Prehospital Tranexamic Acid for Severe Trauma.

BACKGROUND: Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. METHODS: We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury. RESULTS: A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups. CONCLUSIONS: Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).

The impact of a national COVID-19 lockdown on acute coronary syndrome hospitalisations in New Zealand (ANZACS-QI 55).

BACKGROUND: Countries with a high incidence of coronavirus 2019 (COVID-19) reported reduced hospitalisations for acute coronary syndromes (ACS) during the pandemic. This study describes the impact of a nationwide lockdown on ACS hospitalisations in New Zealand (NZ), a country with a low incidence of COVID-19. METHODS: All patients admitted to a NZ Hospital with ACS who underwent coronary angiography in the All NZ ACS Quality Improvement registry during the lockdown (23 March - 26 April 2020) were compared with equivalent weeks in 2015-2019. Ambulance attendances and regional community troponin-I testing were compared for lockdown and non-lockdown (1 July 2019 to 16 February 2020) periods. FINDINGS: Hospitalisation for ACS was lower during the 5-week lockdown (105 vs. 146 per-week, rate ratio 0•72 [95% CI 0•61-0•83], p = 0.003). This was explained by fewer admissions for non-ST-segment elevation ACS (NSTE-ACS; p = 0•002) but not ST-segment elevation myocardial infarction (STEMI; p = 0•31). Patient characteristics and in-hospital mortality were similar. For STEMI, door-to-balloon times were similar (70 vs. 72 min, p = 0•52). For NSTE-ACS, there was an increase in percutaneous revascularisation (59% vs. 49%, p<0•001) and reduction in surgical revascularisation (9% vs. 15%, p = 0•005). There were fewer ambulance attendances for cardiac arrests (98 vs. 110 per-week, p = 0•04) but no difference for suspected ACS (408 vs. 420 per-week, p = 0•44). Community troponin testing was lower throughout the lockdown (182 vs. 394 per-week, p<0•001). INTERPRETATION: Despite the low incidence of COVID-19, there was a nationwide decrease in ACS hospitalisations during the lockdown. These findings have important implications for future pandemic planning. FUNDING: The ANZACS-QI registry receives funding from the New Zealand Ministry of Health.

Out-of-hospital Cardiac Arrest Patient Characteristics: Comparing ventricular arrhythmia and Pulseless Electrical Activity.

BACKGROUND: The proportion of patients suffering out-of-hospital cardiac arrest presenting with ventricular arrhythmias/ventricular fibrillation (VT/VF) is decreasing, while the proportion presenting with pulseless electrical activity (PEA) is increasing. Cardiac arrest interventions target VT/VF and survival rates from PEA are much lower. The aim of this study was to compare clinical characteristics of those suffering PEA and VT/VF. METHODS: We examined the past medical history of all patients suffering cardiac arrest in the Wellington region between 2008-2012 and compared clinical features of those with PEA to VT/VF. RESULTS: We identified 749 cardiac arrests in the study period, and were able to obtain detailed medical histories in 735 (98%) cases. The presenting rhythm was VF/VT in 337 (46%) cases, PEA in 127 (17%), and asystole in 271 (37%). Patients with PEA were older (68±14 versus 63±15 years, p=0.003), a higher proportion were female (35% versus 22%, p=0.002) and were less likely to have prior cardiovascular disease than those with VT/VF (48% versus 59%, p=0.03). Respiratory disease was more common in those with PEA (35% versus 23%, p=0.008). CONCLUSION: The population suffering PEA differs from the VT/VF cohort in a number of ways, and PEA is associated with significantly worse outcomes.

Survival from out-of-hospital cardiac arrest in Wellington in relation to socioeconomic status and arrest location.

AIMS: The study examined the influence of physical location on survival from out-of-hospital cardiac arrest (OHCA). Firstly, OHCAs occurring in residential settings were compared to those occurring in public locations. Secondly, the residential OHCAs were classified according to socioeconomic status and the relationship between socioeconomic status and outcome from OHCA was examined. METHODS: For all OHCAs that occurred between 1 July 2007 and 30 June 2010, we compared OHCA characteristics and outcomes between public and residential locations, and for residential locations examined across deciles of socioeconomic status. RESULTS: Of the 445 arrests that occurred during the study period, 413 met the inclusion criteria. Survival from OHCA in public locations was approximately twice that for residential OHCA (19.8% vs 10.7%, p=0.021). We found no association between survival from residential OHCA and socioeconomic status. Similarly, we found no association between socioeconomic status and witnessing of the event, bystander cardiopulmonary resuscitation, the initial presenting rhythm, and ambulance response time. CONCLUSION: Residential OHCA in the Wellington region has a much poorer prognosis than OHCA in public locations. There is no evidence to suggest that any socioeconomic group in the Wellington region is disadvantaged when a community and ambulance response is required for an OHCA.

Ambulance triage and treatment zones at major rugby events in Wellington, New Zealand: a sobering experience.

