Lay-person and public access defibrillation in the chain of survival in Finland

Sudden cardiac arrest (CA) is one of the leading causes of death in Europe. It has been estimated that about 40 % of CA victims have ventricular fibrillation (VF) at the time of the first heart rhythm analysis. The treatment for VF is immediate cardiopulmonary resuscitation (CPR) and rapid defibrillation. The automated external defibrillator (AED) and the concept of public access defibrillation (PAD) may be a key to shortening defibrillation delays. Recent studies have shown that PAD programs are associated with high survival rates from VF when devices have been placed in certain risk sites and used by trained laypersons. Today many public places are equipped with AEDs. The purpose of this study was to find new ways of utilizing layperson defibrillation and promote the concept of public access defibrillation (PAD). The study explored the use of AEDs by non-medical first responders in Finland and cabin crew on board a commercial aircraft. A simulated study was performed to explore the role of dispatcher assistance in layperson CPR and defibrillation. A 15-year follow-up study of 59 one-year survivors after successful out-of-hospital resuscitation was performed to evaluate the long-term quality of life of the CA patients. Although there are many AEDs in use by non-medical first responders in Finland, the results of the study showed that there are large variations between individual first response units. This is considered to be caused by the lack of national standards and regulations that would define a full integration of first-responder programmes into the Emergency Medical Services system. The goal of rapid defibrillation in five minutes after the onset of CA is difficult to achieve in Finland due to sparse population and long distances. Local PAD programs may shorten the defibrillation delays. Dispatcher assistance in defibrillation by a layperson not trained to use an AED seems feasible and does not compromise the performance of CPR. In a simulated study, the quality of mouth-to-mouth ventilation performed by laypersons was found to be better after CPR training compared with performance with dispatcher assistance before training. Training was not found to have an influence on the quality of compressions or defibrillation compared with dispatcher assistance of untrained laypersons. The target groups for CPR and defibrillation training need further evaluation. The placements of the AEDs in public areas should be known by the emergency response center and the location should be marked with an international sign. The finding that once a good neurological outcome after CA is achieved, it can be maintained for more than 10 years, encourages further efforts to improve the survival of CA patients.Sepelvaltimotauti ja muut sydänsairaudet voivat aiheuttaa äkillisen sydämen pysäyttävän rytmihäiriön. Sydänpysähdys voi olla sydänsairauden ensimmäinen oire. Yleisin sydämen pysäyttävä rytmihäiriö on kammiovärinä. Kammiovärinässä ainoa sydämen käynnistävä hoito on tarkoitukseen suunnitellulla laitteella eli defibrillaattorilla annettava sähköisku eli defibrillaatio. Defibrillaatio tulisi suorittaa viiden minuutin sisällä sydänpysähdyksen alusta, jotta potilaan toipuminen olisi todennäköistä. Jos defibrillaatio viivästyy, lisää painelu-puhalluselvytys todennäköisyyttä, että defibrillaatio käynnistää sydämen. Vain harvoin painelu-puhalluselvytys itsessään käynnistää sydämen. Sydänpysähdyspotilaan ensimmäinen auttaja on yleensä maallikko. Nykyaikaisten neuvovien puoliautomaattisten defibrillaattoreiden avulla maallikko voi myös defibrilloida. Puoliautomaattiset defibrillaattorit tunnistavat kammiovärinän ja ohjaavat käyttäjäänsä defibrilloimaan ääni- ja kuvaohjeiden avulla. Laite ei anna sähköiskua, ellei potilaalla ole kammiovärinää. Väitöskirjatyön tarkoituksena on lisätä tietoisuutta puoliautomaattisista defibrillaattoreista ja maallikon suorittamasta defibrillaatiosta Suomessa. Väitöskirjatyössä selvitettiin puoliautomaattisten defibrillaattoreiden käyttöä sopimus- ja vakinaisten palokuntien yksiköissä sekä matkustajalentokoneissa. Simulaatiotutkimusten avulla tutkittiin hätäkeskuspäivystäjän mahdollisuuksia ohjata maallikkoa puoliautomaattisen defibrillaattorin käytössä puhelimitse. Lisäksi tutkittiin kammiovärinästä elvytettyjen potilaiden pitkäaikaisselviytymistä. Tutkimuksessa todettiin, että maallikon suorittamalla defibrillaatiolla voitaisiin todennäköisesti lyhentää defibrillaatioviiveitä Suomessa. Harva asutus taajamien ulkopuolella sekä pitkät etäisyydet tekevät nopean defibrillaation toteuttamisen haastavaksi. Puoliautomaattisten defibrillaattoreiden määrä on viime vuosina lisääntynyt. Maallikon suorittamaa defibrillaatiota voitaisiin kuitenkin hyödyntää paremmin sydänpysähdyspotilaiden hoidossa. Defibrillaation liittäminen osaksi hätäkeskuksen antamia puhelinelvytysohjeita voisi tehostaa jo olemassa olevien puoliautomaattisten defibrillaattoreiden käyttöä. Julkisiin tiloihin sijoitetuista defibrillaattoreista tulisi laatia rekisteri ja niiden sijainnin tulisi olla hätäkeskuksen tiedossa. Ne tulisi myös merkitä näkyvästi. Kammiovärinästä onnistuneesti elvytettyjen potilaiden kuolleisuus elvytystä seuraavan vuoden sisällä on korkea. Pitkäaikaisselviytyjät vaikuttavat kuitenkin toipuvan hyvin ja palaavan jopa työelämään

