Article

Scene time interval in out-of-hospital cardiac arrest: It is time to measure time until patient contact

scene time interval in out-of-hospital c”>1304 Correspondence / American Journal of Emergency Medicine 36 (2018) 13001320

was no way that they could differentiate TTS from acute anterior myocar- dial infarction (AMI) in their patient, without resorting to emergent coro- nary arteriography. Indeed this applies to almost all patients presenting with symptoms/signs/laboratory findings with a provisional diagnosis of AMI, or acute coronary syndromes, some of whom will eventually be diag- nosed as having suffered a TTS. The authors refer to “an ECG 24 h after pre- sentation was unchanged as compared to the one at presentation and had persistent changes” [1]; did this, or subsequent ECGs, show attenu- ation of the amplitude of QRS complexes (attQRS) in some of the leads, since this ECG evolution has been reported in association with TTS [2]? Was there an attQRS involving any ECG lead, particularly I, aVL, or V5 and V6, which could have been affected by midventricular TTS [3]? Leads avL, V2 and V3 appear to have low QRS amplitude in comparison with the other leads which are of generous amplitude.

Conflicts of interest

There are no conflicts of interest to disclose.

John E. Madias Icahn School of Medicine at Mount Sinai, New York, NY, United States Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway,

Elmhurst, NY 11373, United States.

E-mail address: [email protected].

17 September 2017

https://doi.org/10.1016/j.ajem.2017.11.004

References

  1. Pruthi S, Kobrossi S, Bartaula R, Chaudhuri D. The misleading electrocardiogram – midventricular takotsubo masquerading as anterior wall STEMI. Am J Emerg Med 2017 Jul 27;35(10):1586.e3-1586.e4.
  2. Madias JE. Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome. Eur Heart J Acute Cardiovasc Care 2014;3(1):28-36.
  3. Madias JE. Electrocardiogram lead-specific QRS attenuation in an atypical midventricular case of takotsubo syndrome. J Electrocardiol 2013;46(6):728-9.

    Response to reader’s comments — The misleading electrocardiogram — Midventricular Takotsubo masquerading as anterior wall STEMI

    Thank you for your interest in the manuscript.

    The ECG at presentation or ECG 24 h after presentation did not have any evolution of attenuation of in any leads, unlike reported in ar- ticles cited in your comments.

  4. There was no att QRS in any leads.
  5. All the leads were of generous amplitude and leads aVL, V2 or V3 did not have low amplitude.

    Sonal Pruthi1

    Department of Medicine, State University of New York, Upstate Medical

    University, Syracuse, NY, USA E-mail address: [email protected].

    31 October 2017

    https://doi.org/10.1016/j.ajem.2017.11.005

    1 Address: 50 Presidential Plaza, Apt 2005, Syracuse, New York 13202, USA.

    Scene time interval in out-of-hospital cardiac arrest: It is time to measure time until patient contact

    Sir:

    We read with great interest the article by Ki Hong Kim et al. [1]., showing that, in a national retrospective cohort of 79,832 patients suffering from out- of-hospital cardiac arrest (OHCA), emergency mobile services (EMS) short scene time intervals (STI) were associated with good neurological outcomes. Despite the quality of this study, and regarding the major importance of the subject, we would like to discuss some points that we believe could help understand some missing links in improvement of outcomes in OHCA.

    Indeed, Dr. Ki Hong Kim et al. found that good neurological outcomes, defined by a cerebral performance category 1 or 2 at discharge, were less likely to be reached in longer STI, whether if prehospital return of spon- taneous circulation was reached or not. This result is consistent with existing data [2] and must be considered by every EMS system aiming to enhance their efficiency in OHCA.

    However, it is unclear why only intermediate STI (4 to 8 min) were

    significantly associated with good outcomes. The reason why shorter ones (0 to 4 min) did not lead to similar results is discussable. As Dr. Ki Hong Kim et al. stated, STI were used as proxys for treatment initiation, which was not recorded. Yet, as STI globally neglect the time interval from ambulance arrival at scene until patient contact, the time to treatment initiation may be longer, hence leading to data misinterpretation [3,4]. Moreover, time to treatment initiation may have been delayed due to accessibility constraints encountered by EMS teams after arrival at scene (long on-foot distance, elevated floors, obstacles etc.) [5,6]. The fact that the STI were not separately studied upon the on-scene typology (urban, semi-rural, rural, etc.) may have led to an imperfect analysis of the results, because time to patient con- tact is probably very dependent on such accessibility constraints. South Korea is a highly urbanized country, with over 80% of its popula- tion living in dense cities (50% in the Seoul megalopolis) [7]. It is likely that most of OHCA of the study of Ki Hong Kim et al. occurred in such areas, where time until patient contact significantly differed from measured STI.

