Modifiable Factors Associated With Survival After Out-of-Hospital Cardiac Arrest in the Pan-Asian Resuscitation Outcomes Study.

STUDY OBJECTIVE: The study aims to identify modifiable factors associated with improved out-of-hospital cardiac arrest survival among communities in the Pan-Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network: Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and the United Arab Emirates (Dubai). METHODS: This was a prospective, international, multicenter cohort study of out-of-hospital cardiac arrest in the Asia-Pacific. Arrests caused by trauma, patients who were not transported by emergency medical services (EMS), and pediatric out-of-hospital cardiac arrest cases (<18 years) were excluded from the analysis. Modifiable out-of-hospital factors (bystander cardiopulmonary resuscitation [CPR] and defibrillation, out-of-hospital defibrillation, advanced airway, and drug administration) were compared for all out-of-hospital cardiac arrest patients presenting to EMS and participating hospitals. The primary outcome measure was survival to hospital discharge or 30 days of hospitalization (if not discharged). We used multilevel mixed-effects logistic regression models to identify factors independently associated with out-of-hospital cardiac arrest survival, accounting for clustering within each community. RESULTS: Of 66,780 out-of-hospital cardiac arrest cases reported between January 2009 and December 2012, we included 56,765 in the analysis. In the adjusted model, modifiable factors associated with improved out-of-hospital cardiac arrest outcomes included bystander CPR (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.31 to 1.55), response time less than or equal to 8 minutes (OR 1.52; 95% CI 1.35 to 1.71), and out-of-hospital defibrillation (OR 2.31; 95% CI 1.96 to 2.72). Out-of-hospital advanced airway (OR 0.73; 95% CI 0.67 to 0.80) was negatively associated with out-of-hospital cardiac arrest survival. CONCLUSION: In the PAROS cohort, bystander CPR, out-of-hospital defibrillation, and response time less than or equal to 8 minutes were positively associated with increased out-of-hospital cardiac arrest survival, whereas out-of-hospital advanced airway was associated with decreased out-of-hospital cardiac arrest survival. Developing EMS systems should focus on basic life support interventions in out-of-hospital cardiac arrest resuscitation.

A randomized controlled trial of patient-controlled analgesia compared with boluses of analgesia for the control of acute traumatic pain in the emergency department.

BACKGROUND: The use of patient-controlled analgesia (PCA) has been reported to provide effective pain relief, often resulting in less opioid consumption, and is associated with greater patient satisfaction when it is compared to other techniques of analgesia delivery. OBJECTIVES: This study was done to compare the effectiveness of pain relief and patient satisfaction between PCA and the conventional method of administering boluses of analgesia for acute pain of traumatic origin in the Emergency Department (ED). METHODS: Study patients were randomized into two groups after being given a bolus of morphine. The PCA group was then given morphine via the PCA system, whereas the control group was given the conventional boluses of morphine via titration method. Pain levels were measured using the visual analogue scale at intervals of 0, 15, 30, 45, 60, 90, and 120 min. Any adverse events were also noted. Finally, within 24 h, these patients completed questionnaires regarding their experience with regard to the pain relief they experienced. RESULTS: The PCA group experienced faster and greater pain relief. No life-threatening events were encountered. The satisfaction questionnaire revealed that the PCA group was more satisfied using the PCA method of pain relief than those receiving standard boluses for delivery of analgesia. CONCLUSION: PCA provides more effective pain relief and more patient satisfaction when compared to the conventional method of titrated bolus intravenous injection for the relief of traumatic pain in the ED setting.

The use of end-tidal carbon dioxide monitoring in patients with hypotension in the emergency department.

BACKGROUND: The aim of this study was to determine the usefulness of end tidal carbon dioxide (ETCO2) monitoring in hypotensive shock patients presenting to the ED. METHODS: This was a prospective observational study in a tertiary ED. One hundred three adults in shock with hypotension presenting to the ED were recruited into the study. They were grouped according to different types of shock, hypovolemic, cardiogenic, septic and others. Vital signs and ETCO2 were measured on presentation and at 30-min intervals up to 120 min. Blood gases and serum lactate levels were obtained on arrival. All patients were managed according to standard protocols and treatment regimes. Patient survival up to hospital admission and at 30 days was recorded. RESULTS: Mean ETCO2 for all patients on arrival was 29.07 ± 9.96 mmHg. Average ETCO2 for patients in hypovolemic, cardiogenic and septic shock was 29.64 ± 11.49, 28.60 ± 9.87 and 27.81 ± 7.39 mmHg, respectively. ETCO2 on arrival was positively correlated with systolic and diastolic BP, MAP, bicarbonate, base excess and lactate when analyzed in all shock patients. Early ETCO2 measurements were found to be significantly lower in patients who did not survive to hospital admission (p = 0.005). All patients who had ETCO2 ≤ 12mmHg died in the ED. However, normal ETCO2 does not ensure patient survival. CONCLUSION: The use of ETCO2 in the ED has great potential to be used as a method of non-invasive monitoring of patients in shock.

The use of propofol for procedural sedation and analgesia in the emergency department: a comparison with midazolam.

INTRODUCTION: This study aimed to determine the effectiveness of propofol as an alternative agent for procedural sedation and analgesia (PSA) in the emergency department (ED) and to make a comparison between two different sedative (propofol vs midazolam) drugs used in combination with fentanyl. OBJECTIVES: To compare outcomes between a combination of fentanyl and propofol with fentanyl and midazolam in patients during and after PSA. METHODOLOGY: A randomised single blinded control trial carried out in the ED of a university hospital. 40 patients were randomly allocated equally into two groups: group A, 20 subjects received intravenous fentanyl 3 µg/kg as a bolus dose and a titration maximum bolus dose of propofol 1 mg/kg followed by a maximum titration top-up of 0.5 mg/kg if needed; group B, 20 subjects received intravenous fentanyl 3 µg/kg as a bolus dose and a titration maximum bolus dose of midazolam 0.1 mg/kg and a maximum titration top-up of 0.1 mg/kg if needed. The target sedation level was a Ramsay score of 3 or 4. Outcomes included the presence of any adverse events related to PSA and time to discharge. The Mann-Whitney U test was used to compare the two groups. RESULTS: None of the patients developed any significant adverse events during and after procedures. The mean length of stay in the propofol and midazolam groups was 29.25 (11.03) and 71.75 (60.64) min, respectively (p<0.001). CONCLUSION: Both propofol and midazolam given at the recommended doses were equally safe and effective for PSA in the ED. The propofol group was discharged much earlier than to the midazolam group.