Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance

Objective: Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance. Methods: This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturatio

The James Webb Space Telescope Mission

Twenty-six years ago a small committee report, building on earlier studies, expounded a compelling and poetic vision for the future of astronomy, calling for an infrared-optimized space telescope with an aperture of at least $4m$. With the support of their governments in the US, Europe, and Canada, 20,000 people realized that vision as the $6.5m$ James Webb Space Telescope. A generation of astronomers will celebrate their accomplishments for the life of the mission, potentially as long as 20 years, and beyond. This report and the scientific discoveries that follow are extended thank-you notes to the 20,000 team members. The telescope is working perfectly, with much better image quality than expected. In this and accompanying papers, we give a brief history, describe the observatory, outline its objectives and current observing program, and discuss the inventions and people who made it possible. We cite detailed reports on the design and the measured performance on orbit.Comment: Accepted by PASP for the special issue on The James Webb Space Telescope Overview, 29 pages, 4 figure

Spatiotemporal variation in the risk of out-of-hospital cardiac arrests in Queensland, Australia

BACKGROUND: Spatiotemporal analysis of out-of-hospital cardiac arrest (OHCA) risk is essential to design targeted public health strategies. Such information is lacking in the state of Queensland and Australia more broadly.METHODS: We developed a spatiotemporal Bayesian model accounting for spatial and temporal dimensions, space-time interactions, and demographic factors. The model was fit to data of all OHCA cases attended by paramedics in Queensland between January 2007 and December 2019. Parameter inference was performed using the integrated nested Laplace approximation method. We estimated and thematically mapped area-year risk of OHCA occurrence for all 78 local government areas (LGAs) in Queensland.RESULTS: We observed spatial variability in OHCA risk among the LGAs. Areas in the north half of the state and two areas in the south exhibited the highest risk; whereas OHCA risk was lowest in the west and south west parts of the state. Demographic factors did not have significant impact on the heterogeneity of risk between the LGAs. An overall trend of modestly decreasing risk of OHCA was found.CONCLUSIONS: This study identified areas of high OHCA risk in Queensland, providing valuable information to guide public health policy and optimise resource allocation. Further research is needed to investigate the specifics of the areas that may explain their risk profile.</p

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest : A modelling study

Background: Extracorporeal cardiopulmonary resuscitation (E-CPR) is a method of CPR that passes the patient's blood through an extracorporeal membrane oxygenation (ECMO) device to provide mechanical haemodynamic and oxygenation support in cardiac arrest patients who are not responsive to conventional CPR (C-CPR). E-CPR is being adopted rapidly worldwide despite the absence of high quality trial data and its substantial cost. Published cost-effectiveness data for E-CPR are scarce. Methods: We developed a mathematical model to estimate the cost-effectiveness of E-CPR relative to C-CPR in adult patients with refractory out-of-hospital cardiac arrest (OHCA). The model was a combination of a decision tree for the acute treatment phase and a Markov model for long-term periods. Cost-effectiveness was evaluated from the Australian health system perspective over lifetime. Cost-effectiveness was expressed as Australian dollars (AUD, 2021 value) per quality-adjusted life year (QALY) gained. Variables were parameterised using published data. Probabilistic and univariate sensitivity analyses were performed. Results: The incremental cost-effectiveness ratio (ICER) of E-CPR was estimated to be AUD 45,716 per QALY gained over lifetime (95% uncertainty range 22,102–292,904). The cost-effectiveness of E-CPR was most sensitive to the outcome of the therapy. Conclusion: E-CPR has median ICER that is below common accepted willingness-to-pay thresholds. Local factors within the health care system need to be considered to determine the feasibility of implementing an effective E-CPR program.</p

Ambient temperatures, heatwaves and out-of-hospital cardiac arrest in Brisbane, Australia

