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Prehospital presentation of patients with ST-segment elevation myocardial infarction in Singapore
Poster Presentations / Resuscitation 83 (2012) e24–e123
e63
AP102
AP103
Why civilian based first responder system does not exist in Japan? Factors that limit the implementation of first responder system
The knowledge of PAD programme and usage of AEDs in the Lublin region. Survey analysis
Yoshiki Toyokuni 1,∗ , Masayuki Suzukawa 1 , Katsuaki Kubota 2 , Yasuharu Yasuda 3 , Keisuke Yamashita 1 , Chikara Yonekawa 1 , Kenji Narikawa 4 1
Jichi Medical University, Shimotsuke-shi, Tochigi, Japan 2 National Reserach Institute of Fire and Disaster of Japan, Tyofu-shi, Tokyo, Japan 3 Kyoto Tachibana University, Kyoto-shi, Kyoto, Japan 4 Teikyo University, Itabashi-ku, Tokyo, Japan
Background: Japan is a country with 6,003 ambulance vehicles, 59,650 emergency medical technicians (EMT),1 35 helicopter emergency medical services,2 and about 328,000 installed AED.3 However, survival rate for out-of-hospital cardiac arrest patient is only 11.4%.1 One of the considerable reasons is that no operation of civilian based first responder system that trained community member arrives before ambulance car arrives to provide effective BLS including the use of AED. The major factors that limit the implementation of this system into Japan have been investigated. Method: First responder implementation guidelines were composed by interviewing questionnaire for 1350 residents of selected areas and by conducting first responder system trial in the three different remote rural areas where ambulance vehicle cannot arrive within 10 min. Then the obstacles were identified. Results: (1) People’s anxiety. More than 90% of residents were willing to have first responder system in their area but only 16.7% of them were accepted to be a responder due to threat of encountering death from own BLS procedure. (2) Law. Use of AED law is preventing people to use AED periodically as a care provider unless being a physician. (3) Triage protocol. Require new emergency call triage protocol for not to dispatch responder for their safety. (4) Dispatch system. Require well secured system to send patient information to responder. (5) Jurisdiction. Require each city council authorization since ambulance service within their jurisdiction. (6) People’s true understanding. Require sufficient explanation to the community member including ethical problems, insurance, and budget. (7) Education. Require development of new continuous education system for responders to keep their high quality BLS procedure. Conclusions: Several factors that limit the implementation of first responder system into Japan were revealed. By resolving all factors, now we are progressing to implement civilian based first responder system. Further reading [1].Fire and Disaster Management Agency of Japan. Report of 2011 Emergency Medical System and Rescue of Japan; 2011. [2].Emergency Medical Network of Helicopter and Hospital (a certified nonprofit organization). Hospital-Based Doctor-Heli Station Map; May 2012. [3].Report on a study on CPR related device’s evaluation, proper use and diffuse (Hisayoshi Kondo). http://aed-hyogo.sakura.ne.jp/wpm/archivepdf/ 22/2 11 a.pdf [accessed 04.07.12] [in Japanese].
