Article

Cardiac arrest while exercising on mountains

Correspondence / American Journal of Emergency Medicine 36 (2018) 16931715 1699

dispensing an outpatient prescription. Patients were counseled on all discharge medications per the EDs’ policies and procedures.

A total of 255 individuals were included: 86 individuals received a start- er pack and 169 individuals received alternative anticoagulation. Of the 169 individuals, 87 received a dose of enoxaparin, 22 received a dose of both enoxaparin and warfarin, 1 received a dose of warfarin only, 1 received an intravenous (IV) heparin infusion, 50 received a single dose of rivaroxaban, and 8 received a dose of apixaban. The individual who received an IV hep- arin infusion was given an outpatient prescription for rivaroxaban.

There were no significant differences in baseline characteristics (Table 1). Additionally, there were 103 physicians for the 255 patient visits.

There were no statistically significant differences in ED LOS, return ED visits, or Hospital readmissions (Table 2). Initial outpatient 30-day follow- up was similar between both groups. A sub-group analysis comparing the individual anticoagulants to the starter pack showed no statistical differ- ences in ED LOS.

There was no difference in ED LOS with use of the starter pack compared to alternative anticoagulation. The Average ED LOS was comparable to other studies [3,4]. We hypothesized that ED LOS would be longer with enoxaparin due to weight-based dosing and education related to injection technique and warfarin bridging. Furthermore, treatment with either enoxaparin or a single dose of a direct oral anticoagulant often requires de- termination of outpatient costs to ensure medication access post-discharge. ED LOS may have been similar between groups as standard ED practice is to provide patient education for any new medications prescribed. Additional- ly, our ED providers often discuss initial anticoagulation selection with the patient’s primary care physician, which could impact ED LOS.

Secondary outcomes support previous findings that use of rivaroxaban starter packs in the ED is both safe and effective [5]. Hospital readmissions and ED visits regarding VTE and/or bleeding were similar between groups. Patients were no less likely to seek outpatient follow- up within 30 days. Patient satisfaction was not measured; however, an additional benefit of the starter pack is improved medication access. Thus, challenges with delays in filling prescriptions or problems with ini- tial insurance coverage may be avoided, especially during the period of highest VTE recurrence [6]. Use of rivaroxaban starter packs is likely to in- crease as rivaroxaban is recommended as a first-line option for VTE treat- ment [7]. This study supports rivaroxaban starter packs as a safe and effective choice for initial VTE treatment in patients discharged from the ED to the community.

Conflicts of interest

None declared.

Gina T. Ayers, PharmD, BCPS*

Frank D’Amico, PhD Roberta M. Farrah, PharmD, BCPS, BCACP Patricia M. Klatt, PharmD, BCPS Megan A. Baumgartner, PharmD, BCPS

University of Pittsburgh Medical Center St. Margaret, 815 Freeport Road,

Pittsburgh, PA 15215, United States

*Corresponding author at: 815 Freeport Road, Pittsburgh, PA 15215,

United States.

E-mail address: [email protected] (G.T. Ayers).

14 October 2017

https://doi.org/10.1016/j.ajem.2018.01.043

References

  1. Derlet RW, Richards RJ. Overcrowding in the nation’s emergency departments: com- plex causes and disturbing effects. Ann Emerg Med 2000;35(1):63-8.
  2. Yoon P, Steiner I, Reinhardt G. Analysis of factors influencing length of stay in the emergency department. Can J Emerg Med 2003;5(3):155-61.
  3. Rathley NK, Obendorfer D, White LF, et al. Time series analysis of emergency depart- ment length of stay per 8-hour shift. West J Emerg Med 2012 May;13(2):163-8.
  4. Horwitz LI, Green J, Bradley EH. US emergency department performance on wait time

    and length of visit. Ann Emerg Med 2010 Feb;55(2):133-41.

    Chu A, Limberg J. Findings from a rivaroxaban program for acute venous thromboem- bolism upon emergency department discharge, with focus on utility of commercially available dose pack. Am J Emerg Med 2017 Dec;35(12):1910-4.

  5. Limone BL, Hernandez AV, Michalak D, Bookhart BK, Coleman CI. Timing of recurrent venous thromboembolism early after the index event: a meta-analysis of randomized controlled trials. Thromb Res 2013;132(4):420-6.
  6. Kearon C, Akl EA, Ornelas J, et al. antithrombotic therapy for VTE disease: CHEST guidelines and expert panel report. Chest 2016 Feb;149(2):315-52.

    Cardiac arrest while exercising on mountains

    Letter to the editor,

    Highly interesting data on the risk and outcomes of cardiac arrest while exercising in the mountains have recently been presented in this Journal by Jung et al. [1]. The reported prevalence of cardiac arrest in the mountainous areas of national or provincial parks in Korea was 0.35 per 1,000,000 visits being somewhat higher during the winter season. The prognosis of cardiac arrest in the mountains was poor when com- pared to that not occurring in mountainous areas primarily due to fewer performed defibrillation and significantly longer pre-hospital times. In my opinion, 2 points deserve discussion in more depth. First, 96% of all cardiac arrests in the mountains affected males. This is an

    Table 1

    Baseline characteristics by study group.

