Out-of-hospital resuscitation of a 3 month old boy presenting with recurrent ventricular fibrillation cardiac arrest: a case report

A 3 month old boy, with no known health conditions, suffered a sudden collapse at home. On first EMS arrival, ventricular fibrillation (VF) cardiac arrest was identified and resuscitation following UK national guidelines was initiated. He remained in cardiac arrest for over 25 min, during which he received 10 defibrillation shocks, each effective, but with VF reoccurring within a few seconds of each of the first 9. A return of spontaneous circulation (ROSC) was achieved after the 10th shock. The resuscitation was conducted fully in his home, with the early involvement of Advanced Paramedic Practitioners specialising in critical care (APP- CC). Throughout his resuscitation, there remained a strong focus on delivering quality resuscitation in situ, rather than a ‘load and go’ approach that would have resulted in very early conveyance to hospital with on-going CPR.The patient was subsequently discharged home and is making an excellent recovery. The arrest was later determined to have been caused by a primary arrhythmia as a result of a previously unidentified non-obstructive variant hypertrophic cardiomyopathy.We present data downloaded from the defibrillator used during the resuscitation that illustrates clearly the recurrent nature of his fibrillation.

Out-of-hospital Resuscitation of a 3 Month Old Boy Presenting With Recurrent Ventricular Fibrillation Cardiac Arrest: A Case Report

A 3 month old boy, with no known health conditions, suffered a sudden collapse at home. On first EMS arrival, ventricular fibrillation (VF) cardiac arrest was identified and resuscitation following UK national guidelines was initiated. He remained in cardiac arrest for over 25 minutes, during which he received 10 defibrillation shocks, each effective, but with VF reoccurring within a few seconds of each of the first 9. A return of spontaneous circulation (ROSC) was achieved after the 10th shock. The resuscitation was conducted fully in his home, with the early involvement of Advanced Paramedic Practitioners specialising in critical care (APP- CC). Throughout his resuscitation, there remained a strong focus on delivering quality resuscitation in situ, rather than a ‘load and go’ approach that would have resulted in very early conveyance to hospital with on-going CPR. The patient was subsequently discharged home and is making an excellent recovery. The arrest was later determined to have been caused by a primary arrhythmia as a result of a previously unidentified non-obstructive variant hypertrophic cardiomyopathy. We present data downloaded from the defibrillator used during the resuscitation that illustrates clearly the recurrent nature of his fibrillation.

Reorganisation of stroke care in prehospital emergency medical services: results through transformative learning

Background: Rapid recanalisation is important when treating ischaemic stroke patients. In Finland, the reorganisation of the prehospital emergency medical system and the establishment of emergency medicine as an independent speciality occurred some years ago. These reforms offered the opportunity to develop new prehospital and in-hospital pathways for stroke patients. Methods: In this retrospective study, we examined the immediate impact of implementing a new operating model in prehospital stroke care. We introduced a modified “load-and-go” model using a transformative learning process. We observed the immediate effects of the reorganisation by comparing prehospital time intervals three months before and three months after the reorganisation. Results: The new operating model was implemented using a transformative learning process. There was an immediate reduction of 35.1% from 21.4 to 13.9 minutes (P < 0.001) in the median on-scene time and of 18.2% from 52.7 to 43.1 minutes (P < 0.05) in the median total time, i.e. the time interval between the alarm from the dispatch centre to patient hand-over to ED. Conclusion: By using a transformative learning process in implementing a modified load-and-go operation model in the EMS, we could immediately reduce median on-scene time and median total time in the treatment of acute stroke patients.

Advantages of the Use of Alcor iSED Automated Sed Rate Analyzer vs Manual Sed Rate in Evaluation and/or Monitoring the Treatment in Patients, CMCVAMC Experience

