IntroductionOur previously reported randomized-controlled-trial of point-of-care ultrasound (PoCUS) for patients with undifferentiated hypotension in the emergency department (ED) showed no survival benefit with PoCUS. Here, we examine the data to see if PoCUS led to changes in the care delivered to patients with cardiogenic and non-cardiogenic shock.MethodsA post-hoc analysis was completed on a database of 273 hypotensive ED patients randomized to standard care or PoCUS in six centres in Canada and South Africa. Shock categories recorded one hour after the ED presentation were used to define subcategories of shock. We analyzed initial intravenous fluid volumes, as well as rates of inotrope use and procedures.Results 261 patients could be classified as cardiogenic or non-cardiogenic shock types. Although there were expected differences in the mean fluid volume administered between patients with non-cardiogenic and cardiogenic shock (p-value<0.001), there was no difference between the control and PoCUS groups (mean non-cardiogenic control 1881mL (95% CI 1567-2195mL) vs non-cardiogenic PoCUS 1763mL (1525-2001mL); and cardiogenic control 680mL (28.4-1332mL) vs. cardiogenic PoCUS 744mL (370-1117mL; p= 0.67). Likewise, there were no differences in rates of inotrope administration nor procedures for any of the subcategories of shock between the control group and PoCUS group patients.ConclusionDespite differences in care delivered by subcategory of shock, we did not find any difference in key elements of emergency department care delivered between patients receiving PoCUS and those who did not. This may help explain the previously reported lack of outcome differences between groups.
IntroductionThere is currently no protocol for the initiation of extracorporeal cardiopulmonary resuscitation (ECPR) for out of hospital cardiac arrest (OHCA) in Atlantic Canada. Advanced care paramedics (ACPs) perform advanced cardiac life support in the prehospital setting often completing the entire resuscitation on-scene. Implementation of ECPR will present a novel intervention that is only available at the receiving hospital. Our objective is to determine if an educational program can improve identification of ECPR candidates by paramedics. Establishing paramedic competence will ensure rapid transfer of eligible patients for a potentially life-saving intervention.MethodsAn educational program was delivered to paramedics including a short seminar and pocket card coupled with simulated OHCA cases. A before-and-after study design using a case-based survey was employed. Paramedics were scored on their ability to correctly identify patients suffering OHCA who met the inclusion criteria for our ECPR protocol. A Wilcoxon matched-pairs signed rank test was employed to compare paramedics’ scores before and after the education delivery. A six-month follow-up is planned to assess retention. Qualitative data was also collected from paramedics during simulation to help identify practical issues, potential barriers, and to refine inclusion and exclusion criteria prior to the implementation of our protocol in the prehospital setting.ResultsThe median score pre-education was 10 (IQR: 9-10.5) compared to 14 (IQR: 13-15) after education delivery. The median difference between groups was 5. The Wilcoxon matched-pairs test demonstrated a significant improvement in the paramedics’ ability to correctly identify ECPR candidates after completing our educational program z = -2.67, p = 0.0039.ConclusionParamedic training through a didactic session coupled with a pocket card and simulation appeared to be a feasible method of knowledge translation. Six-month follow-up data will help ensure knowledge retention is achieved.
Introduction
Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for patients with undifferentiated hypotension, yet there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key clinical outcomes. Here we report on resuscitation markers.
Methods
Adult patients presenting to six emergency departments (ED) in Canada and South Africa with undifferentiated hypotension (systolic blood pressure (SBP) <100mmHg or a Shock Index >1.0) were randomized to receive a PoCUS protocol or standard care (control). Reported physiological markers include shock index (SI), and modified early warning score (MEWS), with biochemical markers including venous bicarbonate and lactate, at baseline and four hours.
Results
A total of 273 patients were enrolled, with data collected for 270. Baseline characteristics were similar for each group. Improvements in mean values for each marker during initial treatment were similar between groups: Shock Index; mean reduction in Control 0.39, 95% CI 0.34 to 0.44 vs. PoCUS 0.33, 0.29 to 0.38; MEWS, mean reduction in Control 2.56, 2.22 to 2.89 vs. PoCUS 2.91, 2.49 to 3.32; Bicarbonate, mean reduction in Control 2.71 mmol/L, 2.12 to 3.30 mmol/L vs. PoCUS 2.30 mmol/L, 1.75 to 2.84 mmol/L, and venous lactate, mean reduction in Control 1.39 mmol/L, 0.93 to 1.85 mmol/L vs. PoCUS 1.31 mmol/L, 0.88 to 1.74 mmol/L.
Conclusion
We found no meaningful difference in physiological and biochemical resuscitation markers with or without the use of a PoCUS protocol in the resuscitation of undifferentiated hypotensive ED patients. We are unable to exclude improvements in individual patients or in specific shock types.
Background Patients suffering from out-of-hospital cardiac arrest (OHCA) experience poor survival and neurological outcomes, with rates remaining relatively unchanged despite advancements. Extracorporeal membrane oxygenation (ECMO), termed extracorporeal cardiopulmonary resuscitation (ECPR) in arrests, may offer improved outcomes. We developed local screening criteria for ECPR and then estimated the frequency of use by applying those criteria retrospectively to a cardiac arrest database. The purpose was to determine if an ECPR program is feasible in a medium urban population centre in Atlantic Canada.
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