaxis are often prescribed adrenaline (epinephrine) autoinjectors such as EpiPens. A recent review published in Clinical & Experimental Allergy finds that these autoinjectors, which people use to self-administer adrenaline into the muscle, can deliver high doses of adrenaline into the blood, but these levels are short-lived and may not be sufficient to save lives in cases of fatal anaphylaxis.

Anaphylaxis is an acute systemic hypersensitivity reaction to an allergen or trigger, typically associated with skin reactions, nausea/vomiting, difficulty breathing, and shock.

Investigators noted that data from animal and human studies suggest that intravenous adrenaline infusions delivered directly into the blood can prevent fatal anaphylaxis, but adrenaline autoinjectors may have little impact in such deadly cases.

“For effective management of the most severe allergic reactions, adrenaline given by continuous intravenous infusion, with appropriate fluid resuscitation, is likely to be required—how this is safely achieved in the pre-hospital setting remains to be determined,” the authors wrote. This challenge stems from the fact that fatal anaphylaxis is unpredictable and fast. Fortunately, fatality is rare, with a population incidence of 0.03–0.51 per million per year.

Source: Wiley

Categories : Emergency Medicine Obstetrics & GynaecologyTags :

Sharp Spike Seen in Emergency Visits for Life Threatening Pregnancy Complication

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Findings suggest significant increase in emergency department utilisation for hypertensive disorders of pregnancy over 14 year span

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Hypertensive disorders of pregnancy, the second leading cause of maternal deaths worldwide, may be sending a significantly higher number of pregnant people to the emergency department. Between 2006 and 2020, researchers found a surge in emergency visits and admissions for the condition that causes serious maternal and neonatal complications and accounts for 6.3% of all pregnancy-related deaths in the United States.

The study, which appears in JAMA Network Open, also suggests greater emergency utilisation for the disease among underrepresented racial and ethnic groups. 

“Hypertensive disorders of pregnancy often develop suddenly, even in healthy women, and symptoms may appear without warning and progress rapidly,” said senior author Erica Marsh, MD, professor of obstetrics and gynaecology at the University of Michigan Medical School and chief of the division of reproductive endocrinology and infertility at U-M Health Von Voigtlander Women’s Hospital, of Michigan Medicine.

“Ideally, this risk would be detected during prenatal care and lead to early intervention. Our study indicates more people turning to the emergency department, which may reflect a higher prevalence of the condition or an increased awareness for prompt assessment and treatment.”

Hypertensive disorders of pregnancy, which could include preeclampsia, gestational hypertension, and eclampsia, are serious complications that involve elevated blood pressure. 

The American College of Obstetricians and Gynecologists recommends management of severe blood pressure in pregnancy within 30 to 60 minutes of diagnosis to prevent complications such as stroke, myocardial ischaemia, seizure, placental abruption, and maternal and neonatal mortality.

Disparities in ED reliance, disease severity

Researchers analysed nationally representative data, finding a 76% increase in emergency encounters related to the condition over the 14-year span, up from 31  623 to 55  893, and nearly 1.5 times as many ED admissions – up from 17 338 to 43 563.

Concerns about costs, time constraints, misconceptions about the necessity of early care or barriers to accessing prenatal care may be possible factors for the increase, authors say.

“The disparities in reliance on emergency rooms for this disease may imply limited access to timely outpatient care or other health system barriers,” said lead author Courtney Townsel, MD, MSc, who was at Michigan Medicine at the time of the study and is now at the University of Maryland.

Black, Hispanic, and Asian or Pacific Islander groups were also more likely to both utilise emergency care and be admitted to the hospital for hypertensive disorders of pregnancy.

“The disproportionate rate of admissions among certain racial and ethnic groups suggests worse disease severity by the time people seek care,” Townsel said.

“Racial differences in emergency care utilisation for hypertensive disorders of pregnancy underscore the ongoing racial disparities in US maternal morbidity and mortality and highlight a critical need for accessible, culturally competent community-level interventions for all.”

Original written by Beata Mostafavi. Republished under a Creative Commons Licence.

Source: Michigan Medicine – University of Michigan

 

Categories : Cardiovascular Disease Emergency MedicineTags : 1 Comment

New Approach to Defibrillation may Improve Cardiac Arrest Outcomes

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Joshua Lupton, MD, has no memory of his own cardiac arrest in 2016. He only knows that first responders resuscitated his heart with a shock from a defibrillator, ultimately leading to his complete recovery and putting him among fewer than one in 10 people nationwide who survive cardiac arrest outside of a hospital.

