- Email: [email protected]
371 EMF Multi-organ Dysfunction after Return of Spontaneous Circulation in Post-cardiac Arrest Syndrome
Research Forum Abstracts “90cc.” The third question asked, “According to Iowa law, when can someone ride an ATV on a public road?” and the right answer being “For farming purposes.” The percentage of students with correct answers on these 3 questions pre-intervention were 52, 27 and 46% which rose to 93, 80 and 79% correct on post-exam, respectively. 44% of the participants said they were likely or very likely to use the ATV safety tips they had learned, while 36% said they were unlikely or very unlikely to do so. Conclusion: Most youth in the study demonstrated a deficiency in some ATV safety knowledge. However, our classroom educational intervention was able to increase short-term ATV safety knowledge and a significant proportion of participants felt they would use the safety information presented. Further study is needed to determine if such an intervention results in long-term knowledge acquisition and actual behavior change.
368
Off-Highway Vehicle Parks: Do Increased Regulations and Enforcement Improve All-Terrain Vehicle Safety?
Denning G, Jennissen C, Harland K, Ellis D, Buresh C/University of Iowa Carver College of Medicine, Iowa City, IA; University of Iowa Departments of Emergency Medicine and of Public Health, Iowa City, IA; University of Iowa Department Emergency Medicine, Iowa City, IA
Study Objectives: All-terrain vehicle (ATV) popularity has risen dramatically in the past 15 years and has been accompanied by an even greater increase in crashrelated deaths and injuries. The number of off-highway vehicle parks, both public and private, continues to grow to meet the recreational needs of ATV enthusiasts. These parks require users to obey all state laws, often have additional safety regulations, and in our state have personnel dedicated to enforcement of laws and regulations. Little is known about how off-highway vehicle park regulations and enforcement affects ATV user behavior and safety. The objective of this study was to determine whether there were differences in crash mechanisms and/or compliance with ATV safety laws and regulations when comparing off-road ATV crashes inside and outside state off-highway vehicle parks. Methods: Data were derived from our statewide ATV injury surveillance database (2002-2009). Descriptive analyses were performed for demographics, risk factors (eg , carrying passengers), crash mechanisms, and outcomes of injuries. Comparisons of categorical and continuous variables were performed. Results: A total of 813 injured persons were included in the final analysis; 6% of victims were from OHV park crashes. Relative to outside the parks, a smaller percentage of park victims were under the age of 6teen (7% versus 31%, p⬍0.01), a lower percentage were passengers (2.5% versus 13%, p⫽0.07), and a dramatically higher percentage were helmeted (90% versus 24%, p⬍0.0001). However, park crashes involved more jump-related injuries (34% versus 5%, p⬍0.001). Mean injury severity scores were not different between the 2 locations, but 5% of victims outside the parks had severe brain injuries (GCS ⬍8) as compared to no park victims. Conclusion: Off-highway vehicle park crashes involved more jump-related events, suggesting that additional studies of individual parks may be necessary to identify high-risk areas and to improve park safety. However, park victims exhibited better compliance with ATV safety-related laws and regulations and suffered less severe brain injury outcomes. These findings support the hypothesis that ATV safety regulations accompanied by effective enforcement promote safe behaviors that may prevent injuries.
