Ear, nose and throat manifestation of viral systemic infections in pediatric patients.

OBJECTIVE/METHODS: An exhaustive review of literature was performed to investigate available data and evidences regarding pediatric otolaryngologic manifestations of viral systemic infections. RESULTS/CONCLUSIONS: Modern otolaryngologists should be familiar with viral systemic infections since many have head and neck manifestations. Cooperation between otolaryngologist, paediatrician and virologist can be considered and excellent tool in diagnosis and treatment of these diseases in particular when complications occur.

Socioeconomic status influences bystander CPR and survival rates for out-of-hospital cardiac arrest victims.

OBJECTIVES: While lower socioeconomic status is associated with lower level of education and increased incidence of cardiovascular diseases, the impact of socioeconomic status on out-of-hospital cardiac arrest outcomes is unclear. We used residential property values as a proxy for socioeconomic status to determine if there was an association with: (1) bystander CPR rates and (2) survival to hospital discharge for out-of-hospital cardiac arrest. METHODS: We performed a secondary data analysis of cardiac arrest cases prospectively collected as part of the Ontario Prehospital Advanced Life Support study, conducted in 20 cities with ALS and BLS-D paramedics. We measured patient and system characteristics for cardiac arrests of cardiac origin, not witnessed by EMS, occurring in a single residential dwelling. We obtained property values from the Municipal Property Assessment Corporation. Analyses included descriptive statistics with 95% CIs and stepwise logistic regression. RESULTS: Three thousand six hundred cardiac arrest cases met our inclusion criteria between 1 January 1995 and 31 December 1999. Patient characteristics were: mean age 69.2, male 67.8%, witnessed 44.7%, bystander CPR 13.2%, VF/VT 33.8%, time to vehicle stop 5:36min:s, return of spontaneous circulation 12.7%, and survival 2.7%. Median property value was $184,000 (range $25,500-2,494,000). For each $100,000 increment in property value, the likelihood of receiving bystander CPR increased (OR=1.07; 95% CI 1.01-1.14; p=0.03) and survival decreased (OR=0.77; 95% CI 0.61-0.97; p=0.03). CONCLUSIONS: This is the largest study showing an association between socioeconomic status and survival, and the first study showing an association with bystander CPR. Our findings suggest targeting CPR training among lower socioeconomic groups.

The Canadian C-spine rule for radiography in alert and stable trauma patients.

CONTEXT: High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine (C-spine) radiography in alert and stable trauma patients. OBJECTIVE: To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department (ED) physicians to be more selective in use of radiography in alert and stable trauma patients. DESIGN: Prospective cohort study conducted from October 1996 to April 1999, in which physicians evaluated patients for 20 standardized clinical findings prior to radiography. In some cases, a second physician performed independent interobserver assessments. SETTING: Ten EDs in large Canadian community and university hospitals. PATIENTS: Convenience sample of 8924 adults (mean age, 37 years) who presented to the ED with blunt trauma to the head/neck, stable vital signs, and a Glasgow Coma Scale score of 15. MAIN OUTCOME MEASURE: Clinically important C-spine injury, evaluated by plain radiography, computed tomography, and a structured follow-up telephone interview. The clinical decision rule was derived using the kappa coefficient, logistic regression analysis, and chi(2) recursive partitioning techniques. RESULTS: Among the study sample, 151 (1.7%) had important C-spine injury. The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that mandates radiography (ie, age >/=65 years, dangerous mechanism, or paresthesias in extremities)? (2) is there any low-risk factor present that allows safe assessment of range of motion (ie, simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)? and (3) is the patient able to actively rotate neck 45 degrees to the left and right? By cross-validation, this rule had 100% sensitivity (95% confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%. CONCLUSION: We have derived the Canadian C-Spine Rule, a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients. If prospectively validated in other cohorts, this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography.

CPR-only survivors of out-of-hospital cardiac arrest: implications for out-of-hospital care and cardiac arrest research methodology.

