Introduction: Landmark studies have shown the benefit of implementing TH in cardiac arrest patients. Achieving a fast time to target temperature(T2TT) is an accepted practice during cooling. However, recent reports have suggested poor clinical outcomes with shorter T2TT. Hypothesis: We studied if time to T2TT correlates with survival to discharge. Methods: We conducted a retrospective study in a predominantly minority inner-city population. Subjects were divided into 2 groups: survivors and those with CPS < 4 and non-survivors plus those with CPS > 4 at discharge. Multivariate stepwise logistic regression was utilized to analyze the effect of predictors on survival. Odds ratios (OR) and 95% CI are reported. A pvalue of < 0.05 was considered significant. Results: 80 patients received TH after cardiac arrest. Of them, median age was 62 years (range 23-87), 35 were women (44%), 50 were Latinos (62.5%). Median BMI 28 kg/m2 and APACHEII score was 28.5 (range 8-49), 13 (16.3%) had ventricular fibrillation, 34 (42.5%) AKI, and 24 had coagulopathy (70%), median initial serum lactate was 6.3 (range 0.33-21), & median initial serum pH was 7.21. Median ROSC was 14.5 min (range 0-60) and initial temperature on arrival 36.3C (31.7-39.7). 34 subjects (42,5%) had CPS of < 4 and 46 (57.5%) died in-hospital. Median T2TT was 182.5 (range 0-497 min). Multivariate analysis shows that composite outcomes (Death or CPS >3) was independently associated with greater odds of coagulopathy (4.3, 95% CI 1,28-14.5, p= 0.019) and lower T2TT (OR 0.992, 95% CI 0.987-0.998, p=0.009). Conclusions: Although it is conventional wisdom that rapid cooling is associated with better neuroprotection in the setting of cardiac arrest, our findings show that a lower T2TT among patients receiving TH may be associated with poor outcomes. This phenomenon could be explained by blunted neurological response to TH in those with several neurological damage (CPS > 4 or do not survive cardiac arrest). The significance of this interesting but important discovery needs further elucidation with larger studies in the United States.
Introduction: Initial care in most stroke centers across the USA is delivered by neurologists or ED physicians. Initial care in most stroke centers across the United States (US) is delivered by neurologists or emergency physicians. Lack of organized protocols and concern for bleeding complications are often encountered with thrombolytic therapy. Hypothesis: We studied the occurrence of stroke mimics (SM) and the safety profile of AIS patients who received revascularization interventions(RI) at a certified stroke center using a unique model of a stroke team led by an intensivist. Methods: Stroke protocols were implemented in 2006 utilizing existing 24/7 onsite intensivist presence at Lincoln Hospital. Intensivist was the designated stroke team leader who determined eligibility for RIs. All AIS patients between 2006-2011 were included. IV-tPa was provided to all eligible patents during the 5-year-period while IA-tPA/mechanical-thrombectomy was available after August 2009. Diagnosis of SM was based on the absence of pre and post RIs neuroimaging AIS findings in addition to an alternate discharge diagnosis. Chi square test was utilized to analyze differences in SM proportions and complications. P-value of < 0.05 was considered significant. Results: 628/1411(44.5%) patients who presented within the therapeutic window were screened for eligibility, of whom 112/628(17.8%) received RIs. 78 received IV-tPA alone, 17 IA-tPA/mechanical-thrombectomy and 17 both. Of the 112 subjects who received RIs, only 4(3.57%) were SMs. Of these 4 patients, median age was 39 yrs compared to 65 yrs among true strokes(TSs), median admission-NIHSS was 10 in SM group compared to 13 in TS group, discharge-NIHSS was 0 among SM’s and 4 among TS patients. No SM patient died or had any bleeding complications related to RI’s in-hospital. Among TS subjects who received RI’s, the mortality was 8.8% & bleeding complications occurred in 2(1.6%) pts only. Compared to the published data showing SM diagnosis of 14%, our study proportion of 3.57% is significantly different(p= 0.005) Conclusions: The safety profile of patient undergoing RI including the selection of appropriate candidates for such interventions can be markedly enhanced utilizing an intensivist driven stroke center model. The unique model enables implementation of stroke protocols, training and education of providers and staff, seamless integration of all services around the critical care units to improve the quality of care and safety of patients receiving RI. Our model could serve as a national model for stroke care.