369
Use of Ceiling Mounted Lifts With Patient Slings in the Christiana Emergency Department Considerably Reduces the Incidence of Injury Among Emergency Department and Hospital Personnel, Who Are Required to Lift and Transfer Patients
Burgess B, Burgess T, Price C, Nichols WL/Christiana Care Health Services, Newark, DE
Study Objectives: We sought to demonstrate that injuries associated with manual lifting and transferring patients in particular, low back pain, were reduced by instituting appropriate lifting equipment in the Christiana emergency department (ED). Methods: This retrospective study was completed in a level 1, suburban tertiary care teaching hospital. We compared the incidence of injury amongst ED and hospital staff depicted by “lost time injury rates” over a 2-year period (2009 - 2011). Injury rates associated with lifting and transferring patients were studied as ceiling
Volume , . : October
mounted lifts were being installed in the rooms within the Christiana ED. All patients leaving the ED for diagnostic testing or admission were placed on slings. Results: Injuries related to lifting and transferring patients decreased from 15 to 4 and lost time injury rates decreased from 2.08 to 1.55 during this timeframe. This decrease suggests that injuries to the Christiana staff were substantially reduced in co-workers within the ED and throughout the hospital when ceiling mounted lifts utilizing patient slings were initiated in the ED. This policy change led to an increased utilization of lifting equipment throughout the facility. Conclusion: Health care workers lead all occupations in the US with regards to work-related injuries, in particular low back pain. Over a 2-year period during which the ceiling-mounted lifts were utilized within the ED, a reduction of 11 injuries occurred while the lost time injury rates was decreased by 25.5%. This suggests appreciably fewer total injuries directly associated with lifting and transferring patients amongst hospital personnel. Our study supports best practices which are being implemented to promote staff and patient safety at health care facilities nationwide.
370
The PARTY Program and Distracted Driving: Beliefs and Behaviors of Teen Participants
Oberle A, Schmitter J, DeWitt P, Severyn F, Johnson R, Betz M/University of Colorado School of Medicine, Aurora, CO; University of Colorado Hospital, Aurora, CO; Colorado School of Public Health, Aurora, CO
Study Objectives: Teen drivers account for the highest proportion of distracted drivers in fatal crashes. PARTY (Prevent Alcohol and Risk-Related Trauma in Youth) is an interactive teen program with lectures, simulations and role-playing shown to reduce traumatic injuries. Classic PARTY focuses on alcohol-and drug-impaired driving, with less emphasis on other distractions. We sought to describe participant beliefs and behaviors concerning driving risks from impaired or distracted driving. Methods: Retrospective observational study of PARTY participants at an academic trauma center from August 2010 to July 2011. Sessions were free, with voluntary participation from students in the public school system. Participants completed anonymous, unmatched surveys before, immediately after, and one month after the program with the same multiple-choice questions. We used multivariable ordinal logistic regression to examine possible associations between student beliefs and behaviors with age, sex, survey version, and driver’s license status. Results: Five hundred youth aged 12-20 years (median: 16) participated; response rates were 23% (before) 61% (immediately after) and 25% (one month after). Data were collected unmatched and treated as such with 547 total responses; 56% were female and 37% were licensed drivers. Students appeared more aware of risks related to alcohol- or drug-impaired driving than from texting or talking on a phone while driving. Similarly, more teens reported “never” riding with impaired drivers than “never” talking or texting while driving. In this sample, the PARTY program did not appear to have significant positive effects on beliefs or behaviors. Conclusion: Before PARTY, teens were already aware of the dangers of alcoholor drug-impaired driving, while newer distractions such as texting and talking on a cell phone while driving were generally perceived as less likely to result in injury. This study was limited by the use of self-reported, unmatched data and low response rates. However, observed opinions related to the relative risks between distracted versus intoxicated driving and prevalence of distracted driving support the need for continued efforts to reduce all forms of impaired and distracted driving among teens.
