Therapeutic hypothermia post out-of-hospital cardiac arrest - more questions than answers?

Nearly a decade since the introduction of therapeutic hypothermia to the ICU for cooling out-of-hospital cardiac arrest patients, key questions remain unanswered: when should cooling be initiated, how rapidly should the patient be cooled and using which device? The Time to Target Temperature study group provides important baseline data on the striking direct relationship between body temperature and survival from out-of-hospital cardiac arrest

Introducing social and sustainable enterprise: changing the nature of business

This chapter introduces the volume, Social and Sustainable Enterprise: Changing the Nature of Business, which is edited by Sarah Underwood, Richard Blundel, Fergus Lyon and Anja Schaefer. The book draws together contemporary research contributions that seek to critically explore a range of issues in the specific context of social enterprise, sustainable entrepreneurship and social responsibility. Collectively, the chapters in this volume consider the challenges facing social enterprises globally, their environmental impact and the difficulties for policy makers in their efforts to tackle complex international environmental problems. The volume contributors draw on a range of research themes, methodological approaches and international contexts to enhance our understanding of the meaning, critical nature and value of social and sustainable enterprise development. Thus, this volume speaks directly to the core objectives of this book series by providing an opportunity for the ISBE [Institute for Small Business and Entrepreneurship] community of interest to challenge current thinking and create a research agenda for future inquiry

Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma : an observational study

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.OBJECTIVES: The aim of this study is to describe the demographics of reported traumatic cardiac arrest (TCA) victims, prehospital resuscitation and survival to hospital rate. SETTING: Helicopter Emergency Medical Service (HEMS) in south-east England, covering a resident population of 4.5 million and a transient population of up to 8 million people. PARTICIPANTS: Patients reported on the initial 999 call to be in suspected traumatic cardiac arrest between 1 July 2016 and 31 December 2016 within the trust's geographical region were identified. The inclusion criteria were all cases of reported TCA on receipt of the initial emergency call. Patients were subsequently excluded if a medical cause of cardiac arrest was suspected. OUTCOME MEASURES: Patient records were analysed for actual presence of cardiac arrest, prehospital resuscitation procedures undertaken and for survival to hospital rates. RESULTS: 112 patients were reported to be in TCA on receipt of the 999/112 call. 51 (46%) were found not to be in TCA on arrival of emergency medical services. Of the 'not in TCA cohort', 34 (67%) received at least one advanced prehospital medical intervention (defined as emergency anaesthesia, thoracostomy, blood product transfusion or resuscitative thoracotomy). Of the 61 patients in actual TCA, 10 (16%) achieved return-of-spontaneous circulation. In 45 (88%) patients, the HEMS team escorted the patient to hospital. CONCLUSION: A significant proportion of patients reported to be in TCA on receipt of the emergency call are not in actual cardiac arrest but are critically unwell requiring advanced prehospital medical intervention. Early activation of an enhanced care team to a reported TCA call allows appropriate advanced resuscitation. Further research is warranted to determine which interventions contribute to improved TCA survival.Peer reviewedFinal Published versio

A novel method of non-clinical dispatch is associated with a higher rate of critical Helicopter Emergency Medical Service intervention

Background - Helicopter Emergency Medical Services (HEMS) are a scarce resource that can provide advanced emergency medical care to unwell or injured patients. Accurate tasking of HEMS is required to incidents where advanced pre-hospital clinical care is needed. We sought to evaluate any association between non-clinically trained dispatchers, following a bespoke algorithm, compared with HEMS paramedic dispatchers with respect to incidents requiring a critical HEMS intervention. Methods - Retrospective analysis of prospectively collected data from two 12-month periods was performed (Period one: 1st April 2014 – 1st April 2015; Period two: 1st April 2016 – 1st April 2017). Period 1 was a Paramedic-led dispatch process. Period 2 was a non-clinical HEMS dispatcher assisted by a bespoke algorithm. Kent, Surrey & Sussex HEMS (KSS HEMS) is tasked to approximately 2500 cases annually and operates 24/7 across south-east England. The primary outcome measure was incidence of a HEMS intervention.Results - A total of 4703 incidents were included; 2510 in period one and 2184 in period two. Variation in tasking was reduced by introducing non-clinical dispatchers. There was no difference in median time from 999 call to HEMS activation between period one and two (period one; median 7 min (IQR 4–17) vs period two; median 7 min (IQR 4–18). Non-clinical dispatch improved accuracy of HEMS tasking to a mission where a critical care intervention was required (OR 1.25, 95% CI 1.04–1.51, p = 0.02).Conclusion - The introduction of non-clinical, HEMS-specific dispatch, aided by a bespoke algorithm improved accuracy of HEMS tasking. Further research is warranted to explore where this model could be effective in other HEMS services.Peer reviewedFinal Published versio