Siirtokuljetukset : "ei kenenkään maa" vai kaikkien yhteinen asia?

Teema : potilaan kuljettamine

Overlooking the Obvious during the COVID-19 Pandemic : Dyspnoea with Asymmetric Breath Sounds in a Toddler

Background. Paediatric healthcare specialists are concerned about the secondary effects of the COVID-19 pandemic on children. We report a case of acute respiratory distress in a healthy toddler whose healthcare providers were sidetracked from the correct diagnosis by suspicion of COVID-19. Case Presentation. The patient was a 20-month-old healthy boy. In the morning, he had coughed while drinking milk. He was asymptomatic for the day but presented with acute respiratory distress when lying down in the evening. An ambulance was called, and he was taken to a tertiary hospital's paediatric emergency department, where his condition and oxygen saturation fluctuated. He had mildly elevated temperature and petechiae on his trunk, showed asymmetrical radiographic and auscultatory pulmonary findings, and did not tolerate any exertion. Pneumonia was suspected, SARS-CoV-2 was considered as potential causative agent, and the child was admitted to a Paediatric Intensive Care Unit. As the patient did not show clear signs of infection or bronchial obstruction, the events were thoroughly rediscussed with the caregiver next morning. It was then found out that the child had also been eating cashew nuts. Multiple pieces of cashew nuts were removed from the left bronchial tree in a bronchoscopy. After the procedure, all symptoms promptly resolved. Foreign body aspiration-an obvious cause of acute respiratory distress in our patient's age group-was overlooked by experienced emergency medical care providers and paediatric critical care physicians due to the slightly unusual presentation, incomplete anamnestic information, and a bias to consider COVID-19 in the current exceptional circumstances. Conclusions. Emergency care providers are instructed to consider all patients with respiratory distress as potential COVID-19 patients. However, the clinical course of COVID-19 infection is usually mild in children. Therefore, alternative causes for serious breathing difficulty are more likely, and all differential diagnoses should be considered in the usual unbiased manner.Peer reviewe

Frequency, indications and success of out-of-hospital intubations in Finnish children

Background Earlier studies have shown variable results regarding the success of paediatric emergency endotracheal intubation between different settings and operators. We aimed to describe the paediatric population intubated by physician-staffed helicopter emergency medical service (HEMS) and evaluate the factors associated with overall and first-pass success (FPS). Methods We conducted a retrospective observational cohort study in Finland including all children less than 16 years old who required endotracheal intubation by a HEMS physician from January 2014 to August 2019. Utilising a national HEMS database, we analysed the incidence, indications, overall and first-pass success rates of endotracheal intubation. Results A total of 2731 children were encountered by HEMS, and intubation was attempted in 245 (9%); of these, 22 were younger than 1 year, 103 were aged 1-5 years and 120 were aged 6-15 years. The most common indications for airway management were cardiac arrest for the youngest age group, neurological reasons (e.g., seizures) for those aged 1-5 years and trauma for those aged 6-15. The HEMS physicians had an overall success rate of 100% (95% CI: 98-100) and an FPS rate of 86% (95% CI: 82-90). The FPS rate was lower in the youngest age group (p = .002) and for patients in cardiac arrest (p < .001). Conclusions Emergency endotracheal intubation of children is successfully performed by a physician staffed HEMS unit even though these procedures are rare. To improve the care, emphasis should be on airway management of infants and patients in cardiac arrest.Peer reviewe

Why do infants need out-of-hospital emergency medical services? A retrospective, population-based study