371 EMF
Multi-organ Dysfunction after Return of Spontaneous Circulation in Post-cardiac Arrest Syndrome
Roberts BW, Kilgannon J, Trzeciak S/Cooper University Hospital, Camden, NJ
Study Objective: The 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) recommend physicians “reduce the risk of multi-organ injury and support organ function” in patients resuscitated from cardiac arrest. However, there remains a paucity of clinical data to support these current AHA guidelines. The objective of this study was to determine if extracerebral multiorgan dysfunction is associated with inhospital mortality among patients resuscitated from cardiac arrest. Methods: We performed a prospective observational study in post-cardiac arrest patients at an urban academic medical center, Cooper University Hospital in Camden, NJ. Inclusion criteria were age ⬎ 17, non-trauma cardiac arrest, and comatose after ROSC. In order to quantify the degree of extracerebral multi-organ dysfunction we calculated an initial SOFA score and 72-hour SOFA score (both
Annals of Emergency Medicine S131
Research Forum Abstracts modified to not include the cerebral component) and determined the ⌬SOFA score (ie the difference between the initial SOFA score and the 72-hour SOFA score). The primary outcome measure was inhospital mortality. We used multivariate logistic regression analysis to determine the relative strength of the ⌬SOFA score as an independent predictor of inhospital mortality after adjusting for common confounding variables (ie age, arrest location, arrest rhythm, and Charleson comorbidity score). We then added cerebral dysfunction [ie, Glasgow Coma Score (GCS) motor score ⬍ 6] to the model. Results: Two-hundred and 8 post-cardiac arrest patients were included. The ⌬SOFA score was initially found to be an independent predictor of inhospital mortality with an adjusted odds ratio of 1.21 (95% CI 1.08 - 1.35). After adjusting for cerebral dysfunction the independent association between the ⌬SOFA score and inhospital mortality was lost [odds ratio 1.10 (95% CI 0.98 - 1.25)]. Conclusion: In this sample of post-cardiac arrest patients we found that extracerebral organ dysfunction was common; however, after adjusting for cerebral dysfunction it was not an independent predictor of inhospital mortality.
372
Predictors of the Complication of Post-Intubation Hypotension During Emergency Airway Management
Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE/Carolinas Medical Center, Charlotte, NC
Study Objective: Arterial hypotension is a recognized complication of emergency intubation that is independently associated with increased morbidity and mortality. Our aim was to identify factors associated with post-intubation hypotension following emergency intubation. Methods: Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a one-year period. Patients were included if they were ⬎17 years old and had no systolic blood pressure measurements below 90 mm Hg for 30 consecutive minutes prior to intubation. Patients were analyzed in 2 groups, those with post-intubation hypotension, defined as any recorded systolic blood pressure ⬍ 90 mm Hg within 60 minutes of intubation, and those with no post-intubation hypotension. Multiple logistic regression modeling was used to define predictors of post-intubation hypotension. Results: A total 465 patients underwent emergency intubation during the study period and 300 met inclusion criteria for this study. Post-intubation hypotension occurred in 66/300 (22%) patients and these patients experienced significantly higher inhospital mortality (35% versus 20%; OR 2.1, 95% CI: 1.2 to 3.9). Multiple logistic regression analysis demonstrated that pre RSI shock index (SI), chronic renal disease, intubation for acute respiratory failure and age were independently associated with post-intubation hypotension. Of these, SI was the most strongly associated factor (OR 55; 95% CI: 13-232). Receiver operation characteristic plot showed optimized SI ⱖ 0.8 predicting post-intubation hypotension with 67% sensitivity and 80% specificity. RSI paralysis was associated with a lower incidence of postintubation hypotension (OR 0.04; 95% CI 0.003-0.4). Conclusion: Pre and peri-intubation factors predict the complication of postintubation hypotension. Elevated SI strongly and independently forewarned of cardiovascular deterioration following emergency intubation with pre-RSI SI ⱖ 0.8 as the optimal threshold to identify patients at risk.
