Survival and neurological status after out-of-hospital cardiac arrest in the pediatric population in Andalusia.

OBJECTIVE: Little is known about the evolution and long-term neurological status of pediatric patients who survive out-of-hospital cardiac arrest. Our aim is to describe long-term survival and neurological status. DESIGN: Retrospective observational study, based on the Andalusian Register of out-of-hospital Cardiac Arrest. SETTING: Pre-hospital Care. PATIENTS: The study included patients aged 0-15 years between January 2008 and December 2012. INTERVENTIONS: Patients follow up. VARIABLES: Prehospital and hospital care variables were analyzed and one-year follow-up was performed, along with a specific follow-up of survivors in June 2014. RESULTS: Of 5069 patients included in the register, 125 (2.5%) were aged ≤15 years. Cardiac arrest was witnessed in 52.8% of cases and resuscitation was performed in 65.6%. The initial rhythm was shockable in 7 (5.2%) cases. Nearly half (48.8%) the patients reached the hospital alive, of whom 20% did so while receiving resuscitation maneuvers. Only 9 (7.2%) patients survived to hospital discharge; 5 showed ad integrum recovery and 4 showed significant neurological impairment. The 5 patients with complete recovery continued their long-term situation. The remaining 4 patients, although slight improvement, were maintained in situation of neurological disability. CONCLUSIONS: Survival after out-of-hospital cardiac arrest in pediatric patients was low. The long-term prognosis of survivors with good neurological recovery remains, although improvement in the rest was minimal.

Comentario sobre «Supervivencia y pronóstico neurológico en paradas cardiorrespiratorias extrahospitalarias por ritmos desfibrilables tratadas con hipotermia terapéutica moderada» / Comment on: "Survival and neurological outcome in out-of-hospital cardiac arrests due to shockable rhythms treated with mild therapeutic hypothermia"

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Descripción y resultados iniciales del registro andaluz de parada cardiaca extrahospitalaria / Description of cases in the Andalusian registry of out-of-hospital cardiac arrest and initial results

OBJETIVOS: La incidencia y los resultados en la parada cardiaca extrahospitalaria muestran gran variabilidad entre países o regiones. Nuestro objetivo es describir los procedimientos y resultados de un registro continuo de ámbito regional. MÉTODO: Descripción y análisis de un registro continuo de casos de parada cardiaca extrahospitalaria atendidos por un sistema de emergencias médicas (SEM). Periodo: enero- 2008/diciembre-2010. Se realiza análisis descriptivo y de los factores asociados con el alta hospitalaria con buen estado neurológico (CPC1-2). RESULTADOS: Se registraron 8.889 pacientes y se realizó reanimación en 3.054 (34,4%): 2.103 (71%) hombres y 857 (29%) mujeres. La media de edad fue 60,1 (DE 17,8) años (hombres: 59, DE = 17,8; mujeres: 63, DE = 19,4). En un tercio de las llamadas el motivo no fue inconsciencia. El 30% de las paradas no fueron presenciadas. La hora del colapso se recogió en el 83,7% de los casos. El ritmo inicial fue desfibrilable en el 19,3%. Hubo reanimación previa por testigos en el 12,8%. El 29% de los pacientes llegó con pulso al hospital, que alcanzó el 56,7% cuando el ritmo inicial era desfibrilable. El 9,1% recibieron el alta con CPC1-2. Los factores asociados con CPC1-2 al alta fueron: lugar de parada "no domicilio" (OR: 2,06; IC: 1,22-3,47), parada presenciada (OR: 2,14; IC: 1,12-4,14), ritmo inicial desfibrilable (OR: 7,04; IC: 4,31-11,5), desfibrilación previa a la llegada del equipo de emergencias (EE) (OR: 2,33; IC: 1,09-4,98) y etiología cardiaca (OR: 2,30; IC: 1,27-4,14). CONCLUSIONES: La automatización en la inclusión de pacientes favorece una alta exhaustividad y minimiza sesgos de inclusión. La fase previa a la llegada de los EE es un aspecto clave en la supervivencia con estado neurológico CPC1-2 y un área de mejora para los SEM

