ALS vs. BLS for Trauma

Background: Advanced Life Support (ALS) is regarded to be associated with improved survival in pre-hospital trauma care when compared to Basic Life Support (BLS) irrespective of lack of evidence. The aim of this study is to ascertain ALS improves survival for trauma in prehospital settings when compared to BLS. Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for published controlled trials (CTs), and observational studies that were published until Aug 2017. The population of interest were adults (>18 years old) trauma patients who were transported by ground transportation and required resuscitation in prehospital settings. We compared outcomes between the ALS and BLS groups. The primary outcome was in-hospital mortality and secondary outcomes were neurological outcome and time spent on scene. Results: We identified 2,502 studies from various databases and 10 studies were included in the analysis (two CTs, and eight observational studies). The outcomes were not statistically significant between the ALS and BLS groups (pooled OR 1.14; 95% CI 0.95 to 1.36 for mortality, pooled OR 1.12; 95% CI 0.88 to 1.42 for good neurological outcomes, pooled mean difference −0.96; 95% CI−6.64 to 4.72 for on-scene time) in CTs. In observational studies, ALS prolonged on-scene time and increased mortality (pooled OR 1.56; 95% CI: 1.31 to 1.86 for mortality, and pooled mean difference, 1.26; 95% CI: 0.07 to 2.45 for on-scene time). Conclusions: In prehospital settings, the present study showed no advantages of ALS on the outcomes in patients with trauma compared to BLS

Effectiveness of a hybrid emergency room system in the management of acute ischemic stroke: a single-center experience

IntroductionHybrid emergency room systems (HERSs) have shown promise for the management of severe trauma by reducing mortality. However, the effectiveness of HERSs in the treatment of acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate the impact of HERSs on treatment duration and neurological outcomes in patients with AIS undergoing endovascular therapy.Materials and methodsThis single-center retrospective study included 83 patients with AIS who were directly transported to our emergency department and underwent endovascular treatment between June 2017 and December 2023. Patients were divided into the HERS and conventional groups based on the utilization of HERSs. The primary outcome was the proportion of patients achieving a favorable neurological outcome (modified Rankin Scale score 0–2) at 30 days. The secondary outcomes included door-to-puncture and door-to-recanalization times. Univariate analysis was performed using the Mann–Whitney U test for continuous variables and the chi-squared test or Fisher’s exact test for categorical variables, as appropriate.ResultsOf the 83 eligible patients, 50 (60.2%) were assigned to the HERS group and 33 (39.8%) to the conventional group. The median door-to-puncture time was significantly shorter in the HERS group than in the conventional group (99.5 vs. 131 min; p = 0.001). Similarly, the median door-to-recanalization time was significantly shorter in the HERS group (162.5 vs. 201.5 min, p = 0.018). Favorable neurological outcomes were achieved in 16/50 (32.0%) patients in the HERS group and 6/33 (18.2%) in the conventional group. The HERS and conventional groups showed no significant difference in the proportion of patients achieving favorable neurological outcomes (p = 0.21).ConclusionImplementation of the HERS significantly reduced the door-to-puncture and door-to-recanalization times in patients with AIS undergoing endovascular therapy. Despite these reductions in treatment duration, no significant improvement in neurological outcomes was observed. Further research is required to optimize patient selection and treatment strategies to maximize the benefits of the HERS in AIS management

Association between rapid serum sodium correction and rhabdomyolysis in water intoxication: a retrospective cohort study

Abstract Background Patients with water intoxication may develop rhabdomyolysis. Existing studies suggest a relationship between the serum sodium correction rate and rhabdomyolysis. The aim of the present study was to determine the association between the sodium correction rate and rhabdomyolysis in patients with water intoxication. Methods Medical records from all cases of water intoxication presenting to the emergency department and admitted to a single tertiary emergency hospital between September 2012 and August 2016 were examined retrospectively. Serum sodium correction rate was defined as the difference in serum sodium levels at admission and approximately 24 h after admission, divided by time. The primary outcome was rhabdomyolysis, defined as peak creatine kinase level ≥ 1500 IU/L. Logistic regression analysis was used to calculate the adjusted odds ratio of the serum sodium correction rate controlling for age, sex, convulsion, lying down for >8 h before admission to the emergency department, and serum sodium level on admission. Results A total of 56 cases of water intoxication were included in the study. The median serum sodium correction rate was 1.02 mEq/L/h, and 32 patients (62.5%) had rhabdomyolysis. Logistic regression analysis showed that serum sodium correction rate was an independent risk factor of rhabdomyolysis (adjusted odds ratio, 1.53 per 0.1 mEq/L/h; 95% confidence interval, 1.18–1.97). Conclusions Rapid correction of serum sodium was associated with rhabdomyolysis in patients with water intoxication. Therefore, strict control of serum sodium levels might be needed in such patients