373 374
Abstract Withdrawn
Short-term Prognosis Among Cardiac Arrest Survivors
Coalter K, Radlinski B, Schultz J, Can A, Seamon J, Whalen D, Jones JS/MSU College of Human Medicine, Grand Rapids, MI; Grand Rapids MEP/ Michigan State University, Grand Rapids, MI; Saint Mary’s Health Care, Grand Rapids, MI
Study Objective: Out-of-hospital sudden cardiac arrest (OHCA) is a relatively common situation associated with a high mortality rate. This study describes experiences in one community over 4 years with regard to treatment, outcome, and predictors of outcome among patients hospitalized alive after out-of-hospital cardiac arrest. Our hypothesis was that among patients hospitalized alive after out-of-hospital cardiac arrest factors associated with survival can be defined from history, factors at resuscitation, and status on admission to the emergency department. Methods: This community-based, retrospective study used a database of all admissions to 3 academic medical centers during a 4-year study period. Eligibility criteria: age over 18 years old and having experienced OHCA of presumed
S132 Annals of Emergency Medicine
cardiac origin with at least 1 ECG in supraventricular rhythm. Exclusion criteria were cardiac arrest of noncardiac etiology (ie, trauma, sepsis, acute respiratory failure); pregnancy; and/or known terminal illness before the occurrence of cardiac arrest. Patient demographics, out-of-hospital resuscitation, comorbidity, ED treatment, hospital complications and final disposition were recorded using a standardized classification system. Patients’ neurological recovery and overall performance was estimated at discharge. Survivors were compared with nonsurvivors using odds ratios (OR) and 95% confidence intervals (CI). One investigator performed a blinded review of a random sample of 10% of the medical records to determine reliability (kappa). Results: A total of 93 patients were hospitalized alive after out-of-hospital cardiac arrest during the study period; 37 patients (40%) survived to hospital discharge. Common causes of death included cardiogenic shock (32%), anoxic brain injury (21%), respiratory failure (21%) and cardiomyopathy (11%). Survivors and nonsurvivors were generally comparable in terms of demographics, past medical history, admission ECG patterns, ED treatment, and clinical findings. Five variables were associated with a poor hospital outcome: history of ⬎ 2 co-morbidities (OR 2.2, 95% CI 0.9 to 5.1), diabetes (OR 3.7, 95% CI 1.4 to 9.8) initial asystolic rhythm or pulseless electrical activity (OR 5.0, 95% CI 1.5 to 16.0) delay in return to spontaneous circulation ⬎20 minutes (OR 6.4, 95% CI 2.3 to 17.8), and a late rise (⬎3 hours) in cardiac troponin (OR 2.8, 95% CI 1.2 to 6.5). Surprisingly, patient age, witnessed arrest, or bystander cardiopulmonary resuscitation were not significantly associated with better prognosis. In addition, prolonged scene time with ACLS drugs or intubation did not improve survival in cardiac arrest patients. Interrater reliability was “excellent” (K⫽0.81). Conclusion: Despite community-based interventions, overall survival in OHCA is still low (40%). Early and specific identification of patients with poor prognosis would limit invasive and expensive medical activity and human grief.
375
Mortality Outcomes From Post-Cardiac Arrest Therapeutic Hypothermia in a Community-Based, Multiple Hospital System
Graffeo C, Ford L, Lo B, Ansari S, Devine A/Eastern Virginia Medical School, Norfolk, VA
Background: Therapeutic hypothermia has been shown to improve mortality in patients undergoing cardiac arrest and is recommended in the 2010 American Heart Association Advanced Cardiac Life Support guidelines. Current recommendations however, are based upon findings from tertiary referral centers with limited outcome data from community hospital settings. Study Objective: To evaluate mortality benefits of therapeutic hypothermia in cardiac arrest victims presenting to an emergency department (ED) in a communitybased regional hospital setting. Methods: A retrospective cohort study was performed. Subjects included all outpatient, non-traumatic, cardiac arrest victims age 18 or greater that were transferred to one of 6 emergency departments (5 hospital based, 1 free standing) over a 24-month time period from January 2010 to December 2011. Five of the EDs were community based with one serving as a level 1 urban, regional trauma and tertiary referral center. Selection criteria and therapeutic hypothermia protocols were standardized throughout all study sites using a single computer-based system that defined inclusion and exclusion criteria as well as provide clinicians with a therapeutic hypothermia order entry system. Two independent reviewers abstracted subject data from an electronic medical record database. A third reviewer adjudicated any discrepancy in data interpretation. Data analysis was performed employing chi-square analysis. Results: 781 cardiac arrests were initially reviewed with 293 subjects meeting inclusion criteria for final analysis. Of the 293 subjects, the median age was 63 years (IQR 53-77) with 47% (139/293) females. Overall, 27% (78/293) of subjects met criteria to receive therapeutic hypothermia with no difference in rate of therapeutic hypothermia usage between 2010 and 2011 (25.69%; 39/152 patients versus 27.6%; 39/141 patients, respectively, p⫽0.79). Overall, no survival difference was seen in subjects who underwent therapeutic hypothermia when compared to those who did not (26/78 versus 89/215, OR 0.71, 95% CI 0.41-1.22). Likewise, survival rates of subjects who received therapeutic hypothermia at the tertiary referral center were not improved when compared to either those who did not receive therapeutic hypothermia at the tertiary care facility (OR 1.25, 95% CI 0.39-3.99) or when compared to subjects who received T therapeutic hypothermia in a community hospital (OR 0.61, 95% CI 0.33-1.25).
