Search

The trauma team leader (TTL) is a "model" of a specifically dedicated team leader in the emergency department (ED), but its benefits are uncertain. The primary objective was to assess the impact of the TTL on 72-hour mortality. Secondary objectives included 24-hour mortality and admission delays from the ED.Major trauma admissions (Injury Severity Score (ISS)≥12) in 3 Canadian Level-1 trauma centres were included from 2003 to 2017. The TTL program was implemented in centre 1 in 2005. An interrupted time series (ITS) analysis was performed. Analyses account for the change in patient case-mix (age, sex, and ISS). The two other centres were used as control in sensitivity analyses RESULTS: Among 20,193 recorded trauma admissions, 71.7% (n=14,479) were males. The mean age was 53.5 ± 22.0 years. The median [IQR] ISS was 22 [16-26]. TTL implementation was not associated with a change in the quarterly trends of 72-hour or 24-hour mortality: adjusted estimates with 95% CI were 0.32 [-0.22;0.86] and -0.07 [-0.56;0.41] percentage-point change. Similar results were found for the proportions of patients admitted within 8 hours of ED arrival (0.36 [-1.47;2.18]). Sensitivity analyses using the two other centres as controls yielded similar results.TTL implementation was not associated with changes in mortality or admission delays from the ED. Future studies should assess the potential impact of TTL programs on other patient-centred outcomes using different quality of care indicators.

Summary Background Primary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care. Methods In this open-label, randomised controlled trial, adults (aged 16–55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis. The trial was prospectively registered with the International Standard Randomised Clinical Trials Number, ISRCTN79151659. Findings Of 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0–3]) than in the 113 with available data who received standard care (4 days [IQR 0–8]; p

Background: Shockable rythms are common among victims of witnessed public out-of-hospital cardiac arrest (OHCA), but bystander defibrillation with a public automated external defibrillator (PAED) is rare. Instructions from the emergency medical dispatcher and mobile applications were developed to expedite the localization of PAEDs, but their effectiveness has not been compared. Methods: Participants were enrolled in a three-armed randomized simulation where they witnessed a simulated OHCA on a university campus, were instructed to locate a PAED and provide defibrillation. Participants were stratified and randomized to: (1) no assistance in finding the PAED, (2) assistance from a geolocalization mobile application (AED-Quebec), or (3) verbal assistance. Data collectors tracked each participant’s time elapsed and distance traveled to shock. Results: Of the 52 volunteers participating in the study (46% male, mean age 37), 17 were randomized to the no assistance group, 18 to the mobile application group and 17 to the verbal group. Median (IQR) time to shock was respectively 10:00 min (7:49-10:00), 9:44 (6:30-10:00), and 5:23 (4:11-9:08), with statistically significant differences between the verbal group and the other groups (p≤0.01). The success rate for defibrillation in

Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital. Percutaneous coronary intervention (PCI) is often indicated following OHCA. This study's primary objective was to determine the association between being transported to a PCI-capable hospital and survival to discharge for patients with OHCA. The additional delay to hospital arrival which could offset a potential increase in survival associated with being transported to a PCI-capable center was also evaluated.This study used a registry of OHCA in Montreal, Canada. Adult patients transported to a hospital following a non-traumatic OHCA were included. Hospitals were dichotomized based on whether PCI was available on-site or not. The effect of hospital type on survival to discharge was assessed using a multivariable logistic regression. The added prehospital delay which could offset the increase in survival associated with being transported to a PCI-capable center was calculated using that regression.A total of 4922 patients were included, of whom 2389 (48%) were transported to a PCI-capable hospital and 2533 (52%) to a non-PCI-capable hospital. There was an association between being transported to a PCI-capable center and survival to discharge (adjusted odds ratio = 1.60 [95% confidence interval 1.25-2.05], p .001). Increasing the delay from call to hospital arrival by 14.0 min would offset the potential benefit of being transported to a PCI-capable center.It could be advantageous to redirect patients suffering from OHCA patients to PCI-capable centers if the resulting expected delay is of less than 14 min.

