Remote Ischemic Conditioning in Emergency Medicine—Clinical Frontiers and Research Opportunities

Time-critical acute ischemic conditions such as ST-elevation myocardial infarction and acute ischemic stroke are staples in Emergency Medicine practice. While timely reperfusion therapy is a priority, the resultant acute ischemia/reperfusion injury contributes to significant mortality and morbidity. Among therapeutics targeting ischemia/reperfusion injury (IRI), remote ischemic conditioning (RIC) has emerged as the most promising.RIC, which consists of repetitive inflation and deflation of a pneumatic cuff on a limb, was first demonstrated to have protective effect on IRI through various neural and humoral mechanisms. Its attractiveness stems from its simplicity, low-cost, safety, and efficacy, while at the same time it does not impede reperfusion treatment. There is now good evidence for RIC as an effective adjunct to reperfusion in ST-elevation myocardial infarction patients for improving clinical outcomes. For other applications such as acute ischemic stroke, subarachnoid hemorrhage, traumatic brain injury, cardiac arrest, and spinal injury, there is varying level of evidence.This review aims to describe the RIC phenomenon, briefly recount its historical development, and appraise the experimental and clinical evidence for RIC in selected emergency conditions. Finally, it describes the practical issues with RIC clinical application and research in Emergency Medicine

Time-Stratified Case Crossover Study of the Association of Outdoor Ambient Air Pollution With the Risk of Acute Myocardial Infarction in the Context of Seasonal Exposure to the Southeast Asian Haze Problem

Background-—Prior studies have demonstrated the association of air pollution with cardiovascular deaths. Singapore experiences seasonal transboundary haze. We investigated the association between air pollution and acute myocardial infarction (AMI) incidence in Singapore. Methods and Results-—We performed a time-stratified case-crossover study on all AMI cases in the Singapore Myocardial Infarction Registry (2010–2015). Exposure on days where AMI occurred (case days) were compared with the exposure on days where AMI did not occur (control days). Control days were chosen on the same day of the week earlier and later in the same month and year. We fitted conditional Poisson regression models to daily AMI incidence to include confounders such as ambient temperature, rainfall, wind-speed, and Pollutant Standards Index. We assessed relationships between AMI incidence and Pollutant Standards Index in the entire cohort and subgroups of individual-level characteristics. There were 53 948 cases. Each 30-unit increase in Pollutant Standards Index was association with AMI incidence (incidence risk ratio [IRR] 1.04, 95% CI 1.03–1.06). In the subgroup of ST-segment–elevation myocardial infarction the IRR was 1.00, 95% CI 0.98 to 1.03, while for non–ST-segment– elevation myocardial infarction, the IRR was 1.08, 95% CI 1.05 to 1.10. Subgroup analyses showed generally significant. Moderate/ unhealthy Pollutant Standards Index showed association with AMI occurrence with IRR 1.08, 95% CI 1.05 to 1.11 and IRR 1.09, 95% CI 1.01 to 1.18, respectively. Excess risk remained elevated through the day of exposure and for >2 years after. Conclusions-—We found an effect of short-term air pollution on AMI incidence, especially non–ST-segment–elevation myocardial infarction and inpatient AMI. These findings have public health implications for primary prevention and emergency health services during haze

Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial

BACKGROUND: Cardiac arrests are handled by teams rather than by individual health-care workers. Recent investigations demonstrate that adherence to CPR guidelines can be less than optimal, that deviations from treatment algorithms are associated with lower survival rates, and that deficits in performance are associated with shortcomings in the process of team-building. The aim of this study was to explore and quantify the effects of ad-hoc team-building on the adherence to the algorithms of CPR among two types of physicians that play an important role as first responders during CPR: general practitioners and hospital physicians. METHODS: To unmask team-building this prospective randomised study compared the performance of preformed teams, i.e. teams that had undergone their process of team-building prior to the onset of a cardiac arrest, with that of teams that had to form ad-hoc during the cardiac arrest. 50 teams consisting of three general practitioners each and 50 teams consisting of three hospital physicians each, were randomised to two different versions of a simulated witnessed cardiac arrest: the arrest occurred either in the presence of only one physician while the remaining two physicians were summoned to help ("ad-hoc"), or it occurred in the presence of all three physicians ("preformed"). All scenarios were videotaped and performance was analysed post-hoc by two independent observers. RESULTS: Compared to preformed teams, ad-hoc forming teams had less hands-on time during the first 180 seconds of the arrest (93 +/- 37 vs. 124 +/- 33 sec, P > 0.0001), delayed their first defibrillation (67 +/- 42 vs. 107 +/- 46 sec, P > 0.0001), and made less leadership statements (15 +/- 5 vs. 21 +/- 6, P > 0.0001). CONCLUSION: Hands-on time and time to defibrillation, two performance markers of CPR with a proven relevance for medical outcome, are negatively affected by shortcomings in the process of ad-hoc team-building and particularly deficits in leadership. Team-building has thus to be regarded as an additional task imposed on teams forming ad-hoc during CPR. All physicians should be aware that early structuring of the own team is a prerequisite for timely and effective execution of CPR

Meeting today's healthcare needs: Medicine at the interface

10.47102/annals-acadmedsg.2022196Annals of the Academy of Medicine, Singapore5112787-79

ST-segment elevation myocardial infarction with non-chest pain presentation at the Emergency Department: Insights from the Singapore Myocardial Infarction Registry

ST-segment elevation myocardial infarction (STEMI) often presents acutely at the Emergency Department (ED). Although chest pain is a classical symptom, a significant proportion of patients do not present with chest pain. The impact of a non-chest pain (NCP) presentation on ED processes-of-care and outcomes is not fully understood. We utilised a national registry to characterise predictors, processes-of-care, and outcomes of NCP STEMI presentations. Retrospective data for all STEMI cases occurring between 2010 and 2012 were analysed from the Singapore Myocardial Infarction Registry. Cases of inpatient onset, inter-facility transfers, and out-of-hospital cardiac arrests were excluded. Univariable analysis of demographic, clinical, processes-of-care, and outcome variables was conducted. Multivariable logistic regression ascertained independent predictors of a NCP presentation and 28-day mortality. Of 4667 STEMI cases, 12.9% presented without chest pain. Patients with NCP presentation were older (median, years = 74 vs. 58; p < 0.001), more likely to be female (39.1% vs. 15.7%; p < 0.001), of the Chinese race (72.5% vs. 62.7%; p < 0.001), and with diabetes (48.6% vs. 36.7%; p < 0.001). These patients were more likely to present with syncope (6.0% vs. 1.9%; p < 0.001) or epigastric pain (10.6% vs. 4.9%; p < 0.001). Patients with NCP presentation were less likely to receive percutaneous coronary intervention (27.0% vs. 75.6%; p < 0.001), had longer door-to-balloon time (median, minutes = 83 vs. 63; p < 0.001), and experienced greater mortality at 28 days (31.2% vs. 4.5%; p < 0.001). On multivariable logistic regression, independent predictors of a NCP presentation included age (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] 1.04–1.07), diabetes (aOR = 1.76, 95% CI 1.40–2.19), BMI (aOR = 0.93, 95% CI 0.91–0.96), and dyslipidemia (aOR = 0.73, 95% CI 0.58–0.91). Absence of chest pain was an independent predictor for 28-day mortality (aOR = 3.46, 95% CI 2.64–4.52). Patients who presented with a NCP STEMI had a distinct clinical profile and experienced poorer outcomes. Routine triage ECG could be considered for patients with high-risk factors and non-classical symptoms