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Can prehospital rapid sequence intubation improve outcomes in patients with severe traumatic brain injury?

  1. Top of page
  2. Can prehospital rapid sequence intubation improve outcomes in patients with severe traumatic brain injury?
  3. Does higher case volume improve outcomes in ED patients with sepsis?
  4. Do higher case volumes improve outcomes for out-of-hospital cardiac arrest?
  5. Can passive leg raising improve outcomes in cardiac arrest?

Following traumatic brain injury (TBI), avoidance of secondary brain injury from hypoxia, hypotension and hypercapnia is critical. This prospective randomized controlled study sought to determine whether the potential advantages of prehospital rapid sequence intubation (RSI) might outweigh the potential disadvantages. Over a 5 year period, patients with TBI were randomized to prehospital RSI or hospital endotracheal intubation. Paramedic RSI was protocol-directed and all other treatments were at treating physician discretion. Eligible patients were aged 15 years or more with evidence of head trauma, a Glasgow Coma Scale score of 9 or less and intact airway responses. Patients also had to be more than 10 min from a receiving trauma hospital, with transport that was not being planned by helicopter (generally >30 min from the receiving hospital). The primary outcome measured was the extended Glasgow Outcome Scale (GOSe) at 6 months.

Of the 1045 potential patients, most were excluded because of hospital proximity – too close (19% <10 min) or too far (42% required helicopter transport). In total, 312 patients were enrolled, with similar baseline characteristics and injury severity scores in the two groups. Of the 160 patients randomized to paramedic RSI, two improved rapidly and were transported to hospital without intubation, and one suffered cardiac arrest prior to RSI. Of the 157 patients who underwent RSI, five had oesophageal intubation, which was immediately recognized. There were 10 patients who suffered cardiac arrest during transport in the paramedic RSI group, and two in the hospital RSI group. The mean scene time was 12 min greater in the paramedic RSI group.

The mean GOSe was 3.9 for paramedic RSI group and 3.6 for the hospital group, with median scores of 5 and 3, respectively (P= 0.28). One of the secondary outcomes was the percentage of patients with a favourable neurological outcome (moderate disability or better). This was seen in 51% of paramedic group and 39% of the hospital group – a statistically significant difference (P= 0.046). There was no difference in any of the other secondary outcomes. The authors noted that there were 13 patients lost to follow up (10 in hospital RSI group) and if any of the hospital RSI patients lost to follow up had had a favourable outcome statistical significance would have been lost.

Despite this limitation (among the others described), the authors concluded that the results of the study were positive and that all patients with TBI should undergo paramedic RSI. However, in considering the fate of the 13 patients lost to follow up, it is possible, even likely, that they are living independently (not disabled). It would seem more likely that patients' families would know their relatives whereabouts if they were dead or disabled. If all 13 patients lost to follow up had a good or normal GOSe, then 19% of patients in the paramedic RSI group would have had a good or normal GOSe compared with 22% of the hospital RSI group. Readers will need to consider the potential GOSe of the patients lost to follow up when deciding if the author's conclusions are supported by the results of the present study. (Bernard SA. Ann. Surg. 2010; 252: 959–65)

Does higher case volume improve outcomes in ED patients with sepsis?

  1. Top of page
  2. Can prehospital rapid sequence intubation improve outcomes in patients with severe traumatic brain injury?
  3. Does higher case volume improve outcomes in ED patients with sepsis?
  4. Do higher case volumes improve outcomes for out-of-hospital cardiac arrest?
  5. Can passive leg raising improve outcomes in cardiac arrest?

There are many studies published that demonstrate improved outcomes at high volume centres for surgical patients – both trauma and elective surgery. This cross-sectional analysis looks at the mortality of ED patients admitted with sepsis – specifically whether higher volume centres have the same mortality as lower volume centres. The database used was the 2007 Nationwide Inpatient Sample – 8 043 415 discharges of adult patients from 1044 hospitals in 40 US states. After excluding transfers both in and out, there were 87 166 sepsis patient cases from 551 hospitals. Inhospital mortality was 18%, and the ‘early’ mortality (<48 h) was 7%. The median caseload for each hospital was 249, with a range of 25–1251. After excluding hospitals with <25 cases/year, there remained a wide variation of mortality in a normal distribution pattern.