BackgroundThe challenges encountered in emergency medical services (EMS) contacts with children are likely most pronounced in infants, but little is known about their out-of-hospital care. Our primary aim was to describe the characteristics of EMS contacts with infants. The secondary aims were to examine the symptom-based dispatch system for nonverbal infants, and to observe the association of unfavorable patient outcomes with patient and EMS mission characteristics.MethodsIn a population-based 5-year retrospective cohort of all 1712 EMS responses for infants (agePeer reviewe

A potential method of identifying stroke and other intracranial lesions in a prehospital setting

Background Identifying stroke and other intracranial lesions in patients with a decreased level of consciousness may be challenging in prehospital settings. Our objective was to investigate whether the combination of systolic blood pressure, heart rate and age could be used to identify intracranial lesions. Methods We conducted a retrospective case-control study including patients with a decreased level of consciousness who had their airway secured during prehospital care. Patients with intracranial lesions were identified based on the final diagnoses at the end of hospitalization. We investigated the ability of systolic blood pressure, heart rate and age to identify intracranial lesions and derived a decision instrument. Results Of 425 patients, 127 had an intracranial lesion. Patients with a lesion were characterized by higher systolic blood pressure, lower heart rate and higher age (P = 140 mmHg had an odds ratio (OR) of 3.5 (95% confidence interval [CI] 1.7 to 7.0), and > 170 mmHg had an OR of 8.2 (95% CI 4.5-15.32) for an intracranial lesion (reference: = 100). Age 50-70 had an OR of 4.1 (95% CI 2.0 to 9.0), and > 70 years had an OR of 10.2 (95% CI 4.8 to 23.2), reference: <50. Logarithms of ORs were rounded to the nearest integer to create a score with 0-2 points for age and blood pressure and 0-1 for heart rate, with an increasing risk for an intracranial lesion with higher scores. The area under the receiver operating characteristics curve for the instrument was 0.810 (95% CI 0.850-0.890). Conclusions An instrument combining systolic blood pressure, heart rate and age may help identify stroke and other intracranial lesions in patients with a decreased level of consciousness in prehospital settings.Peer reviewe

A potential method of identifying stroke and other intracranial lesions in a prehospital setting

Background Identifying stroke and other intracranial lesions in patients with a decreased level of consciousness may be challenging in prehospital settings. Our objective was to investigate whether the combination of systolic blood pressure, heart rate and age could be used to identify intracranial lesions. Methods We conducted a retrospective case-control study including patients with a decreased level of consciousness who had their airway secured during prehospital care. Patients with intracranial lesions were identified based on the final diagnoses at the end of hospitalization. We investigated the ability of systolic blood pressure, heart rate and age to identify intracranial lesions and derived a decision instrument. Results Of 425 patients, 127 had an intracranial lesion. Patients with a lesion were characterized by higher systolic blood pressure, lower heart rate and higher age (P = 140 mmHg had an odds ratio (OR) of 3.5 (95% confidence interval [CI] 1.7 to 7.0), and > 170 mmHg had an OR of 8.2 (95% CI 4.5-15.32) for an intracranial lesion (reference: = 100). Age 50-70 had an OR of 4.1 (95% CI 2.0 to 9.0), and > 70 years had an OR of 10.2 (95% CI 4.8 to 23.2), reference: <50. Logarithms of ORs were rounded to the nearest integer to create a score with 0-2 points for age and blood pressure and 0-1 for heart rate, with an increasing risk for an intracranial lesion with higher scores. The area under the receiver operating characteristics curve for the instrument was 0.810 (95% CI 0.850-0.890). Conclusions An instrument combining systolic blood pressure, heart rate and age may help identify stroke and other intracranial lesions in patients with a decreased level of consciousness in prehospital settings.Peer reviewe

Outcomes in children evaluated but not transported by ambulance personnel: Retrospective cohort study

Peer reviewe

Validation of Score to Detect Intracranial Lesions in Unconscious Patients in Prehospital Setting

Objectives: Recognizing stroke and other intracranial pathologies in prehospital phase facilitates prompt recanalization and other specific care. Recognizing these can be difficult in patients with decreased level of consciousness. We previously derived a scoring system combining systolic blood pressure, age and heart rate to recognize patients with intracranial pathology. In this study we aimed to validate the score in a larger, separate population. Materials and methods: We conducted a register based retrospective study on patients >= 16 years old and Glasgow Coma ScorePeer reviewe

Ilmaa hapen sijasta - tunnistatko never event -ilmiön?

Potilasturvallisuus.Lisähappea tarvitsevan potilaan hapenantolaitteen yhdistäminen ilmavirtausmittariin on estettävissä oleva vaaratapahtuma. Kuvatussa tapauksessa tilanne toistui suuressa erikoissairaanhoidon organisaatiossa laskennallisesti yli kolme kertaa kuukaudessa