Objectives
Hyperglycemia is associated with poor outcomes in critically-ill patients. This has implications for prognostication of patients with out-of-hospital cardiac arrest (OHCA) and for post-resuscitation care. We assessed the association of hyperglycemia, on field point-of-care (POC) testing, with survival and neurologic outcome in patients with return of spontaneous circulation (ROSC) after OHCA.
Methods
This was a retrospective analysis of data in a regional cardiac care system from April 2011 through December 2017 of adult patients with OHCA and ROSC who had a field POC glucose. Patients were excluded if they were hypoglycemic (glucose <60 mg/dl) or received empiric dextrose. We compared hyperglycemic (glucose >250 mg/dL) with euglycemic (glucose 60–250 mg/dL) patients. Primary outcome was survival to hospital discharge (SHD). Secondary outcome was survival with good neurologic outcome (cerebral performance category 1 or 2 at discharge). We determined the adjusted odds ratios (AORs) for SHD and survival with good neurologic outcome.
Results
Of 9008 patients with OHCA and ROSC, 6995 patients were included; 1941 (28%) were hyperglycemic and 5054 (72%) were euglycemic. Hyperglycemic patients were more likely to be female, of non-White race, and have an initial non-shockable rhythm compared to euglycemic patients (p < 0.0001 for all). Hyperglycemic patients were less likely to have SHD compared to euglycemic survivors, 24.4% vs 32.9%, risk difference (RD) −8.5% (95 %CI −10.8%, −6.2%), p < 0.0001. Hyperglycemic survivors were also less likely to have good neurologic outcome compared to euglycemic survivors, 57.0% vs 64.6%, RD −7.6% (95 %CI −12.9%, −2.4%), p = 0.004. The AOR for SHD was 0.72 (95 %CI 0.62, 0.85), p < 0.0001 and for good neurologic outcome, 0.70 (95 %CI 0.57, 0.86), p = 0.0005.
Conclusion
In patients with OHCA, hyperglycemia on field POC glucose was associated with lower survival and worse neurologic outcome.
Snake envenomation is a significant global health problem, particularly in tropical and subtropical locations. In this case, a 38-year-old performing military field operations in South America develops systemic symptoms consistent with snake envenomation after falling into brush. His symptoms were recognized by his unit medic who initiated appropriate field care and immediate resuscitation with intravenous fluids. He was rapidly transported to a local hospital. The hospital administered polyvalent snake antivenom given his systemic symptoms while providing continued supportive care. Field care for snake bites includes removal of the patient from the snake’s striking range, immobilization of the affected extremity, and supportive care. Immediate transport to a facility with snake envenomation management capability is crucial for definitive management.
small: our previous study found a median time of 15 minutes with an IQR of 12-19. The LAMS/VAN breakdown (n¼288 patients who received both) was as follows: Low LAMS/Negative VAN: 29% High LAMS/Negative VAN: 8% Low LAMS/Positive VAN: 43% High LAMS/Positive VAN: 20% 71% of patients had high LAMS or positive VAN. Overall, 26% received computed tomography (CT) perfusion imaging, 16% received tissue plasminogen activator (tPA), and 7% received mechanical intervention. 8% of strokes were hemorrhagic, 43% were ischemic, and 12% were transient ischemic attacks (TIA). The median National Institute of Health Stroke Score (NIHSS) at hospital arrival was 6, with an IQR of 2-12 and a range of 0-36. 50% of patients were discharged home, 18% were sent to a skilled nursing facility, 11% were discharged to rehab, and 5% expired. Table 1 summarizes the p-values associated with certain outcome-scale combinations, calculated using Fisher's exact test or Wilcoxon's rank-sum test (NS ¼ not significant). The cohort of patients with a high LAMS and negative VAN (n¼23) had 26% receive CT perfusion, 18% receive tPA, 14% receive mechanical intervention, were 45% ischemic strokes, and had a median NIHSS of 8.5 with an IQR of 6-17.75. Conclusions: The LAMS combined with the modified VAN is no more effective than the LAMS alone. In this study, the use of the LAMS score alone yielded the most effective results in predicting intervention and outcomes for acute stroke. Requiring both a high LAMS and a positive VAN excludes the group of patients with high LAMS and negative VAN, who still had significantly worse outcomes compared to the cohort overall.
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