STUDY OBJECTIVE: There is little evidence that cardiopulmonary resuscitation (CPR) alone may lead to the resuscitation of cardiac arrest victims with other than respiratory causes (eg, pediatric arrest, drowning, drug overdose). The objective of this study was to identify out-of-hospital cardiac arrest survivors resuscitated without defibrillation or advanced cardiac life support. METHODS: This observational cohort included all adult survivors of out-of-hospital cardiac arrest of a cardiac cause from phases I and II of the Ontario Prehospital Advanced Life Support Study. During the study period, the system provided a basic life support/defibrillation level of care but no advanced life support. CPR-only patients were patients determined to be without vital signs by EMS personnel who regained a palpable pulse in the field with precordial thump or CPR only and then were admitted alive to the hospital. Six members of a 7-member expert review panel had to rate the patient as either probably or definitely having an out-of-hospital cardiac arrest, and a rhythm strip consistent with a cardiac arrest rhythm had to be present to be considered a patient. Criteria considered were witness status, citizen or first responder CPR, CPR duration, arrest rhythm and rate, and performance of precordial thump. RESULTS: From January 1, 1991, to June 30, 1997, 9,667 patients with out-of-hospital cardiac arrest were treated. The overall survival rate to hospital discharge was 4.6%. There were 97 apparent CPR-only patients admitted to the hospital. Application of the inclusion criteria yielded 24 CPR-only patients who had true out-of-hospital cardiac arrest and 73 patients judged not to have cardiac arrest. Of the 24 true CPR-only patients admitted to the hospital, 15 patients were discharged alive, 10 patients were witnessed by bystanders, and 7 patients were witnessed by EMS personnel. The initial arrest rhythm was pulseless electrical activity in 9 patients, asystole in 12 patients, and ventricular tachycardia in 3 patients. One patient with ventricular tachycardia converted to sinus tachycardia with a single precordial thump. CONCLUSION: CPR-only survivors of true out-of-hospital cardiac arrest do exist; some victims of out-of-hospital cardiac arrest of primary cardiac cause can survive after provision of out-of-hospital basic life support care only. However, many patients found to be pulseless by means of out-of-hospital evaluation likely did not have a true cardiac arrest. This has implications for the survival rates of most, if not all, previous cardiac arrest reports. Survival rates from cardiac arrest may actually be lower if one excludes survivors who never had a true arrest. The absence of vital signs by out-of-hospital assessment alone is not adequate to include patients in research reports or quality evaluations for cardiac arrest.

Factors affecting survival after prehospital asystolic cardiac arrest in a Basic Life Support-Defibrillation system.

OBJECTIVES: Previous studies have shown a low but meaningful survival rate in cases of prehospital cardiac arrest with an initial rhythm of asystole. There may be, however, an identifiable subgroup in which resuscitation efforts are futile. This study identified potential field criteria for predicting 100% nonsurvival when the presenting rhythm is asystole in a Basic Life Support-Defibrillation (BLS-D) system. METHODS: This prospective cohort study, a component of Phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study, was conducted in 21 Ontario communities with BLS-D level of care, and included all adult arrests of presumed cardiac etiology according to the Utstein Style Guidelines. Analyses included descriptive and appropriate univariate tests, as well as multivariate stepwise logistic regression to determine predictors of survival. RESULTS: From 1991 to 1997, 9899 consecutive cardiac arrest cases with the following characteristics: male (67.2%), bystander-witnessed (44.7%), bystander CPR (14.2%), call response interval (CRI)

Cardiac arrest witnessed by emergency medical services personnel: descriptive epidemiology, prodromal symptoms, and predictors of survival. OPALS study group.

STUDY OBJECTIVE: The Utstein guidelines recommend that emergency medical services (EMS)-witnessed cardiac arrests be considered separately from other out-of-hospital cardiac arrest cases. The objective of this study was to assess EMS-witnessed cardiac arrest and to determine predictors of survival in this group. METHODS: This prospective cohort included all adults with an EMS-witnessed cardiac arrest in the 21 communities of the Ontario Prehospital Advanced Life Support (OPALS) study. Systems provided a basic life support with defibrillation (BLS-D) level of care. Case and survival definitions followed the Utstein style. Descriptive and univariate methods (chi(2) and t test) were used to characterize EMS-witnessed cardiac arrest. Multivariate logistic regression was undertaken to assess predictors of survival to hospital discharge. RESULTS: From January 1, 1991, to December 31, 1996, there were 9,072 cardiac arrest cases in the study communities. Of these, 610 (6.7%) were EMS-witnessed. The majority had preexisting cardiac or respiratory disease (81.5%) and experienced prodromal symptoms before EMS personnel arrived (91.4%). An initial rhythm of pulseless electrical activity was present in 50.1% of the patients, ventricular fibrillation/ventricular tachycardia in 34.2%, and asystole in 15.7%. Survival to discharge was 12.6%. Multivariate analysis identified the following as independent predictors of survival (odds ratio with 95% confidence intervals [CIs]): nitroglycerin use before EMS arrival: 2.3 (95% CI 1.2 to 4.5), prodromal symptoms of chest pain: 2.5 (95% CI 1.4 to 4.5) or dyspnea: 0.5 (95% CI 0.3 to 1.0), and unconsciousness on EMS arrival: 0.5 (95% CI 0.2 to 0.9). Patients with chest pain were more likely than dyspneic patients to experience ventricular fibrillation/ventricular tachycardia (62% versus 17%, P<.0001), and were 5 times more likely to survive (30.6% versus 6.3%, P<.0001). CONCLUSION: EMS-witnessed cases are clearly an important subset of out-of-hospital cardiac arrest and are characterized by 2 distinct symptom groups: chest pain and dyspnea. These symptoms are important predictors of survival and may also help determine underlying mechanisms before patient collapse. A later phase of the OPALS study will prospectively evaluate the impact of out-of-hospital advanced life support on the survival of victims of EMS-witnessed cardiac arrest.