Background: The health impacts of temperatures are gaining attention in Australia and worldwide. While a number of studies have investigated the association of temperatures with the risk of cardiovascular diseases, few examined out-of-hospital cardiac arrest (OHCA) and none have done so in Australia. This study examined the exposure–response relationship between temperatures, including heatwaves and OHCA in Brisbane, Australia. Methods: A quasi-Poisson regression model coupled with a distributed lag non-linear model was employed, using OHCA and meteorological data between 1 January 2007 and 31 December 2019. Reference temperature was chosen to be the temperature of minimum risk (21.4°C). Heatwaves were defined as daily average temperatures at or above a heat threshold (90th, 95th, 98th, 99th percentile of the yearly temperature distribution) for at least two consecutive days. Results: The effect of any temperature above the reference temperature was not statistically significant; whereas low temperatures (below reference temperature) increased OHCA risk. The effect of low temperatures was delayed for 1 day, sustained up to 3 days, peaking at 2 days following exposures. Heatwaves significantly increased OHCA risk across the operational definitions. When a threshold of 95th percentile of yearly temperature distribution was used to define heatwaves, OHCA risk increased 1.25 (95% CI 1.04 to 1.50) times. When the heat threshold for defining heatwaves increased to 99th percentile, the relative risk increased to 1.48 (1.11 to 1.96). Conclusions: Low temperatures and defined heatwaves increase OHCA risk. The findings of this study have important public health implications for mitigating strategies aimed at minimising temperature-related OHCA

Epidemiology, management and survival outcomes of adult out-of-hospital traumatic cardiac arrest due to blunt, penetrating or burn injury

BACKGROUND: Survival from out-of-hospital traumatic cardiac arrest (TCA) is poor. Regional variation exists regarding epidemiology, management and outcomes. Data on prognostic factors are scant. A better understanding of injury patterns and outcome determinants is key to identifying opportunities for survival improvement. METHODS: Included were adult (≥18 years) out-of-hospital TCA due to blunt, penetrating or burn injury, who were attended by Queensland Ambulance Service paramedics between 1 January 2007 and 31 December 2019. We compared the characteristics of patients who were pronounced dead on paramedic arrival and those receiving resuscitation from paramedics. Intra-arrest procedures were described for attempted-resuscitation patients. Survival up to 6 months postarrest was reported, and factors associated with survival were investigated. RESULTS: 3891 patients were included; 2394 (61.5%) were pronounced dead on paramedic arrival and 1497 (38.5%) received resuscitation from paramedics. Most arrests (79.8%) resulted from blunt trauma. Motor vehicle collision (42.4%) and gunshot wound (17.7%) were the most common injury mechanisms in patients pronounced dead on paramedic arrival, whereas the most prevalent mechanisms in attempted-resuscitation patients were motor vehicle (31.3%) and motorcycle (20.6%) collisions. Among attempted-resuscitation patients, rates of transport and survival to hospital handover, to hospital discharge and to 6 months were 31.9%, 15.3%, 9.8% and 9.8%, respectively. Multivariable model showed that advanced airway management (adjusted OR 1.84; 95% CI 1.06 to 3.17), intravenous access (OR 5.04; 95% CI 2.43 to 10.45) and attendance of high acuity response unit (highly trained prehospital care clinicians) (OR 2.54; 95% CI 1.25 to 5.18) were associated with improved odds of survival to hospital handover. CONCLUSIONS: By including all paramedic-attended patients, this study provides a more complete understanding of the epidemiology of out-of-hospital TCA. Contemporary survival rates from adult out-of-hospital TCA who receive resuscitation from paramedics may be higher than historically thought. Factors identified in this study as associated with survival may be useful to guide prognostication and treatment.</p

Surviving out-of-hospital cardiac arrest: the important role of bystander interventions

Background: Substantial variations exist in relation to the characteristics and outcomes of out-of-hospital cardiac arrest (OHCA). As such, an understanding of region-specific factors is essential for informing strategies to improve OHCA survival. Methods: Analysis of a large state-wide OHCA database of the Queensland Ambulance Service, Australia. Adult patients, attended by paramedics between January 2000 and December 2018 for OHCA of medical origin, where the arrest was not witnessed by paramedics, and resuscitation was attempted, were included. Factors associated with survival were investigated. The number needed to treat (NNT) for bystander interventions was estimated. Results: Across a total of 23,510 patients, event survival, survival to discharge and 30-day survival was 22.6%, 11.9% and 11.5%, respectively. The corresponding figures for the Utstein patient group (initial shockable rhythm, bystander-witnessed) were 38.9%, 27.2% and 26.3%, respectively. Bystander cardiopulmonary resuscitation (CPR) and defibrillation substantially improved the likelihood of survival. The NNT for bystander CPR was 41, 63 and 64 for event survival, survival to discharge, and 30-day survival, respectively. The NNT for bystander defibrillation for these survival outcomes was 10, 14 and 14, respectively. Conclusions: Bystander interventions are critical for OHCA survival. Effort should be invested in strategies to improve the uptake of these interventions