He attributes his survival to the rapid defibrillation he received from first responders – but not everybody is so fortunate.

Now, as lead author on an observational study published in JAMA Network Open, he and co-authors from Oregon Health & Science University say the study suggests the position in which responders initially place the two defibrillator pads on the body may make a significant difference in returning spontaneous blood circulation after shock from a defibrillator.

“The less time that you’re in cardiac arrest, the better,” said Lupton, assistant professor of emergency medicine in the OHSU School of Medicine. “The longer your brain has low blood flow, the lower your chances of having a good outcome.”

Researchers used data from the Portland Cardiac Arrest Epidemiologic Registry, which comprehensively recorded the placement position of defibrillation pads from July 1, 2019, through June 30, 2023. For purposes of the study, researchers reviewed 255 cases treated by Tualatin Valley Fire & Rescue, where the two pads were placed either at the front and side or front and back.

They found placing the pads in front and back had 2.64-fold greater odds of returning spontaneous blood circulation, compared with placing the pads on the person’s front and side.

The current common knowledge among health care professionals is that pad placement – whether front and side, or front and back – is equally beneficial in cardiac arrest. The researchers cautioned that their new study is only observational and not a definitive clinical trial. Yet, given the crucial importance of reviving the heartbeat as quickly as possible, the results do suggest a benefit from placing the pads on the front and back rather than the front and side.

“The key is, you want energy that goes from one pad to the other through the heart,” said senior author Mohamud Daya, MD, professor of emergency medicine in the OHSU School of Medicine.

Placing the pads in the front and back may effectively “sandwich” the heart, raising the possibility that the electrical current will be delivered more comprehensively to the organ. 

However, that’s not readily possible in many cases. For example, the patient may be overweight or positioned in such a way that they can’t be easily moved.

“It can be hard to roll people,” said Daya, who also serves as medical director for Tualatin Valley Fire & Rescue. “Emergency medical responders can often do it, but the lay public may not be able to move a person. It’s also important to deliver the electrical current as quickly as possible.”

In that respect, pad placement is only one factor among many in successfully treating cardiac arrest.

Lupton survived his cardiac arrest and went on to complete medical school at the very hospital where he spent several days recovering in the intensive care unit – Johns Hopkins University in Baltimore. The episode led him to alter the focus of his research so that he could examine ways to optimise early care for cardiac arrest patients.

The results of the new study surprised him.

“I didn’t expect to see such a big difference,” he said. “The fact that we did may light a fire in the medical community to fund some additional research to learn more.”

Source: Oregon Health & Science University

Categories : Cardiovascular Disease Emergency MedicineTags :

Standardised Protocols Help Speed up Stroke Treatment

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Research by West Virginia University has demonstrated that American Heart Association and American Stroke Association guidelines are effective at speeding up hospitals’ response times for stroke treatment and can be mastered even by members of ‘ad hoc‘ medical teams that assemble rapidly on the fly.

When a stroke patient arrives at an emergency room, specialists from across hospital departments – emergency medical services, neurologists, pharmacists, physicians, nurses, radiologists and technicians – rush to coordinate a team response. AHA and ASA guidelines put specific limits on how much time can optimally elapse between the onset of ischaemic stroke, in which blood flow to the brain is blocked, and subsequent events like arrival at the hospital and delivery of an infusion.

But experts have questioned whether the communication of those best practices helps medical teams that assemble temporarily and whose members don’t typically collaborate. In a Journal of Operations Management article, WVU associate professor Bernardo Quiroga and coauthors answer that question using data about more than 8000 patients who received stroke care at a large hospital between 2009 and 2017.

“‘Time is brain’ for stroke victims,” Quiroga explained. “Blocked blood flow to the brain kills almost two million neurons a minute, so your life or ability to walk or talk hinges on how quickly multiple professionals coordinate to restore blood flow. If you’re lucky, you’re treated within the first hour of symptom onset. Better yet, you receive a shot of Tissue Plasminogen Activator, which dissolves clots. TPA works better the earlier it’s given and usually isn’t effective after 4.5 hours.”

In 2010, the AHA and ASA launched Target: Stroke, a program that identifies stroke care best practices and standardises each step in the process. Participating hospitals reduced median treatment times from 79 minutes in 2009 to 51 minutes in 2017, but it wasn’t clear if that improvement was driven by adherence to best practices or by clinicians learning through repetition as they handled more stroke cases.

To figure that out, the researchers investigated whether repeated ‘learning by doing’ decreased the hospital’s stroke care time. Then, they evaluated whether deliberate, ‘induced’ learning and implementation of AHA/ASA best practices decreased the time further.