http://dx.doi.org/10.1016/j.resuscitation.2012.08.161
Mariusz Goniewicz ∗ , Bednarz Kamil Medical University of Lublin, Lublin, Poland The purpose: The purpose of the study was to determine the knowledge of the citizens of the Lublin region concerning the selected aspects of first aid, in particular the usage of AEDs (Automatic External Defibrillator). Materials and methods: The study was conducted applying the survey method directed to the citizens of the Lublin region. The answers of 178 respondents were subjected to statistical analysis. The survey comprised of 25 questions, 13 of which were demographic questions. The remaining questions determined the level of knowledge of the AED usage and PAD (Public Access Defibrillation) program. The knowledge of respondents was evaluated based on their answers and divided into three categories: good, average and poor. The knowledge of 49.44% of respondents was evaluated as good knowledge (n = 88), whereas of 46.63% as average (n = 83). Only 3.93% of respondents (n = 7) had poor knowledge. Despite some lacks of knowledge, no less than 96.07% of respondents (n = 171) would be able to perform defibrillation on a person experiencing sudden cardiac arrest. The knowledge of the AED localization is poor. Only 32.58% of respondents were able to localise as least one AED device. The majority of respondents (93.82%) knows the aim of AED introduction and 78% knows the criteria of AED deployment. First aid trainings increase the knowledge of PAD program and AED usage, despite the fact that only 30.71% of the trainings attended by the respondents included information on AED. The highest percentage of courses including the information on AED were mandatory courses at workplace (45.10%) and courses, in which the respondents took part on their own initiative (45.16%). Conclusions: Public awareness concerning the usage of AEDs is high, despite the lack of promotion of such devices in the Lublin region. http://dx.doi.org/10.1016/j.resuscitation.2012.08.162
Acute Coronary Syndromes AP104 Prehospital presentation of patients with ST-segment elevation myocardial infarction in Singapore Andrew F.W. Ho 1,∗ , Stephanie Fook-Chong 2 , Pin Pin Pek 3 , Yih Yng Ng 4 , Marcus E.H. Ong 3 1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore 2 Department of Clinical Research, Singapore General Hospital, Singapore, Singapore 3 Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore 4 Singapore Civil Defence Force, Singapore, Singapore
Objective: Early activation of emergency medical services (EMS), rapid transport and treatment of patients experiencing ST-segment elevation myocardial infarction (STEMI) can improve outcomes. However data regarding prevalence of EMS-transport and first-contact-to-door time (FC2D) in Asia is limited. We aim to determine the prevalence, predictors and outcomes of EMS utilization among Singapore patients presenting with STEMI and to describe FC2D times.
e64
Poster Presentations / Resuscitation 83 (2012) e24–e123
Methods: Retrospective chart review was performed for 462 patients treated at the Emergency Department (ED) of a tertiary hospital for STEMI from December 2006 to April 2008. Patients with cardiac arrest before activating EMS were excluded. Multivariate analysis was used to examine independent factors associated with EMS-transport and effect on symptom-to-balloon time and other secondary outcomes. Subgroup analysis was performed for the 76 patients in the EMS-transport group. Results: EMS transport was used in 16.45% of STEMI patients. In the non-EMS-transport group, 1.73% used a private ambulance provider, 19.26% first consulted a general practitioner and 1.08% first presented to a hospital without around-the-clock percutaneous coronary intervention (PCI) facility. EMS-transport was associated with shorter symptomto-door time (median 92 versus 188 min, p < 0.01), door-to-electrocardiogram time (2.5 versus 7 min, p < 0.01), electrocardiogram-to-diagnosis time (median 2 versus 4 min, p = 0.01), door-to-balloon (D2B) time (median 86 versus 102 min) and symptom-to-balloon time (median 201 versus 297.5 min, p < 0.01). Median FC2D amongst EMS-transport patients was 33.5 min (interquartile range: 27.0, 42.0). Independent predictors of EMS-transport were epigastric pain (OR = 5.83 p < 0.01) and syncope (OR = 4.70 p < 0.01). Conclusion: The study’s population underutilized EMS for STEMI. EMS-transport was associated with shorter symptom to balloon times. Targeted public education to reduce time to definitive care is imperative in improving the care of STEMI patients. http://dx.doi.org/10.1016/j.resuscitation.2012.08.163 AP105 Salvador’s ST Elevation Myocardial Infarction (STEMI) Registry (RESISST)—Transfer to cardiology reference center is an independent protective factor for 30-day mortality D.J.F. Solla 1 , L.G.M.C. Carvalho 1 , L.S.T. Teixeira 1 , S.F.C. Camara 1 , V.O.N. Novais 1 , L.B. Barbosa 1 , H.A.N. Almeida Neto 1 , T.B.M. Mota 1 , I.P.F. Paiva Filho 1,∗ , N.M.F.F. Filgueiras Filhol 1 , S. Timerman 2 , R. Kalil Filho 2 1
SAMU 192 - Service d’Aide Medicale Urgente, Salvador, Bahia, Brazil Heart Institute (InCor) Sao Paulo University, School of Medicine, Sao Paulo, Sao Paulo, Brazil 2
Proposal: To carry out a STEMI registry in the public health system (SUS) of Salvador, Bahia, Brazil. This is the first Brazilian and Latin American prospective registry to include community-based emergency units and general hospitals patients (not only the Cardiology reference Centers ones). This enables a more reliable record of the AMI care reality at the public health system of Brazil, a developing country. Method: The RESISST was conducted between January and November 2011 and included the STEMI victims admitted to 22 public health units (9 general hospitals and 13 community-based emergency units). Monitoring was conducted for 30 days, and we gathered information on presenting symptoms, acute phase therapy, complementary investigation, in-hospital morbidity, postdischarge treatment and30-day mortality. Results: We identified 169 patients, of whom 84 were initially admitted to general hospital and 85 to community-based emergency units, the mean age was 62 ± 12 years, 56.8% males, high frequency of self-reported hypertension (79%) and diabetes (38.4%) and previous AMI in 16.35%. On admission, 81.6% had typical chest pain, Killipclass ≥ II in 38.7% and 77.5% had up to 12 h of symptoms (median pain-admission time 175 min), of which 50% received primary chemical (median door-to-needle time 194 min)
or mechanical (median door-to-balloon time 489 min) reperfusion. Around 55% were transferred to Cardiology reference Centers. The 30-day mortality was 29.8% (53.6% for patients not transferred and 14.5% for transferred ones). In multivariate analysis, the following factors were protective for 30-day death: not having previous CHF (OR = 0.083) or stroke (OR = 0.136), presentation with typical chest pain (OR = 0.121), nitrate (OR = 0.029) and beta-blocker (0.114) use and transfer to the Cardiology center (OR = 0.130). Conclusion: There is a high prevalence of comorbidities and poor compliance to national and international guidelines, especially in regard to the therapy of acute reperfusion. Among the predictors of mortality found in addition to the classically described in the literature, it is noteworthy that the transfer to referral centers was a factor in reducing mortality, independent of primary reperfusion. The expansion of specialized units and better training of the general public care of patients with STEMI can contribute to a reduction factor of mortality in Salvador and Brazil. http://dx.doi.org/10.1016/j.resuscitation.2012.08.164 AP106 Hazards from unrestricted O2 use are underrepresented on websites providing information about MONA (morphine, O2, nitrates, aspirin) in the treatment of acute coronary syndromes Nikolaos Nikolaou ∗ , Ligia Sabadus, Georgia Mavrogianni, Emmanouel Papadakis, Apostolos Christou, Sotirios Patsilinakos Konstantopouleio General Hospital, Athens, Greece Background: Unrestricted O2 use early in the course of acute coronary syndromes (ACS) had been a component of MONA until 2008 when international guidelines recommended a more judicious O2 use because of potential hazards. We studied the extent to which relevant websites has been updated with relevant information. Methods: We performed Goggle searches looking for websites using MONA as a mnemonic for initial treatment of ACS. Using a preformed questionnaire, the content of these sites was scrutinized for the presence of information about therapies that are represented in MONA. Comparisons between percentages were performed using X2 analysis. We