    Characteristic

    Starter pack (n = 86)

    Other (n = 169)

    P-value

    Age (yr) – mean (SD)

    54.5 (16.4)

    54.5 (16.5)

    0.99

    Female sex – freq. (%)

    43 (50)

    74 (43.8)

    0.36

    Charlson Comorbidity Index – mean (SD)

    2.8 (2.3)

    2.9 (2.3)

    0.82

    Serum creatinine (mg/dL) – mean (SD)

    0.93 (0.29)

    0.92 (0.36)

    0.78

    DVTa – freq. (%)

    78 (91.8)

    160 (95.2)

    0.27

    Diagnostic imaging prior to ED visit – freq. (%)

    52 (60.5)

    88 (52.1)

    0.23

    Additional diagnostic imaging – freq. (%)

    20 (23.3)

    23 (13.6)

    0.05

    Medical consult – freq. (%)

    2 (2.3)

    6 (3.6)

    0.7

    a Sample sizes based on n = 85 in starter pack and n = 168 in other, since one person in each group had a diagnosis for both DVT and PE.

    Table 2

    Primary and secondary outcomes.

    Outcomes

    Starter pack (n = 86)

    Other (n = 169)

    Difference

    95% CI for difference

    Primary

    ED LOS (hr) – mean (SD)

    3.1 (1.3)

    3.2 (1.6)

    -0.11

    [-0.5, 0.27]

    Secondary

    7-day readmission – freq. (%)

    3 (3.5)

    11 (6.5)

    -3%

    [-8.3%, 3.8%]

    30-day readmission – freq. (%)

    8 (9.3)

    17 (10.1)

    -0.76%

    [-7.8%, 8%]

    30-day follow-up – freq. (%)

    54 (62.8)

    113 (66.9)

    -5.2%

    [-15%, 0.9%]

    1700 Correspondence / American Journal of Emergency Medicine 36 (2018) 16931715

    important observation defining a risk group for targeted preventive measures which is well in accordance with our observations on Sudden Cardiac Death in the Alps [2]. We demonstrated that beside sex and age, preexisting Cardiovascular risk factors, low fitness level and un- accustomed physical activity during the first days in the mountains and the prolonged abstinence from food and fluid intake during exercise were the most important predictors/triggers for SCD. As a consequence, preventive measures should primarily focus on the high-risk group of physically inactive males who are older than 34 years and suffering from cardiovascular risk factors [3]. Preventive measures may include pharmacological treatment of cardiovascular risk factors, appropriate individual preparation by physical training and recommendations on behavioral aspects during exercise in the mountains [3]. Second, the au- thors supposed that Environmental factors like temperature and alti- tude (hypoxia) are unlikely to impact on the occurrence of cardiac arrest because mountains in Korea are lower than 2000 m [1]. This point also deserves further consideration. Temperature decreases by about 6.5 ?C per 1000 m gain in altitude meaning that ambient temper- ature at the moderate altitude of 1500 m is about 10 ?C lower compared to sea level. Onozuka and Hagihara for example found that low ambient temperature accounted for a substantial proportion of out-of-hospital cardiac arrests in Japan and the majority of these temperature-related cardiac arrests were attributable to moderately Low Temperatures [4]. Cold habituation reduces sympathetic activation after several days with short cold exposures which could represent an effective measure of prevention for high-risk subjects [5]. Moreover, the effects of moder- ate altitude should not be underestimated. Gabry et al. for example showed that high-altitude pulmonary edema (HAPE) may occur in oth- erwise healthy Young people even at moderate altitudes (1400-2400 m) [6]. Another study reported significant increases of mean 24h systol- ic and diastolic systemic blood pressure values during acute exposure to moderate altitude (2035 m) [7]. Furthermore, we found an odds ratio of

    5.7 (95% CI 2.8-11.6) for the risk to suffer from sudden cardiac death on

    the first day at altitude (1710 +- 501 m) when sleeping below 700 m compared with sleeping above 1299 m, indicating some beneficial ef- fects due to altitude/hypoxia pre-conditioning [8]. Taken together, the cardiovascular risk with acute exposure even to moderately low tem- perature and altitudes should not be underestimated but might be re- duced by some pre-acclimatization/pre-conditioning.

    There is no conflict of interest.

    Martin Burtscher, MD, PhD

    University of Innsbruck, Austria

    E-mail address: [email protected].

    https://doi.org/10.1016/j.ajem.2018.01.049

    10 January 2018

    References

    Jung E, Park JH, Kong SY, Hong KJ, Ro YS, Song KJ, et al. Cardiac arrest while exercising on mountains in national or provincial parks: a national observational study from 2012 to 2015. Am J Emerg Med 2018;36(8):1350-5.