Volume , . : October
368
Off-Highway Vehicle Parks: Do Increased Regulations and Enforcement Improve All-Terrain Vehicle Safety?
Denning G, Jennissen C, Harland K, Ellis D, Buresh C/University of Iowa Carver College of Medicine, Iowa City, IA; University of Iowa Departments of Emergency Medicine and of Public Health, Iowa City, IA; University of Iowa Department Emergency Medicine, Iowa City, IA
Study Objectives: All-terrain vehicle (ATV) popularity has risen dramatically in the past 15 years and has been accompanied by an even greater increase in crashrelated deaths and injuries. The number of off-highway vehicle parks, both public and private, continues to grow to meet the recreational needs of ATV enthusiasts. These parks require users to obey all state laws, often have additional safety regulations, and in our state have personnel dedicated to enforcement of laws and regulations. Little is known about how off-highway vehicle park regulations and enforcement affects ATV user behavior and safety. The objective of this study was to determine whether there were differences in crash mechanisms and/or compliance with ATV safety laws and regulations when comparing off-road ATV crashes inside and outside state off-highway vehicle parks. Methods: Data were derived from our statewide ATV injury surveillance database (2002-2009). Descriptive analyses were performed for demographics, risk factors (eg , carrying passengers), crash mechanisms, and outcomes of injuries. Comparisons of categorical and continuous variables were performed. Results: A total of 813 injured persons were included in the final analysis; 6% of victims were from OHV park crashes. Relative to outside the parks, a smaller percentage of park victims were under the age of 6teen (7% versus 31%, p⬍0.01), a lower percentage were passengers (2.5% versus 13%, p⫽0.07), and a dramatically higher percentage were helmeted (90% versus 24%, p⬍0.0001). However, park crashes involved more jump-related injuries (34% versus 5%, p⬍0.001). Mean injury severity scores were not different between the 2 locations, but 5% of victims outside the parks had severe brain injuries (GCS ⬍8) as compared to no park victims. Conclusion: Off-highway vehicle park crashes involved more jump-related events, suggesting that additional studies of individual parks may be necessary to identify high-risk areas and to improve park safety. However, park victims exhibited better compliance with ATV safety-related laws and regulations and suffered less severe brain injury outcomes. These findings support the hypothesis that ATV safety regulations accompanied by effective enforcement promote safe behaviors that may prevent injuries.
369
Use of Ceiling Mounted Lifts With Patient Slings in the Christiana Emergency Department Considerably Reduces the Incidence of Injury Among Emergency Department and Hospital Personnel, Who Are Required to Lift and Transfer Patients
Burgess B, Burgess T, Price C, Nichols WL/Christiana Care Health Services, Newark, DE
Study Objectives: We sought to demonstrate that injuries associated with manual lifting and transferring patients in particular, low back pain, were reduced by instituting appropriate lifting equipment in the Christiana emergency department (ED). Methods: This retrospective study was completed in a level 1, suburban tertiary care teaching hospital. We compared the incidence of injury amongst ED and hospital staff depicted by “lost time injury rates” over a 2-year period (2009 - 2011). Injury rates associated with lifting and transferring patients were studied as ceiling
Volume , . : October
mounted lifts were being installed in the rooms within the Christiana ED. All patients leaving the ED for diagnostic testing or admission were placed on slings. Results: Injuries related to lifting and transferring patients decreased from 15 to 4 and lost time injury rates decreased from 2.08 to 1.55 during this timeframe. This decrease suggests that injuries to the Christiana staff were substantially reduced in co-workers within the ED and throughout the hospital when ceiling mounted lifts utilizing patient slings were initiated in the ED. This policy change led to an increased utilization of lifting equipment throughout the facility. Conclusion: Health care workers lead all occupations in the US with regards to work-related injuries, in particular low back pain. Over a 2-year period during which the ceiling-mounted lifts were utilized within the ED, a reduction of 11 injuries occurred while the lost time injury rates was decreased by 25.5%. This suggests appreciably fewer total injuries directly associated with lifting and transferring patients amongst hospital personnel. Our study supports best practices which are being implemented to promote staff and patient safety at health care facilities nationwide.