used websites ranking according to their traffic as indicated by an online traffic analyzer (http://www.checksitetraffic.com). Results: Search returned 603 websites. After excluding websites devoid of relative information, 225 were included in the analysis. Median site ranking was 130,664 (IQR: 6444, 1,697,863). We found evidence for date of last update for 142 websites. Of them 98 (69%) were last updated after 2008. There was no difference regarding the percentage of sites mentioning any complication of O2 use before n = 3/44 (7%) and after 2008 guidelines n = 14/98(14%), p = 0.27. Table 1 summarizes presence of any information regarding Table 1 Indications administration complications monitoring. Morphine O2 Nitrates Aspirin X2, p
96 (0.98) 94(0.96) 92(0.94) 95(0.97) 0.09, 0.99
90 (0.92) 85(0.87) 92(0.94) 94(0.90) 0.49, 0.92
29(0.30) 14(0.14) 32(0.33) 32(0.33) 8.3, 0.04
29(0.30) 42(0.43) 28(0.29) 32(0.33) 3.74, 0.29
indications, dosing, complications and monitoring of MONA treatments, from 98 sites that were last updated after 2008. Potential hazards from other MONA treatments were mentioned in about a third of websites. Potential complications from O2 use were referred to much less frequently. The need for monitoring of O2
e63
AP102
AP103
Why civilian based first responder system does not exist in Japan? Factors that limit the implementation of first responder system
The knowledge of PAD programme and usage of AEDs in the Lublin region. Survey analysis
Yoshiki Toyokuni 1,∗ , Masayuki Suzukawa 1 , Katsuaki Kubota 2 , Yasuharu Yasuda 3 , Keisuke Yamashita 1 , Chikara Yonekawa 1 , Kenji Narikawa 4 1
Jichi Medical University, Shimotsuke-shi, Tochigi, Japan 2 National Reserach Institute of Fire and Disaster of Japan, Tyofu-shi, Tokyo, Japan 3 Kyoto Tachibana University, Kyoto-shi, Kyoto, Japan 4 Teikyo University, Itabashi-ku, Tokyo, Japan
Background: Japan is a country with 6,003 ambulance vehicles, 59,650 emergency medical technicians (EMT),1 35 helicopter emergency medical services,2 and about 328,000 installed AED.3 However, survival rate for out-of-hospital cardiac arrest patient is only 11.4%.1 One of the considerable reasons is that no operation of civilian based first responder system that trained community member arrives before ambulance car arrives to provide effective BLS including the use of AED. The major factors that limit the implementation of this system into Japan have been investigated. Method: First responder implementation guidelines were composed by interviewing questionnaire for 1350 residents of selected areas and by conducting first responder system trial in the three different remote rural areas where ambulance vehicle cannot arrive within 10 min. Then the obstacles were identified. Results: (1) People’s anxiety. More than 90% of residents were willing to have first responder system in their area but only 16.7% of them were accepted to be a responder due to threat of encountering death from own BLS procedure. (2) Law. Use of AED law is preventing people to use AED periodically as a care provider unless being a physician. (3) Triage protocol. Require new emergency call triage protocol for not to dispatch responder for their safety. (4) Dispatch system. Require well secured system to send patient information to responder. (5) Jurisdiction. Require each city council authorization since ambulance service within their jurisdiction. (6) People’s true understanding. Require sufficient explanation to the community member including ethical problems, insurance, and budget. (7) Education. Require development of new continuous education system for responders to keep their high quality BLS procedure. Conclusions: Several factors that limit the implementation of first responder system into Japan were revealed. By resolving all factors, now we are progressing to implement civilian based first responder system. Further reading [1].Fire and Disaster Management Agency of Japan. Report of 2011 Emergency Medical System and Rescue of Japan; 2011. [2].Emergency Medical Network of Helicopter and Hospital (a certified nonprofit organization). Hospital-Based Doctor-Heli Station Map; May 2012. [3].Report on a study on CPR related device’s evaluation, proper use and diffuse (Hisayoshi Kondo). http://aed-hyogo.sakura.ne.jp/wpm/archivepdf/ 22/2 11 a.pdf [accessed 04.07.12] [in Japanese].
