Evaluating helicopter emergency medical missions: a reliability study of the HEMS benefit and NACA scores.

BACKGROUND: The benefits of the Helicopter Emergency Medical Service (HEMS) and dispatch accuracy are continuously debated, and a widely accepted score to measure the benefits of the mission is lacking. The HEMS Benefit Score (HBS) has been used in Finnish helicopter emergency medical services, but studies are lacking. The National Advisory Committee for Aeronautics (NACA) score is widely used to measure the severity of illness or injury in the pre-hospital setting, but it has many critics due to its subjectivity. We investigated the inter-rater and rater-against-reference reliability of these scores. METHODS: Twenty-five fictional HEMS missions were created by an expert panel. A total of 22 pre-hospital physicians were recruited to participate in the study from two different HEMS bases. The participants received written instructions on the use of the scores. Intraclass correlation coefficients (ICCs) and mean differences between rater-against-reference values were calculated. RESULTS: A total of 17 physicians participated in the study. The ICC was 0.70 (95% CI 0.57-0.83) for the HBS and 0.65 (95% CI 0.51-0.79) for the NACA score. Mean differences between references and raters were -0.09 (SD 0.72) for the HBS and 0.28 (SD 0.61) for the NACA score, indicating that raters scored some lower NACA values than reference values formed by an expert panel. CONCLUSION: The HBS and NACA score had substantial inter-rater reliability. In addition, the rater-against-reference values were acceptable, though large differences were observed between individual raters and references in some clinical cases.

Comparison of 30 and the 100% inspired oxygen concentrations during early post-resuscitation period: a randomised controlled pilot study.

OBJECTIVES: High oxygen concentration in blood may be harmful in the reperfusion phase after cardiopulmonary resuscitation. We compared the effect of 30 and 100% inspired oxygen concentrations on blood oxygenation and the level of serum markers (NSE, S-100) of neuronal injury during the early post-resuscitation period in humans. METHODS: Patients resuscitated from witnessed out-of-hospital ventricular fibrillation were randomised after the return of spontaneous circulation (ROSC) to be ventilated either with 30% (group A) or 100% (group B) oxygen for 60 min. Main outcome measures were NSE and S-100 levels at 24 and 48 h after ROSC, the adequacy of oxygenation at 10 and 60 min after ROSC and, in group A, the need to raise FiO(2) to avoid hypoxaemia. Blood oxygen saturation <95% was the threshold for this intervention. RESULTS: Thirty-two patients were randomised and 28 (14 in group A and 14 in group B) remained eligible for the final analysis. The mean PaO(2) at 10 min was 21.1 kPa in group A and 49.7 kPa in group B. The corresponding values at 60 min were 14.6 and 46.5 kPa. PaO(2) values did not fall to the hypoxaemic level in group A. In another group FiO(2) had to be raised in five cases (36%) but in two cases it was returned to 0.30 rapidly. The mean NSE at 24 and 48 h was 10.9 and 14.2 microg/l in group A and 13.0 and 18.6 microg/l in group B (ns). S-100 at corresponding time points was 0.21 and 0.23 microg/l in group A and 0.73 and 0.49 microg/l in group B (ns). In the subgroup not treated with therapeutic hypothermia in hospital NSE at 24h was higher in group B (mean 7.6 versus 13.5 microg/l, p=0.0487). CONCLUSIONS: Most patients had acceptable arterial oxygenation when ventilated with 30% oxygen during the immediate post-resuscitation period. There was no indication that 30% oxygen with SpO(2) monitoring and oxygen backup to avoid SpO(2)<95% did worse that the group receiving 100% oxygen. The use of 100% oxygen was associated with increased level of NSE at 24h in patients not treated with therapeutic hypothermia. The clinical significance of this finding is unknown and an outcome-powered study is feasible.

Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest.