370
The PARTY Program and Distracted Driving: Beliefs and Behaviors of Teen Participants
Oberle A, Schmitter J, DeWitt P, Severyn F, Johnson R, Betz M/University of Colorado School of Medicine, Aurora, CO; University of Colorado Hospital, Aurora, CO; Colorado School of Public Health, Aurora, CO
Study Objectives: Teen drivers account for the highest proportion of distracted drivers in fatal crashes. PARTY (Prevent Alcohol and Risk-Related Trauma in Youth) is an interactive teen program with lectures, simulations and role-playing shown to reduce traumatic injuries. Classic PARTY focuses on alcohol-and drug-impaired driving, with less emphasis on other distractions. We sought to describe participant beliefs and behaviors concerning driving risks from impaired or distracted driving. Methods: Retrospective observational study of PARTY participants at an academic trauma center from August 2010 to July 2011. Sessions were free, with voluntary participation from students in the public school system. Participants completed anonymous, unmatched surveys before, immediately after, and one month after the program with the same multiple-choice questions. We used multivariable ordinal logistic regression to examine possible associations between student beliefs and behaviors with age, sex, survey version, and driver’s license status. Results: Five hundred youth aged 12-20 years (median: 16) participated; response rates were 23% (before) 61% (immediately after) and 25% (one month after). Data were collected unmatched and treated as such with 547 total responses; 56% were female and 37% were licensed drivers. Students appeared more aware of risks related to alcohol- or drug-impaired driving than from texting or talking on a phone while driving. Similarly, more teens reported “never” riding with impaired drivers than “never” talking or texting while driving. In this sample, the PARTY program did not appear to have significant positive effects on beliefs or behaviors. Conclusion: Before PARTY, teens were already aware of the dangers of alcoholor drug-impaired driving, while newer distractions such as texting and talking on a cell phone while driving were generally perceived as less likely to result in injury. This study was limited by the use of self-reported, unmatched data and low response rates. However, observed opinions related to the relative risks between distracted versus intoxicated driving and prevalence of distracted driving support the need for continued efforts to reduce all forms of impaired and distracted driving among teens.
371 EMF
Multi-organ Dysfunction after Return of Spontaneous Circulation in Post-cardiac Arrest Syndrome
Roberts BW, Kilgannon J, Trzeciak S/Cooper University Hospital, Camden, NJ
Study Objective: The 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) recommend physicians “reduce the risk of multi-organ injury and support organ function” in patients resuscitated from cardiac arrest. However, there remains a paucity of clinical data to support these current AHA guidelines. The objective of this study was to determine if extracerebral multiorgan dysfunction is associated with inhospital mortality among patients resuscitated from cardiac arrest. Methods: We performed a prospective observational study in post-cardiac arrest patients at an urban academic medical center, Cooper University Hospital in Camden, NJ. Inclusion criteria were age ⬎ 17, non-trauma cardiac arrest, and comatose after ROSC. In order to quantify the degree of extracerebral multi-organ dysfunction we calculated an initial SOFA score and 72-hour SOFA score (both
Annals of Emergency Medicine S131
Research Forum Abstracts modified to not include the cerebral component) and determined the ⌬SOFA score (ie the difference between the initial SOFA score and the 72-hour SOFA score). The primary outcome measure was inhospital mortality. We used multivariate logistic regression analysis to determine the relative strength of the ⌬SOFA score as an independent predictor of inhospital mortality after adjusting for common confounding variables (ie age, arrest location, arrest rhythm, and Charleson comorbidity score). We then added cerebral dysfunction [ie, Glasgow Coma Score (GCS) motor score ⬍ 6] to the model. Results: Two-hundred and 8 post-cardiac arrest patients were included. The ⌬SOFA score was initially found to be an independent predictor of inhospital mortality with an adjusted odds ratio of 1.21 (95% CI 1.08 - 1.35). After adjusting for cerebral dysfunction the independent association between the ⌬SOFA score and inhospital mortality was lost [odds ratio 1.10 (95% CI 0.98 - 1.25)]. Conclusion: In this sample of post-cardiac arrest patients we found that extracerebral organ dysfunction was common; however, after adjusting for cerebral dysfunction it was not an independent predictor of inhospital mortality.