http://dx.doi.org/10.1016/j.resuscitation.2012.08.161
Mariusz Goniewicz ∗ , Bednarz Kamil Medical University of Lublin, Lublin, Poland The purpose: The purpose of the study was to determine the knowledge of the citizens of the Lublin region concerning the selected aspects of first aid, in particular the usage of AEDs (Automatic External Defibrillator). Materials and methods: The study was conducted applying the survey method directed to the citizens of the Lublin region. The answers of 178 respondents were subjected to statistical analysis. The survey comprised of 25 questions, 13 of which were demographic questions. The remaining questions determined the level of knowledge of the AED usage and PAD (Public Access Defibrillation) program. The knowledge of respondents was evaluated based on their answers and divided into three categories: good, average and poor. The knowledge of 49.44% of respondents was evaluated as good knowledge (n = 88), whereas of 46.63% as average (n = 83). Only 3.93% of respondents (n = 7) had poor knowledge. Despite some lacks of knowledge, no less than 96.07% of respondents (n = 171) would be able to perform defibrillation on a person experiencing sudden cardiac arrest. The knowledge of the AED localization is poor. Only 32.58% of respondents were able to localise as least one AED device. The majority of respondents (93.82%) knows the aim of AED introduction and 78% knows the criteria of AED deployment. First aid trainings increase the knowledge of PAD program and AED usage, despite the fact that only 30.71% of the trainings attended by the respondents included information on AED. The highest percentage of courses including the information on AED were mandatory courses at workplace (45.10%) and courses, in which the respondents took part on their own initiative (45.16%). Conclusions: Public awareness concerning the usage of AEDs is high, despite the lack of promotion of such devices in the Lublin region. http://dx.doi.org/10.1016/j.resuscitation.2012.08.162
Acute Coronary Syndromes AP104 Prehospital presentation of patients with ST-segment elevation myocardial infarction in Singapore Andrew F.W. Ho 1,∗ , Stephanie Fook-Chong 2 , Pin Pin Pek 3 , Yih Yng Ng 4 , Marcus E.H. Ong 3 1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore 2 Department of Clinical Research, Singapore General Hospital, Singapore, Singapore 3 Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore 4 Singapore Civil Defence Force, Singapore, Singapore
Objective: Early activation of emergency medical services (EMS), rapid transport and treatment of patients experiencing ST-segment elevation myocardial infarction (STEMI) can improve outcomes. However data regarding prevalence of EMS-transport and first-contact-to-door time (FC2D) in Asia is limited. We aim to determine the prevalence, predictors and outcomes of EMS utilization among Singapore patients presenting with STEMI and to describe FC2D times.
e64
Poster Presentations / Resuscitation 83 (2012) e24–e123
Methods: Retrospective chart review was performed for 462 patients treated at the Emergency Department (ED) of a tertiary hospital for STEMI from December 2006 to April 2008. Patients with cardiac arrest before activating EMS were excluded. Multivariate analysis was used to examine independent factors associated with EMS-transport and effect on symptom-to-balloon time and other secondary outcomes. Subgroup analysis was performed for the 76 patients in the EMS-transport group. Results: EMS transport was used in 16.45% of STEMI patients. In the non-EMS-transport group, 1.73% used a private ambulance provider, 19.26% first consulted a general practitioner and 1.08% first presented to a hospital without around-the-clock percutaneous coronary intervention (PCI) facility. EMS-transport was associated with shorter symptomto-door time (median 92 versus 188 min, p < 0.01), door-to-electrocardiogram time (2.5 versus 7 min, p < 0.01), electrocardiogram-to-diagnosis time (median 2 versus 4 min, p = 0.01), door-to-balloon (D2B) time (median 86 versus 102 min) and symptom-to-balloon time (median 201 versus 297.5 min, p < 0.01). Median FC2D amongst EMS-transport patients was 33.5 min (interquartile range: 27.0, 42.0). Independent predictors of EMS-transport were epigastric pain (OR = 5.83 p < 0.01) and syncope (OR = 4.70 p < 0.01). Conclusion: The study’s population underutilized EMS for STEMI. EMS-transport was associated with shorter symptom to balloon times. Targeted public education to reduce time to definitive care is imperative in improving the care of STEMI patients. http://dx.doi.org/10.1016/j.resuscitation.2012.08.163 AP105 Salvador’s ST Elevation Myocardial Infarction (STEMI) Registry (RESISST)—Transfer to cardiology reference center is an independent protective factor for 30-day mortality D.J.F. Solla 1 , L.G.M.C. Carvalho 1 , L.S.T. Teixeira 1 , S.F.C. Camara 1 , V.O.N. Novais 1 , L.B. Barbosa 1 , H.A.N. Almeida Neto 1 , T.B.M. Mota 1 , I.P.F. Paiva Filho 1,∗ , N.M.F.F. Filgueiras Filhol 1 , S. Timerman 2 , R. Kalil Filho 2 1