OBJECTIVE: To investigate the safety and efficacy of thrombolytic treatment for an acute myocardial infarction (AMI) immediately after resuscitation in the out-of-hospital setting. DESIGN: Retrospective. SETTING: A middle-sized urban city (population 540000) served by a single emergency medical system using a tiered response with physicians in field. PATIENTS AND METHODS: Sixty-eight patients with an initial diagnosis of AMI who received thrombolytic treatment in an out-of-hospital setting after cardiac arrest and cardiopulmonary resuscitation (CPR) between January 1st 1994 and December 31st 1998. An ECG and the myocardial enzymes (CK, CK-MB, Troponin-T) were used to diagnose AMI. Myocardial reperfusion was assessed by resolution of the ST-segment elevation. Side effects and complications were studied. The quality of secondary survival was evaluated. The Utstein style was used for a uniform style of reporting the cardiac arrest data. RESULTS: The accuracy of prehospital diagnosis was found to be excellent. Retrospective analysis revealed that thrombolytic therapy had been appropriately administered in 64 (94%) of the 68 patients actually treated. Reperfusion was achieved in 71% of the patients. Haemorrhagic complications were few, and included intracranial haemorrhage (one patient), gastrointestinal bleeding (two patients), bleeding from the puncture site (one patient) and epistaxis (one patient). The incidence of hypotension during streptokinase infusion was 22%. Sixty-three (93%) of the patients were admitted alive to the hospital, with 36 subsequently surviving to discharge. CONCLUSIONS: Thrombolytic treatment is a safe and effective treatment in AMI even after out-of-hospital cardiopulmonary resuscitation.

Telemedicine framework and applications in dermatology and ophthalmology.

Medicine has to balance between the advantages and costs of new technology. As the significance of technical aids has increased, medicine has become more tightly bound to technology. Telemedicine is one of the fastest developing fields, as its development is connected to the development of telecommunication and information technology. Technology sets the ultimate restrictions to telemedicine. However, most challenges are nontechnical. Fast development makes it difficult to perform generalizable studies on the field, and the lack of practical, applicable standardization hinders telemedical system design. The cost of technology is quickly falling compared with the cost of human labour. Because of these factors the efficient use of telemedicine requires strategic decisions at the level of the organization as well as more research concerning the effects of telemedicine on medical practice. This article describes the telemedical frame of reference by using dermatology and ophthalmology as examples.

Utstein style reporting of in-hospital paediatric cardiopulmonary resuscitation.

STUDY OBJECTIVE: To report paediatric in-hospital cardiac arrest data according to Utstein style and to determine the effectiveness of cardiopulmonary resuscitation (CPR) in hospitalized children. DESIGN: Retrospective 5-year case series. SETTING: Urban, tertiary-care children's hospital. PARTICIPANTS: All patients who sustained cardiopulmonary arrest. RESULTS: Altogether 227 patients experienced a cardiopulmonary arrest during the study period, 109 (48.0%) were declared dead without attempted resuscitation, and CPR was initiated in 118 (52.0%). The incidence of cardiac arrest was 0. 7% of all hospital admissions and 5.5% of PICU admissions; the incidence of CPR attempts was 0.4 and 2.5%, respectively. Most of the CPR attempts (64.4%) took place in the PICU and the most frequent aetiology was cardiovascular (71.2%). The 1-year survival rate was 17.8%. Short duration of external CPR was the best prognostic factor associated with survival. With few exceptions, the Paediatric Utstein Style was found to be applicable for reporting retrospective data from in-hospital cardiac arrests in children. CONCLUSIONS: In-hospital cardiopulmonary resuscitation was shown to be an uncommon event in children; the survival rate was similar to earlier studies.

Prehospital thrombolytic treatment of massive pulmonary embolism with reteplase during cardiopulmonary resuscitation.

A 52-year-old previously healthy man experienced acute severe dyspnoea after suffering from gastroenteritis for 3 days. After arrival of the ambulance, cardiac arrest with an initial rhythm of electro mechanical dissociation occurred. Circulation was restored after 10 min of cardiopulmonary resuscitation but soon cardiac arrest reoccurred. Based on a strong clinical suspicion of massive pulmonary embolism, thrombolytic treatment with heparin 5000 IU and reteplase 20 U, given as single boluses and heparin was continued as an infusion 1000 IU h(-1). After 7 min of continued resuscitation, circulation was restored and after 40 min the vital functions began to stabilize, thus indicating pulmonary reperfusion. The diagnosis of pulmonary embolism was confirmed by a ventilation-perfusion scan and by spiral computerised tomography. The patient was discharged from intensive care after 2 days with a cerebral performance category I. Based on previous calculations, the annual number of patients who present with massive pulmonary embolism leading to cardiac arrest (and thus who would theoretically be candidates for thrombolytic treatment) was estimated to be 0.7/100000 inhabitants in this emergency medical services system.