  7. Burtscher M, Ponchia A. The risk of cardiovascular events during leisure time activities at altitude. Prog Cardiovasc Dis 2010;52(6):507-11.
  8. Burtscher M. Risk and protective factors for sudden cardiac death during leisure activ- ities in the mountains: an update. Heart Lung Circ 2017;26(8):757-62.
  9. Onozuka D, Hagihara A. Out-of-hospital cardiac arrest risk attributable to temperature

    in Japan. Sci Rep 2017;7:39538.

    Makinen TM, Mantysaari M, Paakkonen T, Jokelainen J, Palinkas LA, Hassi J, et al. Au- tonomic nervous function during whole-body cold exposure before and after cold ac- climation. Aviat Space Environ Med 2008;79(9):875-82.

  10. Gabry AL, Ledoux X, Mozziconacci M, Martin C. High-altitude pulmonary edema at mod-

    erate altitude (b2,400 m; 7,870 feet): a series of 52 patients. Chest 2003;123(1):49-53.

    Torlasco C, Giuliano A, Del Din S, Gregorini F, Bilo G, Faini A, et al. Effects of acute exposure to hypobaric hypoxia at intermediate altitude on conventional and ambulatory blood pressure values. Data from the highcare-Sestriere study. J Hypertens 2015;33(Suppl. 1):e31.

  11. Lo MY, Daniels JD, Levine BD, Burtscher M. Sleeping altitude and sudden cardiac death. Am Heart J 2013;166(1):71-5.

    Paramedics attitudes toward endotracheal intibation

    Sir,

    The endotracheal intubation is the most desired method to secure the airway patency [1]. Many scientific societies in the field of emergency medicine currently indicate endotracheal intubation as the “gold stan- dard” of securing respiratory airway in an emergency. The purpose of di- rect laryngoscopy is to push aside both the tongue and Soft tissues of the throat in order to visualize the glottis which allows for the insertion of tra- cheal tube into the trachea [2,3].

    In their 2015 guidelines the ERC (European Resuscitation Council) rec- ommends the endotracheal intubation in all cases of cardiac arrest. These guidelines greatly emphasize minimizing the breaks during chest com- pressions, as a factor that directly affects the survival of patients in a state of sudden cardiac arrest, which therefore improves the efficiency of cardiopulmonary resuscitation. Hence, the person performing endotra- cheal intubation should either perform this procedure while continuously compressing the chest or only with a short break to allow the insertion of the endotracheal tube between the vocal folds. Therefore, numerous stud- ies recommend that endotracheal intubation should be performed by the most experienced person [4,5].

    Endotracheal intubation carries a lot of benefits and a risk of potential complications [6]. The possibility of performing continuous chest com- pressions while intubating the patient is among unquestionable benefits as it allows for minimizing the breaks during compressions and increases the organ perfusion. Another advantage is the possibility to constantly monitor the carbon dioxide concentration in the exhaled air with capnometry and ventilating with positive end-expiratory pressure . It was also possible until recently to administer resuscitating drugs through the endotracheal tube when there was no possibility for vascular access. However, this method is not recommended by the cur- rent guidelines of the European Resuscitation Council (ERC) and the American Heart Association (AHA) as there is no method to predict the pharmacodynamics of the endobronchialy administered drugs.

    In the study performed from July to November 2017 a questionnaire was sent to 220 paramedics. It consisted of questions regarding the atti- tude toward usage of various types of laryngoscopes in pre-hospital con- ditions. 100% of paramedics declared the possession of Macintosh and Miller blades in emergency medical rescue teams. 65% of participants have attended the courses during which issues related to the use of video laryngoscopes were discussed. 98% of those who have experience in video laryngoscopy would use this method of intubation as the method of choice when providing help in pre-hospital conditions. 92.3% of partic- ipants declared a will to participate in video laryngoscopy course devoted to adult intubation while 100% declared a will to participate in pediatric video laryngoscopy course.

    Togay Evrin, PhD, MD

    Department of Emergency Medicine, UFuK University Medical Faculty,

    Ankara, Turkey

    Halla Kaminska, PhD, MD

    Department of Children’s Diabetology, Medical University of Silesia,

    Katowice, Poland Wojciech Wieczorek, MSc, EMT-P Department of Anaesthesiology, Intensive Care and Emergency Medicine in Zabrze, Medical University of Silesia, Katowice, Poland Corresponding author at: Department of Anaesthesiology and Intensive Therapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, 3 Maja 13/15 Str., 41-800 Zabrze, Poland. E-mail address: [email protected].

    16 January 2018

    https://doi.org/10.1016/j.ajem.2018.01.053

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