Comparison of APACHE II, MEES and Glasgow Coma Scale in patients with nontraumatic coma for prediction of mortality

INTRODUCTION: There are numerous prehosital descriptive scoring systems, and it is uncertain whether they are efficient in assessing of the severity of illness and whether they have a prognostic role in the estimation of the illness outcome (in comparison with that of the prognostic scoring system Acute Physiology and Chronic Health Evaluation [APACHE] II). The purpose of the present study was to assess the value of the various scoring systems in predicting outcome in nontraumatic coma patients and to evaluate the importance of mental status measurement in relation to outcome. PATIENTS AND METHODS: In a prehospital setting, postintervention values of the Mainz Emergency Evaluation System (MEES) and Glasgow Coma Scale (GCS) were measured for each patient. The APACHE II score was recorded on the day of admission to the hospital. This study was undertaken over a 2-year period (from January 1996 to October 1998), and included 286 consecutive patients (168 men, 118 women) who were hospitalized for nontraumatic coma. Patients younger than 16 years were not included. Their age varied from 16 to 87 years, with mean ± standard deviation of 51.8 ± 16.9 years. Sensitivity, specificity and correct prediction of outcome were measured using the χ(2) method, with four severity scores. The best cutoff point in each scoring system was determined using the Youden index. The difference in Youden index was calculated using the Z score. For each score, the receiver operating characteristic (ROC) curve was obtained. The difference in ROC was calculated using the Z score. P < 0.05 was considered statistically significant. RESULTS: For prediction of mortality, the best cutoff points were 19 for APACHE II, 18 for MEES and 5 for GCS. The best cutoffs for the Youden index were 0.63 for APACHE II, 0.61 for MEES and 0.65 for GCS. The correct prediction of outcome was achieved in 79.9% for APACHE II, 78.3% for MEES and 81.9% for GCS. The area under the ROC curve (mean ± standard error) was 0.86 ± 0.02 for APACHE II, 0.84 ± 0.06 for MEES and 0.88 ± 0.03 for GCS. There were no statistically significant differences among APACHE II, MEES and GCS scores in terms of correct prediction of outcome, Youden index or area under ROC curve. CONCLUSIONS: APACHE II is not much better than prehospital descriptive scoring systems (MEES and GCS). APACHE II and MEES should not replace GCS in assessment of illness severity or in prediction of mortality in nontraumatic coma. For the assessment of mortality, the GCS score provides the best indicator for these patients (simplicity, less time-consuming and effective in an emergency situation

Erythropoietin in post-resuscitation neurological recovery: is there light at the end of the tunnel?

Studies show that erythropoietin, besides its critical role in hematopoiesis, provides neuroprotection in hypoxic-ischemic cerebral injury. Antiapoptotic, anti-inflammatory, angiogenetic, and neurotrophic properties of erythropoietin could increase indications, currently restricted to anemia in chronic renal failure and cancer, to hypoxic-ischemic cerebral insult. In the adult and neonatal animal model of hypoxic-ischemic cerebral injury, erythropoietin significantly reduces infarct size with attenuation of brain damage, and preservation of cortical integrity. The first human study on the impact of erythropoietin in stroke victims showed that erythropoietin is safe and well tolerated at high doses, and associated with improved neurological outcome. Even with intravenous application, concentrations of erythropoietin in cerebrospinal fluid of these patients were many-fold higher than in non-treated patients. In successfully resuscitated cardiac arrest victims overall neurological recovery remains poor despite improved cardiopulmonary resuscitation strategies. Post-resuscitation care needs further advances in order to improve final outcome. Through promotion of neuroangiogenesis, inhibition of hypoxia-induced apoptosis in neurons, and thus support of the survival of neurons in the ischemic brain, erythropoietin could be used to improve functional recovery of these patients. Nevertheless, optimal molecular forms of EPO, therapeutic doses, and treatment time window have to be determined in order to lower the incidence of adverse effects and still preserve neuroprotective properties