AIMS: A prospective analysis was undertaken of the workload of prehospital triage and treatment facilities established in Wellington for the 2011 and 2012 International Rugby Sevens, and the Rugby World Cup 2011 (RWC). The introduction of an alcohol intoxication pathway, the impact of the initiative on ambulance and Emergency Department (ED) workload, and its cost effectiveness were assessed. METHODS: A log of patients seen and their diagnoses and treatment was maintained. An alcohol questionnaire was completed when applicable. Patients intoxicated with alcohol were managed in accordance with a flowchart designed for paramedic use. Costs and savings were calculated. RESULTS: Half the patients were New Zealanders. The average age was 25 years with a slight female preponderance (52.9% female). 30% were students. Alcohol was a contributory or causative factor for the patient's attendance in 80-90% of cases. Approximately 60% of the 121 patients seen at the last two events would have had to be transferred to the ED in the absence of the treatment centre. Cost savings for the ambulance service and ED for the RWC and 2012 Sevens are estimated to be NZ$70,000. No adverse clinical event was identified. CONCLUSIONS: With minimal supervision, event medics and paramedics can safely care for the majority of patients attending large rugby events in New Zealand, easing the pressure on ambulances and the ED, and generating significant cost savings for those services.

Beyond the pre-shock pause: the effect of prehospital defibrillation mode on CPR interruptions and return of spontaneous circulation.

AIMS: The pattern of interruptions to chest compressions in pre-hospital cardiac arrests in Wellington, New Zealand, was examined prospectively to determine whether the mode of defibrillation chosen by paramedics influenced interruptions, shock success and the return of spontaneous circulation (ROSC). METHODS: A prospective observational cohort study of 44 adult cardiac arrests in which 203 shocks were administered by Wellington Free Ambulance (WFA) paramedics was undertaken to compare Code-stat electronic records from Medtronic Lifepak 12 and Lifepak 15 defibrillators used in semi-automated (AED) or manual mode. Interruptions during the 30s prior to shock delivery as well as pre-shock and post-shock pauses were calculated. Shock success and ROSC were the outcome measures. RESULTS: Pre-shock pauses were shorter in manual mode (median 3s, IQR 2-5) versus AED mode (median 4s, IQR 3-6; p=0.003). Interruptions of CPR in the 30s prior to shock delivery were also shorter in manual mode (median 7s, IQR 4-11) versus AED mode (median 14s, IQR 12-16; p=<0.001). Shock success rates and post-shock pauses were not statistically different between modes. ROSC was significantly higher in manual mode (18.49%) versus AED mode (8.33%, p=0.042). CONCLUSION: When paramedics used the defibrillator in manual mode as compared to AED mode, interruptions to CPR during the 30s prior to shock delivery were significantly reduced and pre-shock pauses were also shorter. This was associated with increased ROSC. Manual defibrillation should be the preferred option for appropriately trained paramedics. Training in this locality has been changed accordingly.

Introduction of an extended care paramedic model in New Zealand.

OBJECTIVES: The first extended care paramedic (ECP) model of care in New Zealand was introduced in the Kapiti region, north of Wellington in 2009. The ECP model aimed to increase the proportion of patients presenting to the ambulance service who could be treated in the community. This study evaluated the first 1000 patients seen by ECPs. METHODS: The first 1000 presentations attended by ECPs were examined to determine the proportions of patients transported to the ED and treated in the community. For patients treated in the community we determined the number presenting to the ED within 7 days of ECP attendance. RESULTS: A total of 797 patients (mean age 62 years) had 1000 clinical presentations. In 59% the patient was treated either at home or in the local community, with 40% transported to the ED. Within the same region and time period 74% of patients attended by standard paramedics were transported to the ED. The rate of ECP transport to the ED differed significantly by clinical condition, with 71% of cardiac presentations versus 19% of patients with spinal problems taken to the ED. In 31 cases (5%) where the patient had been managed in the community there was an acute ED presentation within 7 days. CONCLUSION: We observed that ECPs have significant potential to reduce hospital ED attendances by treating more patients in the community, and this is associated with a low rate of subsequent ED presentations. Prioritisation of dispatch of ECPs to particular types of patients might be useful in maximising this reduction.

Patient satisfaction and outcome using emergency care practitioners in New Zealand.

OBJECTIVE: A patient satisfaction survey was undertaken in the Kapiti District of the Wellington Region to ascertain patients' experience and opinions of New Zealand's first extended care paramedic (ECP) service before consideration is given to extending it to other locations within the region. Patient outcomes were also analysed for 1 week following ECP care. METHODS: One hundred patients, 50 attended by ECPs and 50 by standard emergency ambulance service paramedics, were interviewed by an independent assessor, either in person or by phone according to patient preference. The questionnaire was aimed at comparing the experience of both groups of patients, dividing them into those treated at home and those transferred to the ED. ED and general practice records were then reviewed to determine whether the ECP-treated patients attended either facility within 7 days and why. RESULTS: Patients were very satisfied with their experience of both groups of paramedics but expressed a clear desire to be treated at home if possible. Of the 50 ECP-treated patients, 11 were transferred directly to the ED. Only one clinical complication arose over the next 7 days in those treated in the community: a seizure in a patient with refractory epilepsy. CONCLUSION: The avoidance of unnecessary transfers to hospital is beneficial to patients, the ambulance service and the ED. This study demonstrates that patients are very satisfied with their assessment and treatment by ECPs, endorsing the proposal that the scheme should be extended across the Wellington Region, and perhaps New Zealand.