SAMU 192 - Service d’Aide Medicale Urgente, Salvador, Bahia, Brazil Heart Institute (InCor) Sao Paulo University, School of Medicine, Sao Paulo, Sao Paulo, Brazil 2
Proposal: To carry out a STEMI registry in the public health system (SUS) of Salvador, Bahia, Brazil. This is the first Brazilian and Latin American prospective registry to include community-based emergency units and general hospitals patients (not only the Cardiology reference Centers ones). This enables a more reliable record of the AMI care reality at the public health system of Brazil, a developing country. Method: The RESISST was conducted between January and November 2011 and included the STEMI victims admitted to 22 public health units (9 general hospitals and 13 community-based emergency units). Monitoring was conducted for 30 days, and we gathered information on presenting symptoms, acute phase therapy, complementary investigation, in-hospital morbidity, postdischarge treatment and30-day mortality. Results: We identified 169 patients, of whom 84 were initially admitted to general hospital and 85 to community-based emergency units, the mean age was 62 ± 12 years, 56.8% males, high frequency of self-reported hypertension (79%) and diabetes (38.4%) and previous AMI in 16.35%. On admission, 81.6% had typical chest pain, Killipclass ≥ II in 38.7% and 77.5% had up to 12 h of symptoms (median pain-admission time 175 min), of which 50% received primary chemical (median door-to-needle time 194 min)
or mechanical (median door-to-balloon time 489 min) reperfusion. Around 55% were transferred to Cardiology reference Centers. The 30-day mortality was 29.8% (53.6% for patients not transferred and 14.5% for transferred ones). In multivariate analysis, the following factors were protective for 30-day death: not having previous CHF (OR = 0.083) or stroke (OR = 0.136), presentation with typical chest pain (OR = 0.121), nitrate (OR = 0.029) and beta-blocker (0.114) use and transfer to the Cardiology center (OR = 0.130). Conclusion: There is a high prevalence of comorbidities and poor compliance to national and international guidelines, especially in regard to the therapy of acute reperfusion. Among the predictors of mortality found in addition to the classically described in the literature, it is noteworthy that the transfer to referral centers was a factor in reducing mortality, independent of primary reperfusion. The expansion of specialized units and better training of the general public care of patients with STEMI can contribute to a reduction factor of mortality in Salvador and Brazil. http://dx.doi.org/10.1016/j.resuscitation.2012.08.164 AP106 Hazards from unrestricted O2 use are underrepresented on websites providing information about MONA (morphine, O2, nitrates, aspirin) in the treatment of acute coronary syndromes Nikolaos Nikolaou ∗ , Ligia Sabadus, Georgia Mavrogianni, Emmanouel Papadakis, Apostolos Christou, Sotirios Patsilinakos Konstantopouleio General Hospital, Athens, Greece Background: Unrestricted O2 use early in the course of acute coronary syndromes (ACS) had been a component of MONA until 2008 when international guidelines recommended a more judicious O2 use because of potential hazards. We studied the extent to which relevant websites has been updated with relevant information. Methods: We performed Goggle searches looking for websites using MONA as a mnemonic for initial treatment of ACS. Using a preformed questionnaire, the content of these sites was scrutinized for the presence of information about therapies that are represented in MONA. Comparisons between percentages were performed using X2 analysis. We used websites ranking according to their traffic as indicated by an online traffic analyzer (http://www.checksitetraffic.com). Results: Search returned 603 websites. After excluding websites devoid of relative information, 225 were included in the analysis. Median site ranking was 130,664 (IQR: 6444, 1,697,863). We found evidence for date of last update for 142 websites. Of them 98 (69%) were last updated after 2008. There was no difference regarding the percentage of sites mentioning any complication of O2 use before n = 3/44 (7%) and after 2008 guidelines n = 14/98(14%), p = 0.27. Table 1 summarizes presence of any information regarding Table 1 Indications administration complications monitoring. Morphine O2 Nitrates Aspirin X2, p
96 (0.98) 94(0.96) 92(0.94) 95(0.97) 0.09, 0.99
90 (0.92) 85(0.87) 92(0.94) 94(0.90) 0.49, 0.92
29(0.30) 14(0.14) 32(0.33) 32(0.33) 8.3, 0.04
29(0.30) 42(0.43) 28(0.29) 32(0.33) 3.74, 0.29
indications, dosing, complications and monitoring of MONA treatments, from 98 sites that were last updated after 2008. Potential hazards from other MONA treatments were mentioned in about a third of websites. Potential complications from O2 use were referred to much less frequently. The need for monitoring of O2