Learning through repetition worked. The more strokes the hospital treated, the faster it responded. For each doubling of cumulative stroke alerts, ‘door-to-needle time’ – the time to get patients from the hospital door to a TPA infusion – decreased by 10.2%.

Best practices also worked. Specifically, the researchers examined two best practices: the Helsinki Model protocol, which directs that EMS staff keep stroke patients on the stretcher for transport to the CT room rather than transferring them to ER beds; and the Rapid Administration of TPA protocol, which requires the pharmacist to be in the CT room with TPA before completion of the CT scan. Those protocols significantly reduced the hospital’s door-to-needle time beyond improvements from repetition-based learning.

According to Quiroga’s coauthor and former PhD student Brandon Lee, that matters because it demonstrates the efficacy of best practices and shows ad hoc teams learning guidelines and implementing them long-term.

However, Lee emphasised the importance of the presence of the hospital’s stroke advisory committee, which set targets, evaluated stroke teams’ performances and gave feedback.

Without similar “countermeasures to organisational forgetting,” Quiroga acknowledged that best practices aren’t always sustainable, especially on ad hoc teams.

“In the case of the best practice indicated by the Helsinki Model, compliance is difficult because the hospital needs to coordinate with multiple independent EMS systems. Some EMS providers may be reluctant to commit resources to extended time in the CT room, and EMS staff turnover may lead to forgetting,” Quiroga said.

Lee added, “Overall, because ad hoc teams are fluid, information sharing is harder. And when a group of people don’t know each other well, group learning slows. But although ad hoc teams learn more slowly, we determined they still learn.”

The research also assessed whether neurologists’ abilities to meet time goals were affected by their recent experiences treating prior stroke patients.

“As team leaders, neurologists can have an outsized influence on performance,” Quiroga said. “Because other members of the ad hoc team aren’t familiar with each other, they lean on their leader.”

But data showed stroke teams improving response times regardless of how many stroke cases the neurologist had treated individually or what the neurologist’s recent success rate was. Quiroga said that’s good news.

“The implication is that learning and sustaining best practices ensures an even quality of care for patients, regardless of individual neurologists’ experience levels.”

Source: West Virginia University

Categories : Emergency Medicine Injury & TraumaTags :

Optimal Placement for Bleeding Control Kits for the Public in Disaster Situations

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In the event of an accident or an attack, members of the public can save lives by performing first aid measures until the arrival of emergency medical services. But those people willing and able to serve as first responders will also need access to first aid equipment.

“There must also be certain equipment available to manage major bleeding. The question then is where this equipment should be placed, so that people who want to help can quickly access bleeding control kits,” says Carl-Oscar Jonson, adjunct senior associate professor at the Department of Biomedical and Clinical Sciences at Linköping University and head of research at the Center for Disaster Medicine and Traumatology in Linköping.

The first recommendations

Until now, there have been no guidelines for where such bleeding control kits should be located to ensure maximal utility. The current study, published in the journal Disaster Medicine and Public Health Preparedness, now contributes research-based recommendations.

“We found that the largest number of lives saved correlated with bleeding control kits being placed in two or more locations on the premises, but most importantly they shouldn’t be placed at entrances. We also concluded that the equipment must be accessible within 90 seconds’ walking distance,” says Anna-Maria Grönbäck, doctoral student at the Department of Science and Technology at Linköping University, who was involved in developing the simulation.

This means that bleeding control kits should not be placed at entrances, which is often the case with automated external defibrillators (AEDs). The reason for this is that they may be difficult to reach in a situation where many people have to be evacuated at once, such as in the case of attack or major accident. According to attack statistics, roughly 20 injured people will need first aid including a bleeding control kit each. It may be helpful to locate bleeding control kits in the same places as clearly marked AEDs, as long as not located at the entrances.

Bomb consequences simulated

The recommendations are based on conclusions reached by the research team by developing a computer-based simulation of an explosion in a large shopping centre with thousands of simultaneous visitors. In their simulation, the researchers have looked at what happens right after an explosion. The majority of the simulated people try to get out of the premises and move towards the exits. Simulated people close to the blast suffer varying degrees of injury and start bleeding.

In the simulation, some individuals help those injured by applying direct pressure to reduce bleeding, or by trying to find equipment. It is a race against time. Depending on how long it takes to get the equipment, the simulated casualty may die from blood loss.

To find the best strategy for the placement of bleeding control kits, the researchers tested four different scenarios in their simulation. They weighed together the outcomes of the many simulated courses of events for each scenario and compared them to understand which placement of equipment saved the largest number of lives.

Source: Linköping University