Inpatient mortality was significantly lower for the highest ED sepsis volume quartile. Multivariate logistic regression showed that patients admitted to the highest volume quartile had lower early mortality (odds ratio 0.69) and lower hospital mortality (odds ratio 0.73) compared with patients admitted to lowest volume quartile EDs. Teaching hospitals had higher mortality than non-teaching hospitals, and hospitals with larger numbers of beds had a higher mortality than small and medium sized hospitals.

Clearly, there are many unmeasured factors in this cross sectional analysis that can affect sepsis mortality. However, the results reported here should encourage both measurement and comparison of sepsis mortality across hospitals, with analysis of high performing centres. Sepsis is common enough that all centres should accept sepsis patients, rather than see the development of specialized centres similar to the trauma model. (Powell ES. Crit. Care Med. 2010; 38: 2161–8)

Do higher case volumes improve outcomes for out-of-hospital cardiac arrest?

  1. Top of page
  2. Can prehospital rapid sequence intubation improve outcomes in patients with severe traumatic brain injury?
  3. Does higher case volume improve outcomes in ED patients with sepsis?
  4. Do higher case volumes improve outcomes for out-of-hospital cardiac arrest?
  5. Can passive leg raising improve outcomes in cardiac arrest?

In a similar fashion to the study above, the authors of this retrospective study sought to examine whether the outcome of out-of-hospital cardiac arrest (OOHCA) is different in EDs that treat many or few such patients. The database used was a nationwide observational database of OOHCA patients in Korea. Eligible patients were patients with non-traumatic OOHCA with CPR attempted by paramedics.

In general, only basic life support is supplied in Korea and each ambulance has an automatic external defibrillator. Over a 2 year period, 20 457 patients were identified, with 90% dying in the ED. A further 7% died in hospital, leaving a survival to discharge rate of 3.4%. The median caseload was 19, with a range of 0–247. Only 10% were transported to Level 1 EDs, with a survival rate of 8%. Survival rates were lower for Level 2 EDs, and only 1% for Level 3 EDs. A cut-off of 68 cases was chosen as the delineation between high and low volume EDs – and the survival rate was significantly higher (5.9% vs 3.6%) for high volume EDs. After adjustment, both Level 2 and Level 3 EDs had lower mortality in higher volume EDs, but there was no difference in mortality for high and low volume Level 1 EDs.

The authors state that post-resuscitation care is variable across Korea, with few centres providing induced hypothermia. However, only prehospital factors were used in multivariate analysis. As such, it is hard to know how to interpret these results outside of Korea. Just like the study above, it might encourage readers to measure outcomes of OOHCA in their own centre, with high performing centres sharing their techniques. (Shin DS. Resuscitation 2011; 82: 32–9)

Can passive leg raising improve outcomes in cardiac arrest?

  1. Top of page
  2. Can prehospital rapid sequence intubation improve outcomes in patients with severe traumatic brain injury?
  3. Does higher case volume improve outcomes in ED patients with sepsis?
  4. Do higher case volumes improve outcomes for out-of-hospital cardiac arrest?
  5. Can passive leg raising improve outcomes in cardiac arrest?

In this sub-study of a prospective randomized trial in out-of-hospital cardiac arrest (OOHCA), the authors compared the end-tidal carbon dioxide (ETCO2) and outcomes of patients with and without passive leg raising (PLR). During CPR, and after 5 min of ventilation via endotracheal tube, study patients had their heels elevated 35 cm from horizontal – calculated to be about 20 degrees. Of the 503 OOHCA over a 2 year period, 126 had sufficient ETCO2 measurements for the study, and 44 underwent PLR.

Although there was no difference in ROSC (return of spontaneous circulation), a greater number survived to hospital discharge (7% vs 1%) but this was not statistically significant. Patients with PLR had a rise in ETCO2 in the first few minutes after PLR. This is an interesting study; certainly worth repeating in larger numbers. With few described complications from PLR, it might improve the very low survival rate from OOHCA for those patients not responding rapidly to standard resuscitation. (Axelsson A. Resuscitation 2010; 81: 1615–20)