    We hence do believe that the imperfect measurement of EMS re- sponse times and the neglected accessibility constraints encountered until patient contact are important limitations to the interpretation of the results of this study. Further evaluations of the impact of EMS STI on outcomes of urgent time-dependent pathologies, such as OHCA, should record every time intervals and delay determinants.

    Matthieu Heidet, MD, MPH

    Assistance Publique des Hopitaux de Paris (AP-HP), Hopital Universitaire

    Henri Mondor, SAMU94, Creteil, France Universite Paris-Est Creteil (UPEC), EA-4390 (Analysis of Risk in Complex

    Health Systems, ARCHeS), Creteil, France Corresponding author at: Assistance Publique des Hopitaux de Paris (AP-HP), Hopital Universitaire Henri Mondor, SAMU94, Creteil, France.

    E-mail address: [email protected].

    Elise Brami, MD Francois Revaux, MD Charlotte Chollet-Xemard, MD Eric Lecarpentier, MD

    Assistance Publique des Hopitaux de Paris (AP-HP), Hopital Universitaire

    Henri Mondor, SAMU94, Creteil, France

    Eric Mermet, MSC, PhD

    Centre National de la Recherche Scientifique (CNRS), Paris, France

    Correspondence / American Journal of Emergency Medicine 36 (2018) 13001320 1305

    Ecole des Hautes Etudes en Sciences Sociales (EHESS), Centre d’Analyses et

    de Mathematiques Sociales (CAMS), Paris, France Institut des Soins Complexes Paris Ile-de-France (ISC-PIF), Paris, France

    Julien Vaux, MD, MPH Thierry Da Cunha, MD Jean Marty, MD, PhD

    Assistance Publique des Hopitaux de Paris (AP-HP), Hopital Universitaire

    Henri Mondor, SAMU94, Creteil, France Universite Paris-Est Creteil (UPEC), EA-4390 (Analysis of Risk in Complex

    Health Systems, ARCHeS), Creteil, France

    31 October 2017

    https://doi.org/10.1016/j.ajem.2017.11.009

    References

    Kim KH, Shin SD, Song KJ, Ro YS, Kim YJ, Hong KJ, et al. Scene time interval and good neurological recovery in out-of-hospital cardiac arrest. Am J Emerg Med May 2017; 35(11):1682-90 [cited 2017 Oct 26]; Available from: http://linkinghub.elsevier. com/retrieve/pii/S0735675717304333. [Internet].

  6. Pell JP. Effect of reducing Ambulance response times on deaths from out of hospital cardiac arrest: cohort study. BMJ Jun 9 2001;322(7299):1385-8.
  7. Morrison LJ, Angelini MP, Vermeulen MJ, Schwartz B. Measuring the EMS patient ac-

    cess time interval and the impact of responding to high-rise buildings. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir Mar 2005; 9(1):14-8.

    DeRuyter NP, Husain S, Yin L, Olsufka M, McCoy AM, Maynard C, et al. The impact of first responder turnout and curb-to-care intervals on survival from out-of-hospital cardiac arrest. Resuscitation 2017;113:51-5 [cited 2017 Feb 9]; Available from: http://linkinghub.elsevier.com/retrieve/pii/S0300957217300278. [Internet].

  8. Drennan IR, Strum RP, Byers A, Buick JE, Lin S, Cheskes S, et al. Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival. Can Med Assoc J Apr 5 2016;188(6):413-9.
  9. Lateef F, Anantharaman V. Delays in the EMS response to and the evacuation of pa- tients in high-rise buildings in Singapore. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir Dec 2000;4(4):327-32.
  10. South Korea Population. Worldometers. [Internet]. [cited 2017 Oct 29]. Available from: http://www.worldometers.info/world-population/south-korea-population/; 2017, 2018.

    Intranasal fentanyl improves time to analgesic delivery in sickle cell pain crises

    Sickle cell disease (SCD) affects approximately 90,000 Americans [1]. These individuals are perennially at risk for complications of SCD with intermittent, painful vasoocclusive events (VOE) being the most com- mon acute morbidity [2]. A third of children with SCD will experience a VOE in their first year of life, and most will have experienced a VOE by 4 years of age [3]. Accordingly, acute pain management is the most common reason for children with SCD to seek care in pediatric emergency departments (PEDs) [4].