The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest

Introduction: Partial pressure of end-tidal carbon dioxide (PetCO2) during cardiopulmonary resuscitation (CPR) correlates with cardiac output and consequently has a prognostic value in CPR. In our previous study we confirmed that initial PetCO2 value was significantly higher in asphyxial arrest than in ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) cardiac arrest. In this study we sought to evaluate the pattern of PetCO2 changes in cardiac arrest caused by VF/VT and asphyxial cardiac arrest in patients who were resuscitated according to new 2005 Guidelines. Methods: The study included two cohorts of patients: cardiac arrest due to asphyxia with initial rhythm asystole or pulseless electrical activity (PEA), and cardiac arrest due to arrhythmia with initial rhythm VF or pulseless VT. PetCO2 was measured for both groups immediately after intubation and repeatedly every minute, both for patients with or without return of spontaneous circulation (ROSC). We compared the dynamic pattern of PetCO2 between groups. Results: Between June 2006 and June 2009 resuscitation was attempted in 325 patients and in this study we included 51 patients with asphyxial cardiac arrest and 63 patients with VF/VT cardiac arrest. The initial values of PetCO2 were significantly higher in the group with asphyxial cardiac arrest (6.74 +/- 4.22 kPa versus 4.51 +/- 2.47 kPaP = 0.004). In the group with asphyxial cardiac arrest, the initial values of PetCO2 did not show a significant difference when we compared patients with and without ROSC (6.96 +/- 3.63 kPa versus 5.77 +/- 4.64 kPaP = 0.313). We confirmed significantly higher initial PetCO2 values for those with ROSC in the group with primary cardiac arrest (4.62 +/- 2.46 kPa versus 3.29 +/- 1.76 kPaP = 0.041). A significant difference in PetCO2 values for those with and without ROSC was achieved after five minutes of CPR in both groups. In all patients with ROSC the initial PetCO2 was again higher than 1.33 kPa. Conclusions: The dynamic pattern of PetCO2 values during out-of-hospital CPR showed higher values of PetCO2 in the first two minutes of CPR in asphyxia, and a prognostic value of initial PetCO2 only in primary VF/VT cardiac arrest. A prognostic value of PetCO2 for ROSC was achieved after the fifth minute of CPR in both groups and remained present until final values. This difference seems to be a useful criterion in prehospital diagnostic procedures and attendance of cardiac arrest

Difference in end-tidal CO(2 )between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting

INTRODUCTION: There has been increased interest in the use of capnometry in recent years. During cardiopulmonary resuscitation (CPR), the partial pressure of end-tidal carbon dioxide (PetCO(2)) correlates with cardiac output and, consequently, it has a prognostic value in CPR. This study was undertaken to compare the initial PetCO(2 )and the PetCO(2 )after 1 min during CPR in asphyxial cardiac arrest versus primary cardiac arrest. METHODS: The prospective observational study included two groups of patients: cardiac arrest due to asphyxia with initial rhythm asystole or pulseless electrical activity, and cardiac arrest due to acute myocardial infarction or malignant arrhythmias with initial rhythm ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The PetCO(2 )was measured for both groups immediately after intubation and then repeatedly every minute, both for patients with and without return of spontaneous circulation (ROSC). RESULTS: We analyzed 44 patients with asphyxial cardiac arrest and 141 patients with primary cardiac arrest. The first group showed no significant difference in the initial value of the PetCO(2), even when we compared those with and without ROSC. There was a significant difference in the PetCO(2 )after 1 min of CPR between those patients with ROSC and those without ROSC. The mean value for all patients was significantly higher in the group with asphyxial arrest. In the group with VF/VT arrest there was a significant difference in the initial PetCO(2 )between patients without and with ROSC. In all patients with ROSC the initial PetCO(2 )was higher than 10 mmHg. CONCLUSIONS: The initial PetCO(2 )is significantly higher in asphyxial arrest than in VT/VF cardiac arrest. Regarding asphyxial arrest there is also no difference in values of initial PetCO(2 )between patients with and without ROSC. On the contrary, there is a significant difference in values of the initial PetCO(2 )in the VF/VT cardiac arrest between patients with and without ROSC. This difference could prove to be useful as one of the methods in prehospital diagnostic procedures and attendance of cardiac arrest. For this reason we should always include other clinical and laboratory tests

Erythropoietin in post-resuscitation neurological recovery: is there light at the end of the tunnel?