Decreasing skeletal muscle as a risk factor for mortality in elderly patients with sepsis: a retrospective cohort study

Abstract Background Older patients account for the majority of patients with sepsis. The objective of this study was to determine if decreased skeletal muscle mass is associated with outcomes in elderly patients with sepsis. Methods Patients (60\ua0years and older) who were admitted to a tertiary medical center intensive care unit with a primary diagnosis of sepsis between January 2012 and February 2016 were included. Patients who had not undergone abdominal computed tomography on the day of admission, had cardiopulmonary arrest on arrival, or had iliopsoas abscess were excluded from the analyses. Cross-sectional muscle area at the 3rd lumber vertebra was quantified, and the relation to in-hospital mortality was analyzed. Multivariable logistic regression analysis that included sex and APACHE II score as explanatory variables was performed. The optimal cutoff value to define decreased muscle mass (sarcopenia) was calculated using receiver operating characteristic curve analysis, and the odds ratio for in-hospital mortality was determined. Results There were 150 elderly patients with sepsis (median age, 75\ua0years) enrolled; in-hospital mortality and median APACHE II score were 38.7 and 24%, respectively. The skeletal muscle area of deceased patients was significantly lower than that of the survival group ( P \u2009<\u20090.001). The multivariable logistic regression analysis demonstrated that decreased muscle mass was significantly associated with increased mortality (odds ratio\u2009=\u20090.94, 95% confidence interval\u2009=\u20090.90 to 0.97, P \u2009<\u20090.001). The optimal cutoff value of skeletal muscle area to predict in-hospital mortality was 45.2\ua0cm 2 for men and 39.0\ua0cm 2 for women. With these cutoff values, the adjusted odds ratio for decreased muscle area was 3.27 (95% CI, 1.61 to 6.63, P \u2009=\u20090.001). Conclusions Less skeletal muscle mass is associated with higher in-hospital mortality in elderly patients with sepsis. The results of this study suggest that identifying patients with low muscularity contributes to better stratification in this population

Neurological outcomes and duration from cardiac arrest to the initiation of extracorporeal membrane oxygenation in patients with out-of-hospital cardiac arrest: a retrospective study

Abstract Background We investigated the relationship between neurological outcomes and duration from cardiac arrest (CA) to the initiation of extracorporeal membrane oxygenation (ECMO) (CA-to-ECMO) in patients with out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) and determined the ideal time at which ECPR should be performed. Methods During the time period in which this study was conducted, 3451 patients experienced OHCA. This study finally included 79 patients aged 18 years or older whose OHCA had been witnessed and who underwent ECPR in the emergency room between January 2011 and December 2015. Our primary endpoint was survival to hospital discharge with good neurological outcomes (a cerebral performance category of 1 or 2). Results Of the 79 patients included, 11 had good neurological outcomes. The median duration from CA-to-ECMO was significantly shorter in the good neurological outcome group (33 min, interquartile range [IQR], 27–50 vs. 46 min, IQR, 42–56: p = 0.03). After controlling for potential confounders, we found that the adjusted odds ratio of CA-to-ECMO time for a good neurological outcome was 0.92 (95% confidence interval: 0.87–0.98, p = 0.007). The area under the receiver operating characteristic curve of CA-to-ECMO for predicting a good neurological outcome was 0.71, and the optimal CA-to-ECMO cutoff time was 40 min. The dynamic probability of survival with good neurological outcomes based on CA-to-ECMO time showed that the survival rate with good neurological outcome decreased abruptly from over 30% to approximately 15% when the CA-to-ECMO time exceeded 40 min. Discussion In this study, CA-to-ECMO time was significantly shorter among patients with good neurological outcomes, and significantly associated with good neurological outcomes at hospital discharge. In addition, the probability of survival with good neurological outcome decreased when the CA-to-ECMO time exceeded 40 minutes. The indication for ECPR for patients with OHCA should include several factors. However, the duration of CPR before the initiation of ECMO is a key factor and an independent factor for good neurological outcomes in patients with OHCA treated with ECPR. Therefore, the upper limit of CA-to-ECMO time should be inevitably included in the indication for ECPR for patients with OHCA. In the present study, there was a large difference in the rate of survival to hospital discharge with good neurological outcome between the patients with a CA-to-ECMO time within 40 minutes and those whose time was over 40 minutes. Based on the present study, the time limit of the duration of CPR before the initiation of ECMO might be around 40 minutes. We should consider ECPR in patients with OHCA if they are relatively young, have a witness and no terminal disease, and the initiation of ECMO is presumed to be within this time period. Conclusions The duration from CA-to-ECMO was significantly associated with good neurological outcomes. The indication for patients with OHCA should include a criterion for the ideal time to initiate ECPR

