These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.
A 40-year-old male struck his chest against a pole during a basketball game and had sudden out-of-hospital cardiac arrest. After bystander cardiopulmonary resuscitation, fire and emergency medical services personnel provided six defibrillation attempts prior to emergency department arrival. A 7th attempt in the emergency department using a different vector was unsuccessful. On the 8th attempt, using a second defibrillator with defibrillator pads placed adjacent to the primary set of defibrillator pads, two shocks were administered in near simultaneous fashion. The double sequential defibrillation was successful and the patient had return of spontaneous circulation at the next pulse check. He recovered in the intensive care unit, was discharged home 1 month later, and continues to follow up in clinic over 1 year later with a Cerebral Performance Category score of 1 (short-term memory deficits).
The study suggests that ventilating an adult patient is possible with a smaller, pediatric-sized BVM. The tidal volumes recorded with the pediatric BVM were more consistent with lung-protective ventilation volumes.
Background and Purpose
The last known normal (LKN) time is a critical determinant of IV tPA eligibility; however, the accuracy of EMS-reported LKN times is unknown. We determined the congruence between EMS-reported and neurologist-determined LKN times and identified predictors of incongruent LKN times.
Methods
We prospectively collected EMS-reported LKN times for patients brought into the ED with suspected acute stroke and calculated the absolute difference between the EMS-reported and neurologist-determined LKN times (|ΔLKN|). We determined the rate of inappropriate IV tPA use if EMS-reported times had been used in place of neurologist-determined times. Univariate and multivariable linear regression assessed for any predictors of prolonged |ΔLKN|.
Results
Of 251 patients, mean and median |ΔLKN| were 28 and 0 minutes, respectively. |ΔLKN| was <15 min in 91% of the entire cohort and was <15 min in 80% of patients with a diagnosis of stroke (n=86). Of patients who received IV tPA, none would have been incorrectly excluded from IV tPA if the EMS LKN time had been used. Conversely, of patients who did not receive IV tPA, 6% would have been incorrectly included for IV tPA consideration had the EMS time been used. In patients with wake-up stroke symptoms, EMS underestimated LKN times: mean EMS LKN time - neurologist LKN time = −208 minutes. The presence of wake-up stroke symptoms (p<0.0001) and older age (p=0.019) were independent predictors of prolonged |ΔLKN|.
Conclusions
EMS-reported LKN times were largely congruent with neurologist-determined times. Focused EMS training regarding wake-up stroke symptoms may further improve accuracy.
Background
Antipyretic therapy is commonly prescribed to patients with infection, but its impact on clinical outcomes has yielded mixed results. No data currently exist to characterize the use of antipyretic medications in patients with severe sepsis or septic shock.
Objective
We sought to identify clinical and demographic factors associated with antipyretic medication administration in severe sepsis and septic shock.
Methods
Single-center retrospective cohort study of all febrile patients (Tmax ≥ 38.3°C) at a 1,111-bed academic medical center with gram-negative severe sepsis or septic shock between January 2002 and February 2008. Patients were excluded for liver disease, acute brain injury, and allergy to acetaminophen. Generalized estimating equations were used to estimate the effect of clinical factors on treatment of patients with antipyretic medications.
Results
Although 76% of patients in this febrile cohort (n = 241) had an order for an antipyretic agent, only 42% received antipyretic therapy and 95% of antipyretic doses were acetaminophen. Variables associated with antipyretic treatment were temperature (OR 2.11/°C, 1.53 – 2.89), time after sepsis diagnosis (OR 0.88/8 hrs, 0.82 – 0.95), surgery during hospitalization (OR 0.49, 0.31 – 0.80), death within 36 hours (OR 0.35, 0.15 – 0.85), and mechanical ventilation (OR 0.58, 0.34 – 0.98).
Conclusions
Most febrile episodes in patients with gram-negative severe sepsis or septic shock were not treated with antipyretic medications. Treatment factors predicted antipyretic therapy, but severity of illness factors, demographic factors, and location in the hospital did not.
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