BACKGROUND AND OBJECTIVE: The incidence of out-of-hospital cardiac arrest and response outcomes are highly variable between countries or geographic regions. We aimed to describe procedures and outcomes in these cases based on data from a regional registry. METHODS: Description and analysis of registered cases of out-of-hospital cardiac arrest treated by an emergency response service from January 2008 to December 2010. Descriptive statistics were analyzed; we also explored factors associated with a satisfactory cerebral performance category (CPC) of 1 or 2 on discharge. RESULTS: Records were obtained for 8889 patients, of whom 3054 (34.4%) were resuscitated; 2,103 (71.04%) of the patients were men and 857 (29%) women. The mean (SD) age was 60.1 (17.8) years (men, 59 [17.8] years; women, 63 (19.4) years. In a third of the calls, the patient had not lost consciousness. In 30%, no witnesses were present at the time of cardiac arrest, and in 83.7% the time of collapse was recorded. A shockable heart rhythm was detected at the start of resuscitation in 19.3%. Witnesses had previously attempted resuscitation of 12.8%. Pulse was present on arrival at the hospital in 56.7% of the patients with a shockable heart rhythm on start of resuscitation. Discharge with a CPC1-2 was possible in 9.1%. Factors associated with a CPC1-2 were cardiac arrest outside the home (odds ratio [OR], 2.056; 95% CI, 1.218-3.472), witnessed event (OR, 2.137; 95% CI, 1.117-4.138), initial shockable heart rhythm (OR, 7.040; 95% CI, 4.313-11.490), defibrillation prior to arrival of first emergency responders (OR, 2.330; 95% CI, 1.091-4.976), and cardiac etiology (OR, 2.295; 95% CI, 1.270-4.145). CONCLUSIONS: Automatic registry of cases facilitates inclusion of all patients and minimizes bias. Factors during the period prior to the arrival of first emergency responders are key to survival in CPC1-2 status and are an aspect to target for improvement

Síndrome coronario agudo con elevación del segmento ST (SCACEST). Estrategia de consenso para una reperfusión precoz. Empresa pública de emergencias sanitarias (EPES) y grupo ARIAM-Andalucía / Acute coronary syndrome (ACS) with elevated ST segment: consensus strategy for early reperfusion. The Public Enterprise for Health Emergencies and the ARIAM Project Andalusia

El manejo adecuado de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMEST) requiere, como elementos centrales, la accesibilidad inmediata a la desfibrilación y la instauración precoz de tratamiento de reperfusión. La empresa pública de emergencias sanitarias de Andalucía (EPES) y el proyecto análisis de los retrasos en el tratamiento del infarto agudo de miocardio (ARIAM), pretenden construir una estrategia básica común, sobre la cual adaptar aspectos locales, que facilite la toma de decisiones sobre el tratamiento de estos pacientes. Ámbito. Comunidad Autónoma de Andalucía. Período: marzo-mayo 2006. Participantes. Profesionales que atienden a pacientes con IAMEST: médicos del grupo de trabajo en procesos cardiológicos de la EPES, médicos de Servicios de Urgencias hospitalarios y médicos de las Unidades de Cuidados Intensivos de los hospitales del sistema sanitario público de Andalucía. Sistema de trabajo. Niveles de evidencia. Se emplearon los niveles de evidencia recogidos en la guía de práctica clínica ACC/AHA de 2004. Elaboración del consenso. Se mantuvo una reunión de discusión sobre los aspectos que debía abordar el documento. Se realizó un documento base que se distribuyó por correo electrónico entre los participantes. En una reunión final se elaboró el documento de consenso. Conclusiones. El consenso establece como prioritarios los siguientes aspectos: 1. Mantener una aplicación estricta y adecuada del conjunto de medidas generales aconsejadas en el proceso de asistencia al IAMEST. 2. Favorecer la realización de reperfusión precoz a la mayor cantidad de pacientes, promoviendo la extensión de la fibrinólisis extrahospitalaria y la derivación a centro útil para intervencionismo coronario percutáneo primario. 3. Monitorizar y evaluar el manejo realizado, con especial atención sobre los resultados y la seguridad de los pacientes

