After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting.
Background: Prior administrative database studies correlate hyperoxia (based on initial paO2) after cardiac arrest (CA) with increased mortality. These studies did not quantify duration of hyperoxia or incorporate important variables in predicting post-CA survival. We hypothesized hyperoxia duration would not be associated with organ failure or mortality after adjustment for important CA prognostic variables. Methods: 185 CA survivors receiving >24h mechanical ventilation had oxygen exposure classified hourly based primarily on ABG paO2 or if missing within 2h based on SpO2 as: hypoxic (paO2≤50 or SpO2≤88%), normoxic (paO2 51-150 or SpO2 89-99% or 100% on FiO2≤0.40), moderately hyperoxic (paO2 151-300), severely hyperoxic (paO2>300) and probably hyperoxic (SpO2=100 when Fio2>0.40, no ABG). Univariate regression correlated durations of oxygen exposure to 24h SOFA score and survival to hospital discharge with multivariate regressions incorporating CA type, sex and use of hypothermia (p<0.10 in univariate correlations to outcomes). Results: Classification based on initial paO2 revealed no significant differences in survival or SOFA (Table 1). Moderate hyperoxia and to a lesser degree combined moderate and severe hyperoxia exposure were associated with SOFA reduction whereas normoxia and hypoxia exposure were associated with higher SOFA, even after multivariate adjustment (Table 2). Severe hyperoxia exposure was associated with reduced survival in univariate but not multivariate analyses. Conclusions: Exposure to moderate hyperoxia was associated with reduced organ failure whereas severe hyperoxia exposure was not and may correlate with worse survival.
Professor Surg. & Critical Care, University of Pittsburgh Medical Center, Dept. of Surgery, 200 Lothrop street, Suite F1266 PUH, Pittsburgh, PA 15213 [email protected] No conflicts of interest
Coma is common following resuscitation from cardiac arrest. Few data describe the trajectory of recovery the first days following resuscitation. The objective of this study is to describe the evolution in neurological examination during the first 5 days after resuscitation and test if subjects who go on to awaken have different patterns of early recovery.Prospective study of adult subjects resuscitated from out-of-hospital cardiac arrest. We abstracted demographic information and trained clinicians completed daily neurologic examinations using the Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness brainstem (FOUR-B) and motor (FOUR-M) scores during daily sedation interruption. The change in scores between Day 1 and Day 5 was analyzed using the Kruskal-Wallis Test and logistic regression models. The relationship of FOUR-B, FOUR-M, and GCS with time to death was estimated by fitting cox proportional hazard models.FOUR-M and GCS did not differ over time (p = 0.10; p = 0.07). FOUR B increased over time (p < 0.01). Time to recovery of brainstem or motor function differed between those treated at 33 °C and 36 °C (p = 0.0023 and p = 0.0032, respectively). FOUR-B, FOUR-M, and GCS differed between survivors and non-survivors (p < 0.01). Time to recovery of brainstem and motor function differed between survivors and non-survivors. FOUR-M and FOUR-B differed between those with good outcome and poor outcome.The brainstem clinical examination improved during the first 5 days following resuscitation. Brainstem recovery was common in entire cohort and did not differentiate between survivors and non-survivors. Recovery of motor function, however, was associated with survival.
Objective: We investigate whether changes in vital signs between the prehospital scene and emergency department (ED) can be used to develop triage tools to predict the need for life-saving interventions (LSI) and survival in trauma patients. Methods: We analyzed a prospective cohort with any prehospital systolic blood pressure (SBP) ≤ 90 mmHg or Glasgow Coma Scale ≤ 8 who were admitted to an ED at 11 sites of the Resuscitation Outcomes Consortium. The primary outcome was the need for in-hospital LSI (e.g. invasive airway management, invasive bleeding control, blood transfusion, craniotomy, cardiopulmonary resuscitation). Secondary outcome was survival to hospital discharge. Changes in heart rate (HR), SBP, shock index (SI), and respiratory rate (RR) from first prehospital assessment to first ED assessment were considered as predictors in addition to sex, age, mechanism of injury, trauma center level, duration of transport, type of transport, and prehospital fluid volume. Decision trees for each outcome were developed using binary recursive partitioning with predictive performance measured using sensitivity, specificity, and classification error. Results: 5625 subjects were included in our analysis with 49% in need of LSI and 21% dying prior to discharge. Patients needing an LSI tended to either: (1) have an increasing SI (delta ≥ 0.22), (2) have a decreasing SI (delta < 0.22) and >500 mL prehospital fluids, or (3) have a decreasing SI (delta < 0.22), ≤500 mL prehospital fluids, and large change in RR (delta ≥ 9.5 or delta < -7.5). Those surviving to discharge tended to either: (1) have a decreasing SI (delta < 0.57) and a HR that did not decrease greatly (delta > -47) or (2) have an increase in SI (0.57 ≤ delta < 1) and a declining RR (delta < 5). LSI tree had a sensitivity of 58.7% and specificity of 63.3%. Survival tree had sensitivity of 96.2% and specificity of 21.3%. Conclusion: Though the decision trees were constructed with the best data in terms of initial triage and early secondary triage, the classification performance was limited. This highlights the difficulties of developing vital sign based triage tools to predict the need for LSI and survival.
