Background Functionally favorable survival remains low after out-of-hospital cardiac arrest (OHCA). When initial interventions fail to achieve return of spontaneous circulation (ROSC), they are repeated with little incremental benefit. Patients without rapid ROSC do not typically survive with good functional outcome. Novel approaches to OHCA have yielded functionally favorable survival in patients who failed traditional measures, but the optimal transition point from traditional measures to novel therapies is ill defined. Our objective was to estimate the dynamic probability of survival and functional recovery as a function of resuscitation effort duration, in order to identify this transition point. Methods and Results Retrospective cohort study of a cardiac arrest database at a single site. We included 1,014 adult (≥18 years) patients suffering non-traumatic OHCA between 2005–2011, defined as receiving CPR or defibrillation from a professional provider. We stratified by functional outcome at hospital discharge (modified Rankin scale–mRS). Survival to hospital discharge was 11%, but only 6% had mRS 0–3. Within 16.1 minutes of CPR, 89.7% (95%CI: 80.3%, 95.8%) of patients with good functional outcome had achieved ROSC, and the probability of good functional recovery fell to 1%. Adjusting for prehospital and inpatient covariates, CPR duration (minutes) is independently associated with favorable functional status at hospital discharge (OR 0.84; 95%CI 0.72, 0.98;p=0.02). Conclusions Probability of survival to hospital discharge with mRS 0–3 declines rapidly with each minute of CPR. Novel strategies should be tested early after cardiac arrest rather than after complete failure of traditional measures.

Obesity is associated with increased risk of cardiovascular disease (CVD) mortality. CVD is the leading cause of duty-related death among firefighters, and the prevalence of obesity is a growing concern in the Fire Service. Methods. Traditional CVD risk factors, novel measures of cardiovascular health and a measurement of CVD were described and compared between nonobese and obese career firefighters who volunteered to participate in this cross-sectional study. Results. In the group of 116 men (mean age 43 ± 8 yrs), the prevalence of obesity was 51.7%. There were no differences among traditional CVD risk factors or the coronary artery calcium (CAC) score (criterion measure) between obese and nonobese men. However, significant differences in novel markers, including CRP, subendocardial viability ratio, and the ejection duration index, were detected. Conclusions. No differences in the prevalence of traditional CVD risk factors between obese and nonobese men were found. Additionally, CAC was similar between groups. However, there were differences in several novel risk factors, which warrant further investigation. Improved CVD risk identification among firefighters has important implications for both individual health and public safety.

IMPORTANCE It is uncertain what the optimal target temperature is for targeted temperature management (TTM) in patients who are comatose following cardiac arrest. OBJECTIVE To examine whether illness severity is associated with changes in the association between target temperature and patient outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study compared outcomes for 1319 patients who were comatose after cardiac arrest at a single center in Pittsburgh, Pennsylvania, from January 2010 to December 2018. Initial illness severity was based on coma and organ failure scores, presence of severe cerebral edema, and presence of highly malignant electroencephalogram (EEG) after resuscitation. EXPOSURE TTM at 36°C or 33°C. MAIN OUTCOMES AND MEASURES Primary outcome was survival to hospital discharge, and secondary outcomes were modified Rankin Scale and cerebral performance category. RESULTS Among 1319 patients, 728 (55.2%) had TTM at 33°C (451 [62.0%] men; median [interquartile range] age, 61 [50-72] years) and 591 (44.8%) had TTM at 36°C (353 [59.7%] men; median [interquartile range] age, 59 [48-69] years). Overall, 184 of 187 patients (98.4%) with severe cerebral edema died and 234 of 243 patients (96.3%) with highly malignant EEG died regardless of TTM strategy. Comparing TTM at 33°C with TTM at 36°C in 911 patients (69.1%) with neither severe cerebral edema nor highly malignant EEG, survival was lower in patients with mild to moderate coma and no shock (risk difference,-13.8%; 95% CI,-24.4% to-3.2%) but higher in patients with mild to moderate coma and cardiopulmonary failure (risk difference, 21.8%; 95% CI, 5.4% to 38.2%) or with severe coma (risk difference, 9.7%; 95% CI, 4.0% to 15.3%). Interactions were similar for functional outcomes. Most deaths (633 of 968 [65.4%]) resulted after withdrawal of life-sustaining therapies. CONCLUSIONS AND RELEVANCE In this study, TTM at 33°C was associated with better survival than TTM at 36°C among patients with the most severe post-cardiac arrest illness but without severe cerebral edema or malignant EEG. However, TTM at 36°C was associated with better survival among patients with mild-to moderate-severity illness.

Including prehospital provider impression to objective physiologic factors identified three more patients with infection at the cost of overtriaging five. Future research should determine the effect of training or diagnostic aids for improving the sensitivity of prehospital identification of patients with serious infection.

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In this retrospective study of pediatric patients in a community ED, decreasing age, non-black/non-white race, and IV attempt location (hand and lower extremity vs. antecubital fossa) were associated with greater odds of difficult IV access.

When emergency physicians use routine clinical observations, they may miss diagnosing up to two-thirds of patients with delirium. Recognition of delirium can be enhanced with standardised cognitive testing.

Mechanistically, adjunctive therapy with ketamine may attenuate the demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor stimulation in severe ethanol withdrawal, reduce the need for excessive gamma-aminobutyric acid agonist mediated-sedation, and limit associated morbidity. A ketamine infusion in patients with delirium tremens was associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, lower likelihood of intubation, and a trend toward a shorter hospitalization.