372
Predictors of the Complication of Post-Intubation Hypotension During Emergency Airway Management
Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE/Carolinas Medical Center, Charlotte, NC
Study Objective: Arterial hypotension is a recognized complication of emergency intubation that is independently associated with increased morbidity and mortality. Our aim was to identify factors associated with post-intubation hypotension following emergency intubation. Methods: Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a one-year period. Patients were included if they were ⬎17 years old and had no systolic blood pressure measurements below 90 mm Hg for 30 consecutive minutes prior to intubation. Patients were analyzed in 2 groups, those with post-intubation hypotension, defined as any recorded systolic blood pressure ⬍ 90 mm Hg within 60 minutes of intubation, and those with no post-intubation hypotension. Multiple logistic regression modeling was used to define predictors of post-intubation hypotension. Results: A total 465 patients underwent emergency intubation during the study period and 300 met inclusion criteria for this study. Post-intubation hypotension occurred in 66/300 (22%) patients and these patients experienced significantly higher inhospital mortality (35% versus 20%; OR 2.1, 95% CI: 1.2 to 3.9). Multiple logistic regression analysis demonstrated that pre RSI shock index (SI), chronic renal disease, intubation for acute respiratory failure and age were independently associated with post-intubation hypotension. Of these, SI was the most strongly associated factor (OR 55; 95% CI: 13-232). Receiver operation characteristic plot showed optimized SI ⱖ 0.8 predicting post-intubation hypotension with 67% sensitivity and 80% specificity. RSI paralysis was associated with a lower incidence of postintubation hypotension (OR 0.04; 95% CI 0.003-0.4). Conclusion: Pre and peri-intubation factors predict the complication of postintubation hypotension. Elevated SI strongly and independently forewarned of cardiovascular deterioration following emergency intubation with pre-RSI SI ⱖ 0.8 as the optimal threshold to identify patients at risk.
373 374
Abstract Withdrawn
Short-term Prognosis Among Cardiac Arrest Survivors
Coalter K, Radlinski B, Schultz J, Can A, Seamon J, Whalen D, Jones JS/MSU College of Human Medicine, Grand Rapids, MI; Grand Rapids MEP/ Michigan State University, Grand Rapids, MI; Saint Mary’s Health Care, Grand Rapids, MI
Study Objective: Out-of-hospital sudden cardiac arrest (OHCA) is a relatively common situation associated with a high mortality rate. This study describes experiences in one community over 4 years with regard to treatment, outcome, and predictors of outcome among patients hospitalized alive after out-of-hospital cardiac arrest. Our hypothesis was that among patients hospitalized alive after out-of-hospital cardiac arrest factors associated with survival can be defined from history, factors at resuscitation, and status on admission to the emergency department. Methods: This community-based, retrospective study used a database of all admissions to 3 academic medical centers during a 4-year study period. Eligibility criteria: age over 18 years old and having experienced OHCA of presumed
S132 Annals of Emergency Medicine
cardiac origin with at least 1 ECG in supraventricular rhythm. Exclusion criteria were cardiac arrest of noncardiac etiology (ie, trauma, sepsis, acute respiratory failure); pregnancy; and/or known terminal illness before the occurrence of cardiac arrest. Patient demographics, out-of-hospital resuscitation, comorbidity, ED treatment, hospital complications and final disposition were recorded using a standardized classification system. Patients’ neurological recovery and overall performance was estimated at discharge. Survivors were compared with nonsurvivors using odds ratios (OR) and 95% confidence intervals (CI). One investigator performed a blinded review of a random sample of 10% of the medical records to determine reliability (kappa). Results: A total