Studies show that erythropoietin, besides its critical role in hematopoiesis, provides neuroprotection in hypoxic-ischemic cerebral injury. Antiapoptotic, anti-inflammatory, angiogenetic, and neurotrophic properties of erythropoietin could increase indications, currently restricted to anemia in chronic renal failure and cancer, to hypoxic-ischemic cerebral insult. In the adult and neonatal animal model of hypoxic-ischemic cerebral injury, erythropoietin significantly reduces infarct size with attenuation of brain damage, and preservation of cortical integrity. The first human study on the impact of erythropoietin in stroke victims showed that erythropoietin is safe and well tolerated at high doses, and associated with improved neurological outcome. Even with intravenous application, concentrations of erythropoietin in cerebrospinal fluid of these patients were many-fold higher than in non-treated patients. In successfully resuscitated cardiac arrest victims overall neurological recovery remains poor despite improved cardiopulmonary resuscitation strategies. Post-resuscitation care needs further advances in order to improve final outcome. Through promotion of neuroangiogenesis, inhibition of hypoxia-induced apoptosis in neurons, and thus support of the survival of neurons in the ischemic brain, erythropoietin could be used to improve functional recovery of these patients. Nevertheless, optimal molecular forms of EPO, therapeutic doses, and treatment time window have to be determined in order to lower the incidence of adverse effects and still preserve neuroprotective properties

Combination of Quantitative Capnometry, N-Terminal Pro-brain Natriuretic Peptide, and Clinical Assessment in Differentiating Acute Heart Failure from Pulmonary Disease as Cause of Acute Dyspnea in Pre-hospital Emergency Setting: Study of Diagnostic Accuracy

Aim To determine the diagnostic accuracy of the combination of quantitative capnometry (QC), N-terminal pro-brain natriuretic peptide (NT-proBNP), and clinical assessment in differentiating heart failure (HF)-related acute dyspnea from pulmonary-related acute dyspnea in a pre-hospital setting. Methods This prospective study was performed in the Center for Emergency Medicine Maribor, Slovenia, January 2005 – June 2007. Two groups of patients with acute dyspnea apnea were compared: HF-related acute dyspnea group (n = 238) vs pulmonary-related acute dyspnea (asthma/COPD) group (n = 203). The primary outcome was the comparison of combination of QC, NT-proBNP, and clinical assessment vs NT-proBNP alone or NT-proBNP in combination with clinical assessment, in differentiating HF-related acute dyspnea from pulmonary- related acute dyspnea (asthma/COPD) in pre-hospital emergency setting, using the area under the receiver operating characteristic curve (AUROC). The secondary outcomes end points were identification of independent predictors for final diagnosis of acute dyspnea (caused by acute HF or pulmonary diseases), and determination of NT-proBNP levels, as well as capnometry, in the subgroup of patients with a previous history of HF and in the subgroup of patients with a previous history of pulmonary disease. Results In differentiating between cardiac and respiratory causes of acute dyspnea in pre-hospital emergency setting, NT-proBNP in combination with PetCO2 and clinical assessment (AUROC, 0.97; 95% confidence interval [CI], 0.90-0.99) was superior to combination of NT-proBNP and clinical assessment (AUROC, 0.94; 95% CI, 0.88-0.96; P = 0.006) or NT-proBNP alone (AUROC, 0.90; 95% CI, 0.85- 0.94; P = 0.005). The values of NT-proBNP≥2000 pg/mL and PetCO2 ≤ 4 kPa were strong independent predictors for acute HF. In the group of acute HF dyspneic patients, subgroup of patients with previous COPD/asthma had significantly higher PetCO2 (3.8 ± 1.2 vs 5.8 ± 1.3 kPa, P = 0.009). In the group of COPD/asthma dyspneic patients, NT-proBNP was significantly higher in the subgroup of patients with previous HF (1453.3 ± 552.3 vs 741.5 ± 435.5 pg/mL, P = 0.010). Conclusion In differentiating between cardiac and respiratory causes of acute dyspnea in pre-hospital emergency setting, NT-proBNP in combination with capnometry and clinical assessment was superior to NT-proBNP alone or NTproBNP in combination with clinical assessment

Prehospital monitoring in resuscitation : today and the future

There is growing evidence that early detection and response to physiological deterioration can improve outcome for patients. Working out-of-hospital, we often find ourselves in diagnostic dilemmas, thus more reliable data could change our actions as well as give better assessment of patient\u27s condition. Therefore, we are always exploring new perspectives that could be transferred from experimental laboratory settings to our primary working area in the field to help us improve decision-making leading to better outcome. In the following sections, we represent our previous studies about the utility of continuous capnometry and the importance of point-of-care ultrasound in cardiopulmonary resuscitation (CPR), and discuss about the possible future use of transthoracic and transesophageal ultrasound, point-of-care biochemical monitoring, tissue oxygen saturation, pupillometry, and mixed and central venous oxygen saturation monitoring in the prehospital setting