Outcomes from out-of-hospital cardiac arrest in the Wellington region of New Zealand. Does use of the Fire Service make a difference?

AIMS: Survival from community cardiac arrest in the Wellington region was analysed and compared with similar data reported nationally and internationally. In particular, the impact of a dual fire and ambulance service response was studied. METHOD: A retrospective comparative study was undertaken of out-of-hospital cardiac arrests in the Wellington region between 1 July 2007 and 31 December 2009. Data was collected from Wellington Free Ambulance and hospital records in accordance with the Utstein template. The New Zealand Fire Service provided details of firefighter attendance and timings. The primary outcome measure was survival to hospital discharge. RESULTS: Overall survival to hospital discharge was 11% (37/339) whilst survival from initial ventricular fibrillation or tachycardia (VF/VT) was 21% (34/161). Initial VF/VT was more common in witnessed than unwitnessed arrests (57% v. 35%, p=0.001) and this mirrored survival in these groups (15% vs 6%, p=0.01). Survival to hospital discharge was also associated with younger age and shorter emergency service response time. Bystanders attempted CPR in 55% and the fire service in 50% but neither intervention influenced outcome. Although, when activated, the fire service arrived on average 1-2 minutes ahead of the ambulance, the dual response did not influence survival to hospital admission or discharge. CONCLUSION: Survival from out-of-hospital cardiac arrest in Wellington is similar to that of other New Zealand cities and better than that reported from several large centres overseas. The combined fire and ambulance response was not shown to have any beneficial impact on survival over and above that achieved by the ambulance service alone. System changes are proposed to try and improve survival from community cardiac arrest in Wellington.

An unmet need for implantable cardioverter-defibrillators in New Zealand.

AIMS: This study examined the prior history of all patients presenting to the regional ambulance service with community cardiac arrest to determine what proportion of these patients had prior indications for implanted cardioverter-defibrillator (ICD) therapy. METHODS AND RESULTS: We reviewed the medical history of all adult patients presenting to our regional ambulance service with cardiac arrest between 1 June 2007 and 31 May 2008 (n= 144). Patients were classified as either not having an ICD indication, having a possible ICD indication, or having an ICD indication by two electrophysiologists. Eighty-seven patients (60%) had no pre-existing indication for an ICD. Twenty-two patients (15%) had a possible indication for an ICD but required further investigation to confirm this. This group consisted of 6 patients (4%) with previously documented left ventricular ejection fraction <35%, but without a measurement in the last 12 months, 14 patients (10%) with heart failure (n= 10) or syncope (n= 4) without appropriate investigations, and 2 patients with an ICD indication but with co-morbidities that required further investigation. Thirty-five patients (24%) had a documented indication for an ICD. In 11 (8%) there was no evidence of a contraindication, in 3 (2%) alternative therapy was judged more appropriate, and in 21 (15%) contraindications to ICD implantation were also present. Addition of the 11 patients with an ICD indication and the 6 patients with a documented indication requiring updated measurement, 17 patients (12%) had a prior documented ICD indication but had not been referred for this therapy. CONCLUSIONS: Our observation that 12% of sudden cardiac arrest patients had prior indications for an ICD demonstrates that there is an unmet need for ICDs in New Zealand.

Survival from out-of-hospital cardiac arrest in New Zealand following the 2005 resuscitation guideline changes.

AIMS: The effect of cardiopulmonary resuscitation guideline changes on out-of-hospital survival rates and defibrillation efficacy was investigated. The guideline changes were those recommended by the International Liaison Committee on Resuscitation in 2005. METHODS: A retrospective comparative study was undertaken of out-of-hospital cardiac arrests in the Wellington region. The effect of guideline changes between the periods of 1st July 2005-30th June 2006 and 1st June 2007-31st May 2008 was examined. Data was collected from Wellington Free Ambulance and hospital records in accordance with the Utstein template. The primary outcome measure was survival to hospital discharge. Additional end points included individual shock success, return of spontaneous circulation (ROSC) and survival to hospital admission. RESULTS: There was no significant increase in survival to hospital discharge with 11% (18/162) pre-change and 12% (20/170) post-change (p=0.5). First-shock efficacy decreased from 68% (65/96) to 62% (57/92) (p=0.75). Second shock efficacy decreased from 47% (14/30) to 27% (9/33) (p=0.12). The proportion of patients with ROSC increased from 34% (55/162) to 42% (72/170) (p=0.07, Chi squared). The proportion surviving to hospital increased significantly from 22% (36/162) to 36% (61/170) (p=0.006). Withdrawal of atropine in 2005 had no adverse effect on the outcome. CONCLUSION: This study suggests that in the Wellington Region of New Zealand, the new guidelines have improved survival to hospital but not to discharge. Whilst the guideline changes have resulted in a trend towards decreased shock success rates, ROSC and survival to hospital admission have both increased.