Objective-To determine the effectiveness of extended trained ambulance personnel (paramedics) for the management of out of hospital cardiac arrest. Methods-A retrospective cohort study of patients who suffered a cardiac arrest between 1 January 1992 and 31 July 1994, and who were transported to their local accident and emergency (A&E) department. Data were collected on basic demography, operational time intervals, and ambulance crew status. Further clinical data were collected, and outcome measures included status on arrival at A&E, status on leaving A&E (hospital admission), and status on leaving hospital. The data were analysed using univariate and multivariate techniques. Results-Univariate analysis showed the likelihood of arriving in A&E with a return of spontaneous circulation was more than doubled among patients attended by a paramedic crew compared with those attended by technicians (relative risk = 2.48, 95% confidence interval 1.34 to 4.60). The likelihood of successful hospital admission was also significantly increased (RR = 1.92, 95% CI 1.13 to 3.27); however, beyond this point, further survival benefits appeared to be much smaller. Similar findings were revealed using multivariate analysis. Second level modelling revealed further possible differences between paramedic and technician crews according to type of incident. Patients successfully admitted to hospital who died before discharge remained severely disabled between admission and death. Conclusions-There are marked short term survival advantages after cardiac arrest associated with paramedic care, but these probably diminish rapidly over time.
The popularity of paracetamol as a drug for self poisoning has increased dramatically since the early 1980s 1 2 ; nowadays almost 50% of episodes of self poisoning presenting to hospital involve the ingestion of paracetamol or paracetamol containing drugs. [3][4][5] It is estimated that about 70 000 episodes of paracetamol self poisoning occur each year in Britain. 6 Although serious morbidity and deaths are rare, 6 7 these usually result from late presentation, which reduces the eVectiveness of available antidotes. 8 9 The epidemiology of paracetamol self poisoning has not previously been described in detail in relation to recorded delays in presentation for treatment. We studied, retrospectively, all episodes of paracetamol self poisoning occurring at either of the two acute hospital units in Nottingham during the first six months of 1996. These included patients seen only in the accident and emergency department, as well as those admitted for inpatient care. Methods and resultsIn Nottingham all patients presenting with suspected or confirmed self poisoning involving paracetamol undergo testing for plasma paracetamol concentrations. The results are routinely recorded in a computerised laboratory database from which all positive tests (>5 mg/l) were identified and subsequently confirmed by reference to the clinical records of each person. During the first six months of 1996 we noted 417 episodes involving 361 people; data on time of ingestion and presentation were available for 330 episodes (79.1%) involving 294 people (81.4%). To avoid bias caused by repeat attenders, only the first presentation by each person during the study period was used in the analysis. Persons in whom the time of ingestion was unknown were more likely to be male (51% versus 42%) but this diVerence was not significant ( 2 =1.9 with 1 df, p=0.17). Similarly, no significant diVerences were detected with respect to age group (0-24 years versus 25-44 versus >45: 2 =2.0 with 2 df, p=0.37); however, persons were more likely to be admitted to hospital when time of ingestion was unknown (67% versus 42%, 2 =14.1 with 1 df, p=0.0002). It was not possible to compare the amounts ingested by these two groups, because of the large number of cases in which both time and amount were unknown. In 132 of 361 cases (36.6%) paracetamol was ingested as a constituent of a fixed ratio combination product, in 110 cases (30.5%) together with other separate pharmaceutical products, and in 133 cases (36.8%) with alcohol. Serum paracetamol concentrations measured less than four hours after ingestion are unlikely to represent peak concentration; therefore unless the amount ingested has been very large or the time of ingestion cannot be determined, treatment is not started until the four hour concentration is known. Accordingly, we designated presentation times within four hours as "optimal", but any longer than this as potentially delaying the onset of eVective treatment. While we found that the majority of patients who had taken a paracetamol overdose (71.1%) presen...
Background: Mutations in the GCH-1 gene are associated with Autosomal Dominant Dopamine Responsive Dystonia (DYT 5). One of the hallmarks of this condition is dramatic and sustained response to low doses of levodopa. Case Report: We present the case of a 22 year old female patient with genetically confirmed GCH-1 Dopa-Responsive Dystonia who had no response to low dose Levodopa but who achieved symptom control on a total dose of 900 mg/day. Discussion: Autosomal Dominant Dopa-Responsive Dystonia is a phenotypical heterogenous condition that, in some cases, may require high doses of levodopa for treatment response. Highlights Mutations in the GCH-1 gene are associated with Autosomal Dominant Dopamine Responsive Dystonia which is typically defined by dramatic responses to low doses of levodopa. We report a patient with genetically confirmed Dopa-Responsive Dystonia who had no response to low dose Levodopa but who achieved symptom control with 900 mg/day.
Background The HSE National Consent Policy recommends health care professionals ‘develop specific mechanisms for the documentation and dissemination of decisions relating to resuscitation’. We also felt a need to promote a move away from a unidimensional CPR focus more towards documentation of appropriate and inappropriate care for the individual patient. Methods In December 2018 we conducted a baseline study of the quality of documentation of patient resuscitation and escalation plans in our hospital. We reviewed the charts of patients on 4 wards on a single day. Results Of 80 patients, 19 had some documentation regarding a CPR discussion. Of those 19 one had been determined at time of an arrest call and one at the time of a deterioration. Only 13 of 19 had some documentation of a discussion surrounding the decision. Only 5 had any documentation of the reasoning behind the decision. Conclusion Other hospitals in our hospital group had implemented a `Do Not Attempt CPR' and Treatment Escalation Plan form in the last year. With their permission we used their form as a template to develop a form for use across our hospital .This form is to be readily accessible in an emergency and out of hours, and contains quality information regarding the goals of care for an individual patient. The form is a single page, easily identifiable with a red border and filed inside the front cover of the chart. We have had the form approved by our Lead Clinicians forum and Hospital’s Resus Committee. To promote the successful introduction of the form we have conducted education sessions across the departments of Medicine, Surgery, Anaesthesia and Obstetrics and Gynaecology. The form has is currently being printed and will be implemented in the coming weeks. We will be closely liaising with users and reviewing its use following implementation.
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