of 93 patients were hospitalized alive after out-of-hospital cardiac arrest during the study period; 37 patients (40%) survived to hospital discharge. Common causes of death included cardiogenic shock (32%), anoxic brain injury (21%), respiratory failure (21%) and cardiomyopathy (11%). Survivors and nonsurvivors were generally comparable in terms of demographics, past medical history, admission ECG patterns, ED treatment, and clinical findings. Five variables were associated with a poor hospital outcome: history of ⬎ 2 co-morbidities (OR 2.2, 95% CI 0.9 to 5.1), diabetes (OR 3.7, 95% CI 1.4 to 9.8) initial asystolic rhythm or pulseless electrical activity (OR 5.0, 95% CI 1.5 to 16.0) delay in return to spontaneous circulation ⬎20 minutes (OR 6.4, 95% CI 2.3 to 17.8), and a late rise (⬎3 hours) in cardiac troponin (OR 2.8, 95% CI 1.2 to 6.5). Surprisingly, patient age, witnessed arrest, or bystander cardiopulmonary resuscitation were not significantly associated with better prognosis. In addition, prolonged scene time with ACLS drugs or intubation did not improve survival in cardiac arrest patients. Interrater reliability was “excellent” (K⫽0.81). Conclusion: Despite community-based interventions, overall survival in OHCA is still low (40%). Early and specific identification of patients with poor prognosis would limit invasive and expensive medical activity and human grief.
375
Mortality Outcomes From Post-Cardiac Arrest Therapeutic Hypothermia in a Community-Based, Multiple Hospital System
Graffeo C, Ford L, Lo B, Ansari S, Devine A/Eastern Virginia Medical School, Norfolk, VA
Background: Therapeutic hypothermia has been shown to improve mortality in patients undergoing cardiac arrest and is recommended in the 2010 American Heart Association Advanced Cardiac Life Support guidelines. Current recommendations however, are based upon findings from tertiary referral centers with limited outcome data from community hospital settings. Study Objective: To evaluate mortality benefits of therapeutic hypothermia in cardiac arrest victims presenting to an emergency department (ED) in a communitybased regional hospital setting. Methods: A retrospective cohort study was performed. Subjects included all outpatient, non-traumatic, cardiac arrest victims age 18 or greater that were transferred to one of 6 emergency departments (5 hospital based, 1 free standing) over a 24-month time period from January 2010 to December 2011. Five of the EDs were community based with one serving as a level 1 urban, regional trauma and tertiary referral center. Selection criteria and therapeutic hypothermia protocols were standardized throughout all study sites using a single computer-based system that defined inclusion and exclusion criteria as well as provide clinicians with a therapeutic hypothermia order entry system. Two independent reviewers abstracted subject data from an electronic medical record database. A third reviewer adjudicated any discrepancy in data interpretation. Data analysis was performed employing chi-square analysis. Results: 781 cardiac arrests were initially reviewed with 293 subjects meeting inclusion criteria for final analysis. Of the 293 subjects, the median age was 63 years (IQR 53-77) with 47% (139/293) females. Overall, 27% (78/293) of subjects met criteria to receive therapeutic hypothermia with no difference in rate of therapeutic hypothermia usage between 2010 and 2011 (25.69%; 39/152 patients versus 27.6%; 39/141 patients, respectively, p⫽0.79). Overall, no survival difference was seen in subjects who underwent therapeutic hypothermia when compared to those who did not (26/78 versus 89/215, OR 0.71, 95% CI 0.41-1.22). Likewise, survival rates of subjects who received therapeutic hypothermia at the tertiary referral center were not improved when compared to either those who did not receive therapeutic hypothermia at the tertiary care facility (OR 1.25, 95% CI 0.39-3.99) or when compared to subjects who received T therapeutic hypothermia in a community hospital (OR 0.61, 95% CI 0.33-1.25).
Volume , . : October