IntroductionRapid access to defibrillation is a key element in the management of out-of-hospital cardiac arrests (OHCAs). Public automated external defibrillators (PAEDs) are becoming increasingly available, but little information exists regarding the relation between the proximity to the arrest and their usage in urban areas.MethodsThis study is a retrospective, observational, cross-sectional analysis of non-traumatic OHCA during a 24-month period in the greater Montreal area (Quebec, Canada). Using logistic regression, bystander shock odds are described with regards to distance from the OHCA scene to the nearest PAED, adjusted for prehospital care arrival delay and time of day, and stratifying for type of location.ResultsOut of a total of 2,443 OHCA victims identified, 77 (3%) received bystander PAED shock, 622 (26%) occurred out-of-home, and 743 (30%) occurred during business hours. When controlling for time (business hours versus other hours) and minimum response delay for prehospital care arrival, a marginal negative association was found between bystander shock and distance to the nearest PAED in logged meters (aOR=0.80; CI, 0.64-0.99) for out-of-home cardiac arrests. No significant association was found between distance and bystander shock for at-home arrests. Out-of-home victims had significantly higher odds of receiving bystander shock up to 175 meters of distance to a PAED inclusively (aOR=2.52; CI, 1.07-5.89).ConclusionFor out-of-home cardiac arrests, proximity to a PAED was associated with bystander shock in the greater Montreal area. Strategies aiming to increase accessibility and use of these life-saving devices could further expand this advantage by assisting bystanders in rapidly locating nearby PAEDs.Neves BriardJ, de MontignyL, RossD, de ChamplainF, SegalE. Is distance to the nearest registered public automated defibrillator associated with the probability of bystander shock for victims of out-of-hospital cardiac arrest?Prehosp Disaster Med. 2018;33(2):153–159.

Background: This preliminary report describes our experience using unmanned aerial vehicles (UAVs) to identify swimmers in distress at the 2018 Mont-Tremblant IRONMAN triathlon (Quebec, Canada). Me...

ObjectivesPatients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. The implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital shocks delivered and survival to hospital discharge among patients in OHCA.MethodsThis cohort study included adult patients with an initial shockable rhythm over a 5-year period from a registry of OHCA in Montreal, Canada. The relationship between the number of prehospital shocks delivered and survival to discharge was described using dynamic probabilities. The association between the number of prehospital shocks delivered and survival to discharge was assessed using multivariable logistic regression.ResultsA total of 1,788 patients (78% male with a mean age of 64 years) were included in this analysis, of whom 536 (30%) received treatments from an advanced care paramedic. A third of the cohort (583 patients, 33%) survived to hospital discharge. The probability of survival was highest with the first shock (33% [95% confidence interval 30%-35%]), but decreased to 8% (95% confidence interval 4%-13%) following nine shocks. A higher number of prehospital shocks was independently associated with lower odds of survival (adjusted odds ratio=0.88 [95% confidence interval 0.85-0.92], p < 0.001).ConclusionSurvival remains possible even after a high number of shocks for patients suffering from an OHCA with an initial shockable rhythm. However, requiring more shocks is independently associated with worse survival.

Article chosenEbinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014;311(16):1622-31.Clinical questionDoes prehospital thrombolysis in specialized ambulances reduce delay to thrombolysis in acute ischemic stroke?ObjectiveTo determine the effect of prehospital thrombolysis for acute ischemic stroke administered in specialized ambulances on delay in thrombolytic administration, thrombolysis rate, post-thrombolysis intracerebral hemorrhage, and 7-day mortality.

The prehospital electrocardiogram (ECG) allows earlier identification of acute ST-segment elevation myocardial infarction (STEMI). Its utility for detection of other acute cardiac events, as well as for transient ST-segment abnormalities no longer present when the first hospital ECG is performed, is not well characterized.We sought to examine whether the prehospital ECG adds supplemental information to the first ECG obtained in hospital, by comparing data on possible cardiac ischemia and arrhythmias provided by the two ECGs, in ambulance patients later diagnosed as having cardiac disorders, including STEMI.Ambulance personnel acquired 12-lead ECGs for patients suspected of having an acute ischemic event, prior to transport to hospital. The first emergency department 12-lead ECG was provided by medical records at the receiving hospital, and the principal hospital diagnosis for the event was extracted from chart data. Two cardiologists, blinded to the hospital diagnosis, provided their consensus interpretation of 1,209 pairs of ECGs, noting the presence or absence of specific abnormalities on each tracing.Among the 82 patients who had an eventual hospital diagnosis of STEMI, the study cardiologists identified 71 with ST-segment elevations on the ECGs they examined. The vast majority of these (97%) were observed on both ECGs, but the prehospital ECG showed ST-segment elevation for two additional patients (3%). No additional instances were seen only on the hospital ECG. Among the 116 patients with a hospital diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI), the cardiologists identified 36 with ST-segment depressions: 28 (78%) of these were present on both ECGs, seven (19%) only on the prehospital ECG, and one (3%) only on the hospital ECG. Among the 567 patients with any cardiac hospital diagnosis, the cardiologists identified 87 with arrhythmias: 73 (84%) on both ECGs, 12 (14%) only on the prehospital ECG, and two (2%) only on the hospital ECG.Beyond identifying ST-segment elevation earlier, prehospital ECGs detect important transient abnormalities, information not otherwise available from the first emergency department ECG. These data can expedite diagnosis and clinical management decisions among patients suspected of having an acute cardiac event. The prehospital ECG should be fully integrated into emergency medicine practice.