A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest.

STUDY OBJECTIVE: More than 1,000 patients experience sudden cardiac arrest each day. Treatment for this includes cardiopulmonary resuscitation (CPR) and emergency medical services (EMS) that provide CPR-basic life support (BLS), BLS with defibrillation (BLS-D), or advanced life support (ALS). Our previous systematic review of treatments for sudden cardiac arrest was limited by suboptimal data. Since then, debate has increased about whether bystander CPR is effective or whether attention should focus instead on rapid defibrillation. Therefore a cumulative meta-analysis was conducted to determine the relative effectiveness of differences in the defibrillation response time interval, proportion of bystander CPR, and type of EMS system on survival after out-of-hospital cardiac arrest. METHODS: A comprehensive literature search was performed by using a priori exclusion criteria. We considered EMS systems that provided BLS-D, ALS, BLS plus ALS, or BLS-D plus ALS care. A generalized linear model was used with dispersion estimation for random effects. RESULTS: Thirty-seven eligible articles described 39 EMS systems and included 33,124 patients. Median survival for all rhythm groups to hospital discharge was 6.4% (interquartile range, 3.7 to 10.3). Odds of survival were 1.06 (95% confidence interval [CI], 1.03 to 1.09; P <.01) per 5% increase in bystander CPR. Survival was constant if the defibrillation response time interval was less than 6 minutes, decreased as the interval increased from 6 to 11 minutes, and leveled off after 11 minutes (P <.01). Compared with BLS-D, odds of survival were as follows: ALS, 1. 71 (95% CI, 1.09 to 2.70; P =.01); BLS plus ALS, 1.47 (95% CI, 0.89 to 2.42; P =.07); and BLS with defibrillation plus ALS, 2.31 (95% CI, 1.47 to 3.62; P <.01.) CONCLUSION: We confirm that greater survival after sudden cardiac arrest is associated with provision of bystander CPR, early defibrillation, or ALS. More research is required to evaluate the relative benefit of early defibrillation versus early ALS.

Improved out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program: OPALS study phase II. Ontario Prehospital Advanced Life Support.

CONTEXT: Survival rates for out-of-hospital cardiac arrest are low; published survival rates in Ontario are only 2.5%. This study represents phase II of the Ontario Prehospital Advanced Life Support (OPALS) study, which is designed to systematically evaluate the effectiveness and efficiency of various prehospital interventions for patients with cardiac arrest, trauma, and critical illnesses. OBJECTIVE: To assess the impact on out-of-hospital cardiac arrest survival of the implementation of a rapid defibrillation program in a large multicenter emergency medical services (EMS) system with existing basic life support and defibrillation (BLS-D) level of care. DESIGN: Controlled clinical trial comparing survival for 36 months before (phase I) and 12 months after (phase II) system optimization. SETTING: Nineteen urban and suburban Ontario communities (populations ranging from 16 000 to 750 000 [total, 2.7 million]). PATIENTS: All patients who had out-of-hospital cardiac arrest in the study communities for whom resuscitation was attempted by emergency responders. INTERVENTIONS: Study communities optimized their EMS systems to achieve the target response interval from when a call was received until a vehicle stopped with a defibrillator of 8 minutes or less for 90% of cardiac arrest cases. Working both locally and provincially, communities implemented multiple measures, including defibrillation by firefighters, base paging, tiered response agreements with fire departments, continuous quality improvement for response intervals, and province-wide revision and implementation of standard dispatch policies. All response times were obtained from a central dispatch system. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: The 4690 cardiac arrest patients studied in phase I and the 1641 in phase II were similar for all clinical and demographic characteristics, including age, sex, witnessed status, rhythm, and receipt of bystander cardiopulmonary resuscitation. The proportion of cases meeting the 8-minute response criterion improved (76.7% vs 92.5%; P<.001) as did most median response intervals. Overall survival to hospital discharge for all rhythm groups combined improved from 3.9% to 5.2 % (P = .03). The 33% relative increase in survival represents an additional 21 lives saved each year in the study communities (approximately 1 life per 120000 residents). The charges were estimated to be US $46900 per life saved for establishing the rapid defibrillation program and US $2400 per life saved annually for maintaining the program. CONCLUSION: An inexpensive, multifaceted system optimization approach to rapid defibrillation can lead to significant improvements in survival after cardiac arrest in a large BLS-D EMS system.