Prehospital therapeutic hypothermia after cardiac arrest - from current concepts to a future standard

Therapeutic hypothermia has been shown to improve survival and neurological outcome after prehospital cardiac arrest. Existing experimental and clinical evidence supports the notion that delayed cooling results in lesser benefit compared to early induction of mild hypothermia soon after return of spontaneous circulation. Therefore a practical approach would be to initiate cooling already in the prehospital setting

Aetiology of in-hospital cardiac arrest on general wards

Aim: Aetiology of in-hospital cardiac arrests (IHCAs) on general wards has not been studied. We aimed to determine the underlying causes for IHCAs by the means of autopsy records and clinical judgement of the treating consultants. Furthermore, we investigated whether aetiology and preceding vital dysfunctions are associated with long-term survival. Design and setting: Prospective observational study between 2009-2011 including 279 adult IHCA patients attended by medical emergency team in a Finnish university hospital's general wards. Results: The median age of the patients was 72 (64, 80) years, 185 (66%) were male, 178 (64%) of events were monitored/witnessed, first rhythm was shockable in 42 (15%) cases and 53 (19%) patients survived six months. Aetiology was determined as cardiac in 141 events, 73 of which were due to acute myocardial infarction. There were 138 non-cardiac IHCAs; most common causes were pneumonia (39) and exsanguination (16). No statistical difference was observed in the incidence of objective vital dysfunctions preceding the event between the cardiac and non-cardiac groups (40% vs. 44%, p = 0.448). Subjective antecedents were more common in the cardiac cohort (47% vs. 32%, p = 0.022), chest pain being an example (11% vs. 0.7%, p <0.001). Reviewing all 279 IHCAs, only shockable primary rhythm, monitored/witnessed event and low comorbidity score were independently associated with 180-day survival. Conclusions: Cardiac aetiology underlies half of the IHCAs on general wards. Both objective and subjective antecedents are common. However, neither the cardiac aetiology nor the absence of preceding deterioration of vital signs were factors independently associated with a favourable outcome. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

Obstetric early warning system to predict maternal morbidity of pre-eclampsia, postpartum hemorrhage and infection after birth in high-risk women : a prospective cohort study

Objective: The purpose of early warning systems is to detect deterioration of the patient and to enable timely intervention to prevent possible severe illness. The most common causes of maternal morbidity and mortality after birth are worsening pre-eclampsia, postpartum haemorrhage and puerperal infection. Our aim was to validate the accuracy of the obstetric early warning system and different physiological triggers to predict morbidity on the postnatal ward in high-risk women. Design: A prospective cohort study. Setting: A tertiary referral hospital in Finland. Participants: High-risk women (n= 828) (body mass index > 35 kg/m(2), postpartum haemorrhage > 1,500 g, preeclampsia, chorioamnionitis during birth, type 1 diabetes or anxiety over the maternal condition based on clinical judgement) were studied on the postnatal ward in the first 24 hours after giving birth. In this study population the women without any morbidity served as a control group. The study was conducted between 1.11.2016 - 30.4. 2018 covering a period of 18 months. Measurements and findings: The accuracy of the obstetric early warning system and its five physiological parameters-respiratory rate, oxygen saturation, blood pressure, heart rate and body temperature-and a pain score to predict worsening pre-eclampsia, complications related to postpartum haemorrhage and puerperal infection were determined. A red trigger is as a single, markedly abnormal observation, and a yellow trigger is a combination of two mildly abnormal observations. The sensitivity of obstetric early warning system at its best was 72% for pre-eclampsia, 52% for infection and 25% for postpartum haemorrhage. The red triggers were significantly associated with morbidity in each outcome studied. The red triggers of systolic blood pressure (OR 25.7, 95% CI 13.2-50.1) and diastolic blood pressure (OR 22.1, 95% CI 11.3-43.0) were independently associated with pre-eclampsia, systolic blood pressure (OR 2.7, 95% CI 1.4-5.6) and heart rate (OR 3.6, 95% CI 1.7-7.6) with postpartum haemorrhage and heart rate (OR 3.3, 1.0-10.3) with infection.Keyconclusions: The sensitivity of obstetric early warning system varied depending on the type of morbidity. The highest sensitivity and positive predictive value were in pre-eclampsia. Systolic and diastolic blood pressure and heart rate were the strongest physiological parameters to predict morbidity. Implications for practice: The systematic use of obstetric early warning system helps to improve maternal safety after birth in high-risk women. Blood pressure and pulse are the most important measurements.Peer reviewe

Ability of the National Early Warning Score and its respiratory and haemodynamic subcomponents to predict short-term mortality on general wards : a prospective three-centre observational study in Finland