    The National Heart, Lung, and Blood Institute (NHLBI) has published

    utilizing an initial dose of INF in the treatment of VOEs compared to routine care.

    We conducted a retrospective cohort study at a single, urban, quater- nary PED. Inclusion criteria included patients presenting to the PED with a known diagnosis of SCD, age between 1 and 21 years, and suspected VOE at the time of presentation to triage. Exclusion criteria included non-VOE pain, temperature N 38.0 ?C, hypoxia (oxygen saturation b 93% on ambi- ent air) or diagnosis of Acute chest syndrome, presentation concerning for neurologic event, transfer from another facility, pregnancy, or allergy to fentanyl. Consecutive visits between January 1, 2015 and December 31, 2015 were eligible for inclusion. For grouping, patients were consid- ered to have been treated with the INF protocol if they received a dose of INF prior to IV analgesic therapy (“routine care”). The primary outcome studied was time to initial analgesic administration. Secondary outcomes included time to disposition decision, overall ED length of stay , pain trajectories during ED visit, time to pain reassessments, time to adminis- tration of second dose of opiate medication, and ED disposition. Local in- stitutional review board approval was obtained.

    During the study period, 487 visits made by 105 distinct patients met inclusion criteria. 376 (77%) patients were treated with the INF protocol and 111 (23%) were treated with routine care. The baseline characteris- tics of both groups are summarized in Table 1. Gender distribution and hemoglobin genotype were similar between the two groups. There was a significant difference in age (16.3 vs 18.2 years, P b 0.001) and triage pain score between the two groups (9 vs 8, P b 0.001).

    The performance characteristics of both groups are summarized in Table 2. There was a significantly reduced mean time to first opiate admin- istration in the INF group (29 vs 78 min, P b 0.001). The percentage of pa- tients receiving their first medication within the NHLBI-recommended 30 min was significantly higher with INF as well (67% vs 5%, P b 0.001).

    Median pain scores differed significantly between the two groups at the time of the first and second pain reassessments, however changes in pain scores at each interval were not significantly different. Pain trajec- tories through the course of the ED visit for each group were similar and are depicted in Fig. 1. Both median time to Disposition decision (237 vs 276 min, P b 0.001) and overall LOS (316 vs 363 min, P = 0.003) were significantly shorter in the INF group. Overall rates of disposition did not vary between the two groups.

    This study had several limitations. The study design was retrospec- tive and observational; patients were not randomized to receive INF or not. In our electronic health record, no systematic means of docu- mentation exists to record the physician’s decision to use INF or not, which represents a potential source of confounding bias. We do not re- port non-opioid analgesic measures in this study. However, all patients seen for VOEs in our PED generally receive IV ketorolac, IV fluids, and additional Symptomatic treatment (anti-emetics, anti-pruritics, etc.) unless a specific contraindication exists.

    Our retrospective study demonstrated a significantly reduced time to initiation of opioid analgesic therapy when using INF compared to

    Table 1

    Baseline characteristics and demographics.

    Guideline recommendations for VOE management including timely ini- tiation of analgesic therapy [5]. The recommendation for analgesia initi-

    INF (n = 376)

    Routine care (n = P

    111)

    ation is within 30 min of presentation to triage, although in clinical practice there are often lengthy delays [5-8]. Additionally, patients with SCD wait longer to be seen by a physician and for initial analgesic medication administration than in other comparable, painful conditions [9]. The use of intranasal fentanyl (INF) has been shown to help over- come some of these challenges [10]. The benefits of INF include improv- ing time to analgesic administration, rapid onset of action and rapid absorption via the nasal mucosa, and Analgesic efficacy similar to intra- venous (IV) or intramuscular opioids [11,12]. The purpose of our study was to investigate the performance characteristics of a pain pathway

    Age (years), mean (SD) 16.3 (4.8) 18.2 (3.6) b0.001

    Visits per distinct patient, median 2 (1-4) 1 (1-3) 0.511

    (IQR)

    Male gender, n (%) 248 (66%) 69 (62%) 0.543

    Sickle cell genotype, n (%) 0.159

    SS 242 (64%) 62 (56%)

    SC 82 (22%) 26 (23%)

    S/?+ thalassemia 36 (10%) 15 (14%)

    S/?0 thalassemia 10 (3%) 7 (6%)

    Othera 6 (2%) 1 (1%)

    Triage pain score, median (IQR) 9 (8-10) 8 (7-9) b0.001

    a Includes hemoglobin S/O (Arab) and hemoglobin SD.

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