Association between sub-phenotypes identified using latent class analysis and neurological outcomes in patients with out-of-hospital cardiac arrest in Japan

Abstract Background In patients who experience out-of-hospital cardiac arrest (OHCA), it is important to assess the association of sub-phenotypes identified by latent class analysis (LCA) using pre-hospital prognostic factors and factors measurable immediately after hospital arrival with neurological outcomes at 30 days, which would aid in making treatment decisions. Methods This study retrospectively analyzed data obtained from the Japanese OHCA registry between June 2014 and December 2019. The registry included a complete set of data on adult patients with OHCA, which was used in the LCA. The association between the sub-phenotypes and 30-day survival with favorable neurological outcomes was investigated. Furthermore, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by multivariate logistic regression analysis using in-hospital data as covariates. Results A total of, 22,261 adult patients who experienced OHCA were classified into three sub-phenotypes. The factor with the highest discriminative power upon patient’s arrival was Glasgow Coma Scale followed by partial pressure of oxygen. Thirty-day survival with favorable neurological outcome as the primary outcome was evident in 66.0% participants in Group 1, 5.2% in Group 2, and 0.5% in Group 3. The 30-day survival rates were 80.6%, 11.8%, and 1.3% in groups 1, 2, and 3, respectively. Logistic regression analysis revealed that the ORs (95% CI) for 30-day survival with favorable neurological outcomes were 137.1 (99.4–192.2) for Group 1 and 4.59 (3.46–6.23) for Group 2 in comparison to Group 3. For 30-day survival, the ORs (95%CI) were 161.7 (124.2–212.1) for Group 1 and 5.78 (4.78–7.04) for Group 2, compared to Group 3. Conclusions This study identified three sub-phenotypes based on the prognostic factors available immediately after hospital arrival that could predict neurological outcomes and be useful in determining the treatment strategy of patients experiencing OHCA upon their arrival at the hospital

Clinical parameter‐guided initial resuscitation in adult patients with septic shock: A systematic review and network meta‐analysis

Abstract Aim To identify the most useful tissue perfusion parameter for initial resuscitation in sepsis/septic shock adults using a network meta‐analysis. Methods We searched major databases until December 2022 for randomized trials comparing four tissue perfusion parameters or against usual care. The primary outcome was short‐term mortality up to 90 days. The Confidence in Network Meta‐Analysis web application was used to assess the quality of evidence. Results Seventeen trials were identified. Lactate‐guided therapy (risk ratios, 0.59; 95% confidence intervals [0.45–0.76]; high certainty) and capillary refill time‐guided therapy (risk ratios, 0.53; 95% confidence intervals [0.33–0.86]; high certainty) were significantly associated with lower short‐term mortality compared with usual care, whereas central venous oxygen saturation‐guided therapy (risk ratio, 1.50; 95% confidence intervals [1.16–1.94]; moderate certainty) increased the risk of short‐term mortality compared with lactate‐guided therapy. Conclusions Lactate or capillary refill time‐guided initial resuscitation for sepsis/septic shock patients may decrease short‐term mortality. More research is essential to personalize and optimize treatment strategies for septic shock resuscitation

Additional file 1: Figure S1. of Effect of ultrasonography and fluoroscopic guidance on the incidence of complications of cannulation in extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a retrospective observational study

Cannulation method details of the comparison and exposure group. (PDF 8931 kb

Additional file 1 of Comparison of the effects of lidocaine and amiodarone for out-of-hospital cardiac arrest patients with shockable rhythms: a retrospective observational study from a multicenter registry

Additional file 1: e-Table 1. STROBE Statement—checklist of items that should be included in reports of observational studies

Additional file 2 of Comparison of the effects of lidocaine and amiodarone for out-of-hospital cardiac arrest patients with shockable rhythms: a retrospective observational study from a multicenter registry

Additional file 2: e-Table 2. List of ethics committee of participating institutions of Japanese Association for Acute Medicine- out-of-hospital cardiac arrest registry