The two pillars of the appropriate management of patients with ST-elevation myocardial infarction (STEMI) are immediate access to defibrillation and early reperfusion. The Public Enterprise for Health Emergencies (EPES) and the Andalusian ARIAM (Analysis of the Delay in the Treatment of Acute Myocardial Infarction) Project aim to implement a common basic strategy that can be adapted to local situations in order to facilitate decision making about the treatment of these patients. Context. The Autonomous Community of Andalusia. Period: March-May 2006. Participants. Professionals that attend patients with STEMI: physicians in the EPES’ work group on cardiological processes, emergency department physicians, and physicians working in the intensive care units in the hospitals of the public healthcare system of Andalusia. Approach. Levels of evidence. The levels of evidence laid out in the 2004 ACC/AHA Clinical Practice Guidelines. Reaching a consensus. A meeting was held to discuss the aspects to be included in the document. A working document was drafted and distributed to the participants via email. The final consensus document was drafted at another meeting. Conclusions. The consensus document establishes the following priorities: 1. To apply the set of general measures recommended for the care of STEMI patients strictly and appropriately 2. To foster the use of early reperfusion in as many patients as possible, promoting the extension of fibrinolysis outside of hospitals and referral to a center with facilities for primary percutaneous coronary intervention. 3. To monitor and evaluate the management of these patients, with special attention placed on outcome and safety

[Acute coronary syndrome (ACS) with elevated ST segment: consensus strategy for early reperfusion. The Public Enterprise for Health Emergencies and the ARIAM Project Andalusia]. / Síndrome coronario agudo con elevación del segmento ST (SCACEST). Estrategia de consenso para una reperfusión precoz. Empresa pública de emergencias sanitarias (EPES) y grupo ARIAM-Andalucía.

UNLABELLED: The two pillars of the appropriate management of patients with ST-elevation myocardial infarction (STEMI) are immediate access to defibrillation and early reperfusion. The Public Enterprise for Health Emergencies (EPES) and the Andalusian ARIAM (Analysis of the Delay in the Treatment of Acute Myocardial Infarction) Project aim to implement a common basic strategy that can be adapted to local situations in order to facilitate decision making about the treatment of these patients. CONTEXT: The Autonomous Community of Andalusia. PERIOD: March-May 2006. PARTICIPANTS: Professionals that attend patients with STEMI: physicians in the EPES' work group on cardiological processes, emergency department physicians, and physicians working in the intensive care units in the hospitals of the public healthcare system of Andalusia. APPROACH: Levels of evidence. The levels of evidence laid out in the 2004 ACC/AHA Clinical Practice Guidelines. REACHING A CONSENSUS: A meeting was held to discuss the aspects to be included in the document. A working document was drafted and distributed to the participants via email. The final consensus document was drafted at another meeting. CONCLUSIONS: The consensus document establishes the following priorities: 1. To apply the set of general measures recommended for the care of STEMI patients strictly and appropriately 2. To foster the use of early reperfusion in as many patients as possible, promoting the extension of fibrinolysis outside of hospitals and referral to a center with facilities for primary percutaneous coronary intervention. 3. To monitor and evaluate the management of these patients, with special attention placed on outcome and safety.

