Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions.

BACKGROUND: The PARAMEDIC cluster randomised trial evaluated the LUCAS mechanical chest compression device, and did not find evidence that use of mechanical chest compression led to an improvement in survival at 30 days. This paper reports patient outcomes from admission to hospital to 12 months after randomisation. METHODS: Information about hospital length of stay and intensive care management was obtained through linkage with Hospital Episode Statistics and the Intensive Care National Audit and Research Centre. Patients surviving to hospital discharge were approached to complete questionnaires (SF-12v2, EQ-5D, MMSE, HADS and PTSD-CL) at 90days and 12 months. The study is registered with Current Controlled Trials, number ISRCTN08233942. RESULTS: 377 patients in the LUCAS arm and 658 patients in the manual chest compression were admitted to hospital. Hospital and intensive care length of stay were similar. Long term follow-up assessments were limited by poor response rates (53.7% at 3 months and 55.6% at 12 months). Follow-up rates were lower in those with worse neurological function. Among respondents, long term health related quality of life outcomes and emotional well-being was similar between groups. Cognitive function, measured by MMSE, was marginally lower in the LUCAS arm mean 26.9 (SD 3.7) compared to control mean 28.0 (SD 2.3), adjusted mean difference -1.5 (95% CI -2.6 to -0.4). CONCLUSION: There were no clinically important differences identified in outcomes at long term follow-up between those allocated to the mechanical chest compression compared to those receiving manual chest compression.

Characteristics of patients who are not resuscitated in out of hospital cardiac arrests and opportunities to improve community response to cardiac arrest.

AIM: This study explores why resuscitation is withheld when emergency medical staff arrive at the scene of a cardiac arrest and identifies modifiable factors associated with this decision. METHODS: This is a secondary analysis of unselected patients who sustained an out of hospital cardiac arrest attended by ambulance vehicles participating in a randomized controlled trial of a mechanical chest compression device (PARAMEDIC trial). Patients were categorized as 'non-resuscitation' patients if there was a do-not-attempt-cardiopulmonary-resuscitation (DNACPR) order, signs unequivocally associated with death or resuscitation was deemed futile (15min had elapsed since collapse with no bystander-CPR and asystole recorded on EMS arrival). RESULTS: Emergency Medical Services attended 11,451 cardiac arrests. Resuscitation was attempted or continued by Emergency Medical Service staff in 4805 (42%) of cases. Resuscitation was withheld in 6646 cases (58%). 711 (6.2%) had a do not attempt resuscitation decision, 4439 (38.8%) had signs unequivocally associated with death and in 1496 cases (13.1%) CPR was considered futile. Those where resuscitation was withheld due to futility were characterised by low bystander CPR rates (7.2%) and by being female. CONCLUSIONS: Resuscitation was withheld by ambulance staff in over one in ten (13.1%) victims of out of hospital cardiac arrest on the basis of futility. These cases were associated with a very low rate of bystander CPR. Future studies should explore strengthening the 'Chain of Survival' to increase the community bystander CPR response and evaluate the effect on the numbers of survivors from out of hospital cardiac arrest.

Deliberate self-harm: a follow-up study of 279 patients.

Two-hundred-and-seventy-nine patients (103 men, 176 women) were followed-up 1-2 years after an act of non-fatal deliberate self-harm. Of 155 patients offered a psychiatric out-patient appointment at the time, only 68 completed the treatment. A further act of deliberate self-harm was committed by 26 men and 41 women within twelve months. The factors most highly associated with repetition were previous psychiatric treatment, a previous act of deliberate self-harm, and a criminal record. These factors held good for a separate series of patients. Significantly more repeaters received prolonged psychiatric care after the initial episode of deliberate self-harm. The implications of these findings for the clinical management of such patients are discussed.

Deliberate self-harm: clinical and socio-economic characteristics of 368 patients.

In this study 368 patients were interviewed after they had attended the Bristol Royal Infirmary Accident and Emergency Department following a non-fatal act of deliberate self-harm. There were twice as many women (247) as men (121), and two thirds of the patients were in the 15-35 age group. Ninety-five per cent had taken a drug overdose, most commonly one or more of the tranquillizers, antidepressants, hypnotics or analgesics. Seventy-eight per cent had taken drugs prescribed by a doctor. Half the patients mentioned interpersonal conflict as a major precipitating factor in the episode. A psychiatric diagnosis was completed for all admitted patients, of whom 52 per cent were considered to be suffering from neurotic depression, 29 per cent from personality disorder, 12 per cent from functional psychosis and 10 per cent from alcohol addiction. Almost half had deliberately harmed themselves on a previous occasion. The series showed a greater than average incidence of unemployment, overcrowded living conditions, divorce and antisocial behaviour. The implications of these findings for the clinical management and prevention of non-fatal deliberate self-harm are discussed.

The urban distribution of non-fatal deliberate self-harm.

1. The incidence of non-fatal deliberate self-harm throughout the City of Bristol during 1972 and 1973 was assessed by means of a survey of patients presenting to Accident and Emergency Departments of hospitals in the area. Fatal or repeated acts of self-harm were not included in the survey. 2. The rates for females exceeded those for males at all ages, with peak incidence of 645 per 100,000 females (age group 15-29 years) and 334 per 100,000 males (age group 25-29 years). Ninety-three per cent had taken a drug overdose of some kind. 3. The problem was found in all electoral wards of tE CITY, THOUGH ITS DISTRIBUTION WAS MARKEDLY CENTRIPETAL, WITH A CENTRAL AREA HAVING MORBIDITY RATES UP TO 2-8 TIMES THAT FOR THE CITY AS A WHOLE. 4. The socio-economic correlates of deliberate self-harm were examined by reference both to a series of 368 patients interviewed soon after the event and to the pattern of its distribution throughout the city. A significant positive association was found with areas of overcrowding, lack of exclusive domestic amenities and high proportion of foreign born residents, but there was no correlation with the proportion of persons living alone nor with the type of accommodation. 5. The central high rate area was found to be heterogeneous in socio-economic terms, ranging from a student and young professionals' bed-sitter area to one with a high proportion of unskilled manual labourers and New Commonwealth immigrants. 6. The aetiological implications of the ecological findings for deliberate self-harm throughout the city are discussed.