Objectives The automated Alcor iSED automated instrument has a major impact on the proper management of the patients in a timely manner with use of a minimal amount of the blood (100 µL). The Alcor iSED analyzer has introduced a new technology that forgoes sample preparation by using a Load and Go technology. We were previously using the Westergren tube method, which required special preparation of the tube to load into a special provided sealed cup. The entire procedure was tedious and time-consuming. To overcome, we acquired and implemented the Alcor iSED analyzer for an efficient and prompt reporting of sedimentation rate. Methods A sample was aspirated and dispensed from a closed tube, then dispensed into a capillary, and quantitative capillary photometry (aggregation) was used to measure ESR faster than traditional methods by capturing the kinetics of red blood cell aggregation in a controlled testing environment during the most critical phase of sedimentation, commonly referred to as the lag or Rouleaux formation phase. As a part of quality assurance monitoring, retrospective split analysis was performed for 75 samples. Analysis was performed using a Passing-Bablok regression analysis with the MedCalc program. Results Our results demonstrated significant differences between the two methods for the TAT. The TAT was significantly decreased with Alcor iSED (3 minutes for the first specimen and then 15-20 seconds for each sequential specimen) as compared to the manual Westergren method (1 hour), which significantly improved the reporting of results to the providers to monitor the treatment. Conclusion The Alcor iSED analyzer has provided truly shortened TAT erythrocyte sedimentation rate, allowing for better patient care and treatment.

Abstract 170: Challenges in Implementing an ECPR Program for Out of Hospital Cardiac Arrest

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapy. Many institutions are interested in developing their own ECPR program. However, there are challenges in logistics and implementation. Hypothesis: Development of an ECPR team and identification of UPMC Presbyterian as a receiving center will increase recognition of potential ECPR candidates. Methods: We developed an infrastructure of Emergency Medical Services (EMS), Medic Command, and an in-hospital ECPR team. We identified inclusion criteria for patients with an out of hospital cardiac arrest (OHCA) likely to have a reversible arrest etiology and developed them into a simple checklist. These criteria were: witnessed arrest with bystander CPR, shockable rhythm, and ages 18 to 60. We trained local EMS crews to screen patients and review the checklist with a Command Physician prior to transport to our hospital. Results: From October 2015 to March 31 st 2018, there were 1165 dispatches for OHCA, of which 664 (57%) were treated and transported to the hospital and 120 to our institution. Of these, five patients underwent ECPR. Of the remaining cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. Prehospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) underwent mechanical CPR with LUCAS device. Time from arrest to arrive on scene was 5 [IQR 4-6] min and time call MD command was 13 [IQR 7-21] min. Time to transport was 20 [IQR 19-21] min. Time from arrest to initiation of ECMO was 63 [IQR 59-69] min. Conclusions: ECPR is a relatively infrequent occurrence. Implementation challenges include prompt identification of patients with reversible OHCA causes, preferential transport to an ECPR capable facility and changing the focus of EMS in these select patients from a “stay and play” to a “load and go” mentality.

Abstract 182: Prehospital Intravenous Epinephrine May Boost Survival of Patients with Traumatic Cardiopulmonary Arrest

Background: Prehospital resuscitation for patients with major trauma emphasized load-and-go principle. However, for those with traumatic cardiopulmonary arrest (TCPA), the role of prehospital intravenous epinephrine (PIE) remained unclear. This study aimed to evaluate the effectiveness of PIE in patients with TCPA. Method: We analyzed data from an Utstein registry for out-of-hospital cardiac arrest in Taipei to test the association between PIE and outcomes of TCPAs. Enrollees were adult patients (≧18 year-old) with TCPA. Patients with signs of obvious death like decapitation or rigor mortis, or with existing do-not-resuscitation order were excluded. Primary outcome was survival to admission, and secondary outcome was survival to discharge. A subgroup analysis was performed by stratified total prehospital time. Result: From Jun 1, 2010 to May 31, 2013 there were total 514 cases enrolled. PIE was administrated in 43 (8.4%) cases. Patients who received PIE were more likely with witnessed collapse, initial shockable rhythm, placement of advanced airway, longer total prehospital time and less blunt injury. Patient number with survival to admission and survival to discharge was 101 (19.6%) and 20 (3.9%), respectively. In parsimonious models, the adjusted odds ratios (AOR) of PIE was 2.57 (95% confidence interval (CI) 1.24-5.31) on primary outcome (Figure 1), and 3.53 (95%CI 0.84-15.47) on secondary outcome. Subgroup analysis showed increased ORs of PIE in cases with longer prehospital time (Figure 2). Conclusion: Among patients with TCPA, PIE was associated with increased survival to admission in an Asian metropolitan area, especially for those with longer prehospital time.