Actividad de los equipos de emergencias extrahospitalarios / Activity of the out of hospital emergency teams

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Incorporación de la Troponina T en la evaluación extrahospitalaria del dolor torácico / Incorporation of Troponin T in the pre-hospital evaluation of chest pain

Objetivo: La determinación de marcadores de daño miocárdico es un importante elemento diagnóstico y pronóstico en el manejo del dolor torácico. El presente trabajo pretende evaluar la viabilidad de la determinación extrahospitalaria de Troponina T (TnTc), así como su relación con el diagnóstico y el pronóstico de los pacientes. Métodos: Se incluyeron pacientes mayores de 25 años atendidos por dolor torácico agudo en servicios de emergencias extrahospitalarios. Además de variables clínicas, se realiza electrocardiograma y determinación cuantitativa de TnTc (TnTc- < 0,05 ng/ml, TnTc+ 005-0,1 ng/ml y TnTc++ igual o mayor a 0,1 ng/ml). Se realiza seguimiento al ingreso y a los seis meses. Análisis descriptivo y de supervivencia. Resultados: Un total de 597 pacientes fueron incluidos en el análisis final. La edad media fue 66 años, y el 61,3 por ciento fueron hombres. La determinación de TnTc fue positiva en 71 casos (11,9 por ciento). El diagnóstico final fue de Infarto Agudo de Miocardio (IAM) o de Angina Inestable (AI) en 60 de los 71 (84,5 por ciento) pacientes. En los primeros seis meses fallecieron 53 (8,9 por ciento) de los 597 pacientes. De ellos 19 tuvieron TnTc positiva (5 TnTc+ y 14 TnTc++).La mortalidad a los seis meses fue significativamente más alta en los pacientes de mayor edad, o en aquellos con TnTc positiva o con diagnóstico hospitalario de IAM o de AI. La TnTc se comportó como variable independiente predictora de mortalidad. Conclusiones: La determinación cuantitativa de TnTc es factible en el medio extrahospitalario y, aunque tiene una baja sensibilidad, permite disponer de un dato objetivo que se relaciona directamente con el diagnóstico final y con el pronóstico de los pacientes (AU)

Sistema integral de urgencias: funcionamiento de los equipos de emergencias en España / Emergency care integral system: working of the out-of hospital emergency teams in Spain

Hoy día, la asistencia a las urgencias sanitarias se entiende dentro del concepto de sistema integral de urgencias, el cual unifica los diferentes niveles asistenciales implicados en la resolución de éstas, en un único proceso asistencial. Uno de los últimos eslabones incorporados a esta cadena han sido los equipos de emergencias (EE) extrahospitalarios, implantados en la actualidad en casi toda la geografía española. Estos EE, por sus peculiaridades en cuanto a su composición, funcionamiento y en torno de trabajo, tienen una entidad propia dentro de la cadena asistencial de las urgencias y emergencias sanitarias (AU)

[Survival and the quality of life in extrahospital cardiorespiratory arrest]. / Supervivencia y calidad de vida en la parada cardiorrespiratoria extrahospitalaria.

BACKGROUND: There are few data in Spain on out-of-hospital cardiac arrest and the efficacy of emergency systems. The objectives of the present study were to evaluate an emergency system, comparing survival at hospital discharge according to the origin, cardiac or non-cardiac, of cardiac arrest in out-of-hospital critically ill patients, and to describe the quality of life of the survivors. PATIENTS AND METHODS: Prospective study on 282 patients treated during 1995 and 1996 by ICU ambulances units of the Andalusian Public Health Emergency Company (061) in Granada, Almería and El Ejido-Poniente (Spain). The Utstein style was followed, gathering the mortality at different times up to 6 months after hospital discharge and the origin (cardiac/non-cardiac) of the arrest. Quality of life 6 months after discharge was collected among survivors. RESULTS: Advanced cardiopulmonary resuscitation (CPR) was applied to 176 (62.4%) patients. The survival rate to discharge was 4.9% for patients with cardiac etiology (7/142 x 100) and 5.9% for those with non-cardiac etiology (2/34 x 100), with non-significant differences between the two groups. An optimal quality of life in all domains, except for pharmacological dependence in seven, was found in the eight survivors 6 months after hospital discharge. CONCLUSIONS: The origin (cardiac/non-cardiac) of out-of-hospital cardiac arrest is not associated with survival at hospital discharge. The survivors exhibit an optimal quality of life 6 months after discharge.