Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria.

INTRODUCTION: We aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis. METHODS: This study used a convenience sample of prehospital patients meeting established criteria for sepsis. Paramedics received education on systemic inflammatory response syndrome (SIRS) criteria, were trained in the use of TATs and hand-held lactate meters, and enrolled patients who had a recent history of infection, met ≥ 2 SIRS criteria, and were being transported to a participating hospital. Blood lactate was measured by paramedics in the prehospital setting and again in the emergency department (ED) via usual care. Paramedics entered data using an online database accessible at the point of care. RESULTS: Prehospital lactate values obtained by paramedics ranged from 0.8 to 9.8 mmol/L, and an elevated lactate (i.e. ≥ 4.0) was documented in 13 of 112 enrolled patients (12%). The unadjusted correlation of prehospital and ED lactate values was 0.57 (p< 0.001). The median interval between paramedic assessment of blood lactate and the electronic posting of the ED-measured lactate value in the hospital record was 111 minutes. Overall, 91 patients (81%) were hospitalized after ED evaluation, 27 (24%) were ultimately diagnosed with sepsis, and 3 (3%) died during hospitalization. Subjects with elevated prehospital lactate were somewhat more likely to have been admitted to the intensive care unit (23% vs 15%) and to have been diagnosed with sepsis (38% vs 22%) than those with normal lactate levels, but these differences were not statistically significant. CONCLUSION: In this pilot, EMS use of a combination of objective SIRS criteria, subjective assessment of infection, and blood lactate measurements did not achieve a level of diagnostic accuracy for sepsis that would warrant hospital prenotification and committed resources at a receiving hospital based on EMS assessment alone. Nevertheless, this work provides an early model for increasing EMS awareness and the implementation of novel devices that may enhance the prehospital assessment for sepsis. Additional translational research studies with larger numbers of patients and more robust methods are needed.

Chest Compression Injuries Detected via Routine Post-arrest Care in Patients Who Survive to Admission after Out-of-hospital Cardiac Arrest.

Abstract Objective. To examine injuries produced by chest compressions in out-of-hospital cardiac arrest (OHCA) patients who survive to hospital admission. Methods. A retrospective cohort study was conducted among 235 consecutive patients who were hospitalized after nontraumatic OHCA in Minnesota between January 2009 and May 2012 (117 survived to discharge; 118 died during hospitalization). Cases were eligible if the patient had received prehospital compressions from an emergency medical services (EMS) provider. One EMS provider in the area was using a mechanical compression device (LUCASTM) as standard equipment, so the association between injury and use of mechanical compression was also examined. Prehospital care information was abstracted from EMS run sheets, and hospital records were reviewed for injuries documented during the post-arrest hospitalization that likely resulted from compressions. Results. Injuries were identified in 31 patients (13%), the most common being rib fracture (9%) and intrathoracic hemorrhage (3%). Among those who survived to discharge, the mean length of stay was not statistically significantly different between those with injuries (13.5 days) and those without (10.8 days; p = 0.23). Crude injury prevalence was higher in those who died prior to discharge, had received compressions for >10 minutes (versus ≤10 minutes) and underwent computer tomography (CT) imaging, but did not differ by bystander compressions or use of mechanical compression. After multivariable adjustment, only compression time > 10 min and CT imaging during hospitalization were positively associated with detected injury (OR = 7.86 [95% CI = 1.7-35.9] and 6.30 [95% CI = 2.6-15.5], respectively). Conclusion. In patients who survived OHCA to admission, longer duration of compressions and use of CT during the post-arrest course were associated positively with documented compression injury. Compression-induced injuries detected via routine post-arrest care are likely to be largely insignificant in terms of length of recovery.