Temperature post out-of-hospital cardiac arrest: the TOPCAT study

INTRODUCTION Out-of-hospital cardiac arrest (OHCA) is a significant cause of death and severe neurological disability in Scotland. Optimal pre-hospital resuscitation is required for the patient to achieve return of spontaneous circulation (ROSC). The only post-ROSC therapy shown to increase survival is mild therapeutic hypothermia (MTH), but its mechanism of action and optimal application are still unknown. The quality of pre-hospital resuscitation in Scotland is unmeasured. The relationship between body temperature post-OHCA, systemic inflammation, markers of brain injury and outcome are still poorly defined. This study examines two aspects of OHCA; firstly, the clinical practice of resuscitation in the pre¬ hospital and Emergency Department (ED) setting and, secondly, the post-ROSC physiological changes of body temperature, systemic inflammation and serum markers of brain injury.METHODS Prospective observational study of all OHCA patients admitted to a single centre for a 14- month period (1/08/2008 to 1/02/2010). Oesophageal temperature was measured, blood samples assayed for markers of systemic inflammation (TNF-a, IL-ip, 1L-6, IL-8, IL-10, 1L12, elastase, cell surface markers of neutrophil activation) and markers of brain injury (neuron-specific enolase [NSE], SI00b, glial fibrillary acidic protein [GFAP]) in the ED and Intensive Care Unit (ICU). Selected patients had pre-hospital temperature monitoring and blood sampling. Routine physiological variables were recorded. Patients who survived to ICU had repeat blood samples taken at 24-,48-,72- and 120-hours post-ROSC. Patients were followed up for 6-months. We conducted qualitative analysis of the effect of having a doctor on-scene at an OHCA and performed a Scottish national survey on the ED management of post-OHCA patientsRESULTS 236 OHCA patients were included in the study. 161 (68%) were pronounced dead at the scene or in the ED. 75 (32%) were admitted to ICU for cooling; 49 (21%) died in ICU and 27 (11%) survived to hospital discharge. We have characterised the natural progression of core body temperature post-OHCA. Patients who achieved ROSC and had oesophageal temperature measured pre-hospital all had temperatures below normal. Quality of pre¬ hospital resuscitation performed by ambulance crews was observed to be highly variable. Standard ED care of post-OHCA patients varied across Scotland. All patients arriving in the ED post-OHCA had a relatively low temperature (34.3°C, 95% CI 34.1-34.5). Patients surviving to hospital discharge were warmer on admission to ICU than patients who died in hospital (35.6°C vs. 34.4°C, p<0.01). Patients surviving to hospital discharge also took longer to reach target therapeutic hypothermia level than non-survivors (222 vs. 313 min, p<0.05). Cell surface markers of neutrophil activation, IL-6, IL-8, IL-10 and elastase were all significantly raised in the early post-ROSC period. The degree of cytokinaemia at 24- hours was related to survival outcome. In the context of MTH, SI00b at 24-hours was superior to NSE and GFAP at predicting in-hospital death following OHCA, with an AUCROC of 0.90 (95% CI 0.82-0.98).CONCLUSIONS The quality of pre-hospital and in-hospital resuscitation in Scotland is variable. Both prehospital and ED management of OHCA patients varied on a local and national scale.Following OHCA all patients have oesophageal temperatures below normal in the pre¬ hospital phase and on arrival in the ED. Patients who achieve ROSC following OHCA and survive to hospital discharge are warmer on arrival in ICU and take longer to reach target MTH temperatures compared to patients who die in hospital.A systemic inflammatory response occurs earlier in the post-ROSC phase than previously anticipated. SI00b is a more reliable predictor of outcome following OHCA than NSE or GFAP. The mechanisms of action underlying changes in oesophageal temperature and survival from OHCA remain unclear. This study adds to the information around oesophageal temperature post-OHCA and MTH further studies are warranted to clarify the mechanism of action of MTH post-OHCA and the role of inflammatory response in determining survival