Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions

Emergency care in Belgium

Problems and objectives: Europe encompasses not only fifty or more different languages and cultures, but also a similar number of different systems of healthcare and medical practice. Each country has different medical traditions, different systems of professional registration and differing lists of medical specialties. Methodology: Literature, Report of The European Observatory on Health Systems, as well as World Health Organization health statistics analysis Results and conclusions: In this chapter, the Belgian healthcare system will be discussed, as well as the area of emergency medicine, which is currently recognized as an independent specialty. The different stakeholders in emergency medicine will also be discussed in this chapter, and their qualifications and responsibilities will be presented

The influence of targeted temperature management on the pharmacokinetics of drugs administered during and after cardiac arrest : a systematic review

Objective: Pharmacokinetic parameters of drugs are widely investigated under normothermic conditions and normal hemodynamic parameters. The European Resuscitation Council recommends the use of targeted temperature management (TTM) with a target temperature of 34 degrees C in cardiac arrest (CA) patients. The aim of this literature review is to investigate the influence of CA combined with TTM on the pharmacokinetics of drugs. Results of preclinical and clinical studies are compared with each other. Only the most important drugs, administered during CA in emergency setting, were studied. Methods: A literature search was conducted within PubMed and Google Scholar. The search terms included 'therapeutic hypothermia', 'TTM', 'drug metabolism', 'pharmacokinetics during hypothermia', 'cardiac arrest/etiology'. In Pubmed, MeSH-terms were also included: 'myocardial infarction/therapy', 'heart arrest/complications' and 'hypothermia'. To search for preclinical studies: the search terms 'pigs' and 'swine' were used. After the primary shift of relevant findings, further articles were found through references of these (snowballing method), as well as through related articles as suggested by the databases. Results: Due to the reduced cardiac output during TTM, most of the distribution volume (V-D) of drugs included in this literature study is decreased. Only the V-D of chlorzoxazone in CA rats and midazolam in non-CA patients are significantly increased during respectively deep and mild hypothermia. The renal, hepatic and biliary clearance of drugs administered during CA/TTM/hypothermia are decreased. Discussion: The combination of a decreased V-D and a decrease in the metabolization/excretion of drugs during CA/TTM result in higher plasma concentrations compared to the plasma concentrations during CA without TTM

Blood lactate and lactate kinetics as treatment and prognosis markers for tissue hypoperfusion

Objective: Blood lactate concentration (L) and lactate kinetic (LK) over time might be a helpful marker of the shock severity. The purpose of this study is to analyze whether the L and LK could correlate with the outcome and the therapy of patients with different types of shock. Methods: Design: A 3.5-year retrospective observational study. Patients: Eighteen years of age or older, diagnosed with shock were included. Arterial L measurements were performed upon admission and approximatively 3 and 6 h later. The evolution of lactate over this period of time was correlated with the outcome and therapy. Interventions: Univariate and multivariable statistical tests were performed to examine the relation between the initial L/LK and the in-hospital mortality, total mortality, length of stay (LOS), the LOS at the intensive care unit and the administered therapy. The optimal cut-off point of the LK over time to predict the mortality was calculated. Results: The initial L and the 6 h LK were significantly associated with the outcome. The higher the initial L and lower the LK, the higher the risk of mortality in the hospital or within 6 months. Moreover, the higher the initial L and lower the 6 h LK, the longer was the LOS. A relation between the initial L/LK and the required therapy was found. The optimal cut-off for the 6-h LK is 38.1%. Patients with a 6 h LK >38.1% had a significantly higher chance of survival. Conclusions: A significant relationship between the L/6-h LK and the outcome and treatment was found. The optimal survival cut-off point of 6 h LK in our study was 38.1%

Resuscitative mild hypothermia as a protective tool in brain damage : is there evidence?

Resuscitative mild hypothermia is and will increasingly be used in the emergency department as protection for the brain after an ischaemic insult. The clinical application of resuscitative mild hypothermia and its limitations will be summarized in this paper. The evidence for each application and its underlying mechanism will also be reviewed. (C) 2004 Lippincott Williams & Wilkins

Combination of therapeutic hypothermia and other neuroprotective strategies after an ischemic cerebral insult

Abrupt deprivation of substrates to neuronal tissue triggers a number of pathological events (the “ischemic cascade”) that lead to cell death. As this is a process of delayed neuronal cell death and not an instantaneous event, several pharmacological and non-pharmacological strategies have been developed to attenuate or block this cascade. The most promising neuroprotectant so far is therapeutic hypothermia and its beneficial effects have inspired researchers to further improve its protective benefit by combining it with other neuroprotective agents. This review provides an overview of all neuroprotective strategies that have been combined with therapeutic hypothermia in rodent models of focal cerebral ischemia. A distinction is made between drugs interrupting only one event of the ischemic cascade from those mitigating different pathways and having multimodal effects. Also the combination of therapeutic hypothermia with hemicraniectomy, gene therapy and protein therapy is briefly discussed. Furthermore, those combinations that have been studied in a clinical setting are also reviewed

The impact of burn-out on emergency physicians and emergency medicine residents : a systematic review

Objective: In this systematic review we explored the different aspects of burnout in emergency medicine physicians and residents. We also investigated the possible solutions for this frequent burden. Design: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Data sources: Search terms such as (Burnout OR Burn-out OR 'Burn out') AND ('physicians'[MeSH Terms] OR 'physicians' OR 'physician'*) were utilised to identify studies investigating burnout in emergency physicians and emergency medicine residents. We used four electronic databases (MEDLINE (via the PubMed interface), PsycINFO, Embase (via embas.com interface)), in combination with a manual search amongst reference lists of eligible articles. Results: A total of eleven eligible studies were reviewed. Out of these, 7 and 4 were, respectively, conducted among emergency physicians and emergency medicine residents. The prevalence of burnout varies between 25,4 and 71,4% and between 55,6% and 77,9% in, respectively, emergency physicians and emergency medicine residents. In 82% of the studies Maslach Burnout Inventory (MBI) was used to estimate this prevalence, while 18% used other methods. The trigger factors for developing burnout in emergency medicine physicians and residents are plural and divers. Conclusions: A wide variety in the burnout prevalence was found in emergency physicians and emergency medicine residents. A non-patient-related problem (such as large administrative tasks) as well as human relations issues were reported as a trigger factor for burnout. Tackling these issues could lead to a breakthrough in the prevention and treatment for burnout