OBJECTIVES: To validate the ability of the National Early Warning Score (NEWS) to predict short-term mortality on hospital wards, with a special reference to the NEWS's respiratory and haemodynamic subcomponents. DESIGN: A large, 1-year, prospective, observational three-centre study. First measured vital sign datasets on general wards were prospectively collected using a mobile solution system during routine patient care. Area under receiver operator characteristic curves were constructed, and comparisons between ROC curves were conducted with Delong's test for two correlated ROC curves. SETTING: One university hospital and two regional hospitals in Finland. PARTICIPANTS: All 19 001 adult patients admitted to 45 general wards in the three hospitals over the 1-year study period. After excluding 102/19 001 patients (0.53%) with data on some vital signs missing, the final cohort consisted of 18 889 patients with full datasets. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was 1-day mortality and secondary outcomes were 2-day and 30-day mortality rates. RESULTS: Patients' median age was 70 years, 51% were male and 31% had a surgical reason for admission. The 1-day mortality was 0.36% and the 30-day mortality was 3.9%. The NEWS discriminated 1-day non-survivors with excellent accuracy (AUROC 0.91, 95% CI 0.87 to 0.95) and 30-day mortality with acceptable accuracy (0.75, 95% CI 0.73 to 0.77). The NEWS's respiratory rate component discriminated 1-day non-survivors better (0.78, 95% CI 0.72 to 0.84) as compared with the oxygen saturation (0.66, 95% CI 0.59 to 0.73), systolic blood pressure (0.65, 95% CI 0.59 to 0.72) and heart rate (0.67, 95% CI 0.61 to 0.74) subcomponents (p<0.01 in all ROC comparisons). As with the total NEWS, the discriminative performance of the individual score components decreased substantially for the 30-day mortality. CONCLUSIONS: NEWS discriminated general ward patients at risk for acute death with excellent statistical accuracy. The respiratory rate component is especially strongly associated with short-term mortality. TRIAL REGISTRATION NUMBER: NCT04055350.publishedVersionPeer reviewe

Random forest machine learning method outperforms prehospital National Early Warning Score for predicting one-day mortality : A retrospective study

Aim of the study: The National Early Warning Score (NEWS) is a validated method for predicting clinical deterioration in hospital wards, but its performance in prehospital settings remains controversial. Modern machine learning models may outperform traditional statistical analyses for predicting short-term mortality. Thus, we aimed to compare the mortality prediction accuracy of NEWS and random forest machine learning using prehospital vital signs. Methods: In this retrospective study, all electronic ambulance mission reports between 2008 and 2015 in a single EMS system were collected. Adult patients (>= 18 years) were included in the analysis. Random forest models with and without blood glucose were compared to the traditional NEWS for predicting one-day mortality. A ten-fold cross-validation method was applied to train and validate the random forest models. Results: A total of 26,458 patients were included in the study of whom 278 (1.0%) died within one day of ambulance mission. The area under the receiver operating characteristic curve for one-day mortality was 0.836 (95% CI, 0.810-0.860) for NEWS, 0.858 (95% CI, 0.832-0.883) for a random forest trained with NEWS variables only and 0.868 (0.843-0.892) for a random forest trained with NEWS variables and blood glucose. Conclusion: A random forest algorithm trained with NEWS variables was superior to traditional NEWS for predicting one-day mortality in adult prehospital patients, although the risk of selection bias must be acknowledged. The inclusion of blood glucose in the model further improved its predictive performance.Peer reviewe

External validation of the NeuroImaging Radiological Interpretation System and Helsinki computed tomography score for mortality prediction in patients with traumatic brain injury treated in the intensive care unit : a Finnish intensive care consortium study

Background Admission computed tomography (CT) scoring systems can be used to objectively quantify the severity of traumatic brain injury (TBI) and aid in outcome prediction. We aimed to externally validate the NeuroImaging Radiological Interpretation System (NIRIS) and the Helsinki CT score. In addition, we compared the prognostic performance of the NIRIS and the Helsinki CT score to the Marshall CT classification and to a clinical model. Methods We conducted a retrospective multicenter observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted in four university hospital ICUs during 2003-2013. We analyzed the CT scans using the NIRIS and the Helsinki CT score and compared the results to 6-month mortality as the primary outcome. In addition, we created a clinical model (age, Glasgow Coma Scale score, Simplified Acute Physiology Score II, presence of severe comorbidity) and combined clinical and CT models to see the added predictive impact of radiological data to conventional clinical information. We measured model performance using area under curve (AUC), Nagelkerke's R-2 statistics, and the integrated discrimination improvement (IDI). Results A total of 3031 patients were included in the analysis. The 6-month mortality was 710 patients (23.4%). Of the CT models, the Helsinki CT displayed best discrimination (AUC 0.73 vs. 0.70 for NIRIS) and explanatory variation (Nagelkerke's R-2 0.20 vs. 0.15). The clinical model displayed an AUC of 0.86 (95% CI 0.84-0.87). All CT models increased the AUC of the clinical model by + 0.01 to 0.87 (95% CI 0.85-0.88) and the IDI by 0.01-0.03. Conclusion In patients with TBI treated in the ICU, the Helsinki CT score outperformed the NIRIS for 6-month mortality prediction. In isolation, CT models offered only moderate accuracy for outcome prediction and clinical variables outweighing the CT-based predictors in terms of predictive performance.Peer reviewe

Posttraumatic epilepsy in intensive care unit–treated pediatric traumatic brain injury patients

Objective Posttraumatic epilepsy (PTE) is a well-described complication of traumatic brain injury (TBI). The majority of the available data regarding PTE stem from the adult population. Our aim was to identify the clinical and radiological risk factors associated with PTE in a pediatric TBI population treated in an intensive care unit (ICU). Methods We used the Finnish Intensive Care Consortium database to identify pediatric ( Results Of the 290 patients included in the study, 59 (20%) developed PTE. Median age was 15 years (interquartile range [IQR] 13-17), and 80% had an admission Glasgow Coma Scale (GCS) score Significance We showed that PTE is a common long-term complication after ICU-treated pediatric TBI. Higher age, moderate injury severity, obliterated suprasellar cisterns, seizures during ICU stay, and surgical treatment are associated with an increased risk of PTE. Further studies are needed to identify strategies to decrease the risk of PTE.Peer reviewe

Advising and limiting medical treatment during phone consultation : a prospective multicentre study in HEMS settings

Background We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). Methods A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. Results Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or 'not eligible for intensive care' (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. Conclusion Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.Peer reviewe