Epidemiology of open limb fractures attended by ambulance clinicians in the out-of-hospital setting: A retrospective analysis

Background: Open limb fractures are a time-critical orthopaedic emergency that present to jurisdictional ambulance services. This study describes the demographic characteristics and epidemiological profile of these patients. Methods: We undertook a retrospective analysis of all patients that presented to Queensland Ambulance Service with an open limb fracture (fracture to the humerus, radius/ulna, tibia/fibula or femur) over a two-year period (January 2018 – December 2019). Results: Overall, 1020 patients were included. Patients were mainly male (65.9%) and middle-aged (age 41 years, IQR 22–59). Fractures predominately occurred in the lower extremities (64.9%) with transport crashes the primary mechanism of injury (47.8%). The location of the fracture varied depending on the cause of injury, with femur fractures associated with motorcycle crashes, and fractures to the radius/ulna attributed to falls of greater than one metre (p = 0.001). The median prehospital episode of care was 83 min (IQR 62–144) with aeromedical air ambulance involvement and the attendance of a critical care paramedic or emergency physician, both independent factors that increased this time interval. Conclusion: Open limb fractures are a relatively infrequent injury presentation encountered by ambulance clinicians. The characteristics of these patients is consistent with previously described national and international out-of-hospital trauma cohort

Epidemiology of Oxytocin Administration in Out-of-Hospital Births Attended by Paramedics

Aim: Primary postpartum hemorrhage (PPH) is a life-threatening obstetric emergency that can be mitigated through the administration of a uterotonic to actively manage the third stage of labor. This study describes the prehospital administration of oxytocin by paramedics following attendance of out-of-hospital (OOH) births. Methods: A retrospective analysis was undertaken of all OOH births between the 1st January 2018 and 31st December 2018 attended by the Queensland Ambulance Service. The demographic and epidemiological characteristics of patients that were administered oxytocin and the occurrence of adverse side effects were described. Results: In total, 350 OOH births were included in this study with the majority involving multigravidas women (94.3%) and all but two involving singleton pregnancies. Oxytocin was administered following 222 births (63.4%), while 67 patients (19.1%) declined administration preferring a physiological third stage of labor, and in 61 cases (17.4%) oxytocin was withheld by the attending paramedic. There were no documented adverse events or side effects following administration. Oxytocin administration occurred on average 14 minutes (interquartile range 9-25) following the time of birth. The median time from oxytocin administration to placenta delivery was 10 minutes (interquartile range 5-22). Conclusion: Oxytocin is well accepted and safe treatment adjunct for the management of the third stage of labor in OOH births and should be considered for routine practice by other emergency medical services.</p

Prehospital study of survival outcomes from out-of-hospital cardiac arrest in ST-elevation myocardial infarction in Queensland, Australia (the PRAISE study)

AimPatients that experience an out-of-hospital cardiac arrest in the context of a paramedic-identified ST-segment elevation myocardial infarction are a unique cohort. This study identifies the survival outcomes and determinants of survival in these patients.MethodsA retrospective analysis was undertaken of all patients, attended between 1 January 2013 and 31 December 2017 by the Queensland Ambulance Service, who had a ST-segment elevation myocardial infarction identified by the attending paramedic prior to deterioration into out-of-hospital cardiac arrest. We described the ‘survived event’ and ‘survived to discharge’ outcomes of patients and performed univariate analysis and multivariate logistic regression to identify factors associated with survival.ResultsIn total, 287 patients were included. Overall, high rates of survival were reported, with 77% of patients surviving the initial out-of-hospital cardiac arrest event and 75% surviving to discharge. Predictors of event survival were the presence of an initial shockable rhythm (adjusted odds ratio 8.60, 95% confidence interval (CI) 4.16–17.76; P ConclusionThis subset of out-of-hospital cardiac arrest patients was found to be highly salvageable and responsive to resuscitative measures, having arrested in the presence of paramedics and presented with an identified reversible cause