A multicenter ICNARC-supported study of 832 COPD patients admitted to intensive care units showed a 180-day mortality of 37.9%.
A prognostic model was developed that was a better discriminator than the clinicians’ judgement. Factors associated with a poor prognosis included abnormal acute physiology, poor functional status (bed or chair bound, house bound or restricted), atrial fibrillation, male sex, number of days in hospital before intensive care admission, reduced midarm circumference as a measure of nutrition and muscle mass, years of age over 70 and reduced Glasgow Coma Score.
The COPD acute physiology score contains heart rate, mean arterial pressure, pH, sodium, urea, creatinine, albumin and white cell count.
According to a commentary in Thorax, “Results previously published from this study show that a large majority of patients with COPD achieve acceptable quality of life following their stay in the intensive care unit and would want to be readmitted under similar circumstances. This paper suggests that more should be done to help to get them this chance.”
Hear, hear.
QJM. 2009 Jun;102(6):389-99
Category Archives: All Updates
A Systematic Review of Corticosteroids in the Treatment of Severe Sepsis and Septic Shock in Adults
This thorough review confirms that steroids have no clear benefit on mortality in severe sepsis / septic shock. Looking at prolonged courses of low dose steroids, there may be a beneficial effect but this did not reach statistical significance.
JAMA. 2009 Jun 10;301(22):2362-75
http://www.ncbi.nlm.nih.gov/pubmed/19509383
Etomidate versus ketamine for rapid sequence intubation
Finally a well designed blinded randomised controlled trial on this subject. 0.3 mg/kg etomidate was compared with 2mg/kg ketamine for RSI in 655 patients requiring emergency intubation in the pre-hospital, emergency department, or intensive care unit environments. No difference was observed in intubation conditions or the primary endpoint of maximum SOFA score in the first three days, although the etomidate group had a higher rate of adrenal insufficiency as defined by response to an ACTH test.
Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial.
Lancet. 2009 Jul 25;374(9686):293-300
Ambulance transport induces stress
Plasma levels of adrenaline and noradrenaline increased signficantly in patients with acute coronary syndrome during ambulance transportation – a finding in keeping with studies on normal volunteers. I wonder how much more of an effect helicopter retrieval might have?
Emergency ambulance transport induces stress in patients with acute coronary syndrome
Emerg Med J. 2009 Jul;26(7):524-8.
Paeds BVM for adult resus
Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation
A comparison between two sizes of self-inflating resuscitation bags revealed improved adherence to resuscitation guidelines with the smaller bag. Student paramedics were more likely to produce suboptimal tidal volumes and ventilation rates with a 1500ml bag than a 1000ml bag during simulated ventilation of an artificial lung model.
BMC Emerg Med. 2009 Feb 20;9:4
http://www.ncbi.nlm.nih.gov/pubmed/19228432
Full text at http://www.biomedcentral.com/1471-227X/9/4
Prehospital management of severe traumatic brain injury
Prehospital management of severe traumatic brain injury
A review of current practice and evidence base of this important topic can be found at
BMJ. 2009 May 19;338:b1683
http://www.ncbi.nlm.nih.gov/pubmed/19454738
Full text http://www.bmj.com/cgi/content/full/338/may19_1/b1683
London's getting worse
The physician-led pre-hospital service London HEMS examined its penetrating trauma caseload between 1991 and 2006. Overall, stabbings rose annually by 23.2% and shootings by 11.0%.
Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service
Injury. 2009 May;40(5):560-3
http://www.ncbi.nlm.nih.gov/pubmed/19232594
Ad hoc resus teams less effective
During simulated cardiac arrest resuscitations, a comparision was made between those run by teams that had had time to form before the arrest, and those that had to be assembled ad hoc after the arrest occurred. 99 teams of three doctors, including GPs and hospital physicians were studied. ACLS algorithms were less closely followed in the ad hoc formed teams, with more delays to therapies such as defibrillation. Analysis of voice recordings revealed the ad hoc teams to make fewer leadership utterances (eg. ‘we should defibrillate’ or ‘the next countershock will be 360J’) and more reflective utterances (eg. ‘what should we do next?’). The authors suggest that team building is therefore to be regarded as an additional task imposed on teams formed ad hoc during CPR that may substantially impact on outcome. No surprise to those of us who banned ‘cardiac arrest teams’ from our emergency department resuscitation rooms many years ago!
Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial
BMC Emerg Med. 2009 Feb 14;9:3
http://www.ncbi.nlm.nih.gov/pubmed/19216796
Full text at http://www.biomedcentral.com/1471-227X/9/3
Population density & use of ambulance services
Does ambulance use differ between geographic areas? A survey of ambulance use in sparsely and densely populated areas
A lower use of emergency department health care services by rural residents as compared with urban residents has previously been described. This Swedish study examined the use of ambulance services in relation to geography, showing that patients from sparsely populated areas were sicker. required more treatment, and were assessed as not needing prehospital care less than half as often as their urban counterparts (16% vs 39%). Take home message is that population density is related to inappropriate use of ambulance services.
Am J Emerg Med. 2009 Feb;27(2):202-11
http://www.ncbi.nlm.nih.gov/pubmed/19371529
72000 retrievals by Flying Doctors
Over twelve years in Queensland the RFDS undertook over 72000 fixed wing retrievals, including over 4000 critically ill patients. Trauma was the commonest diagnostic category. There were only 90 primary retrievals, from locations without healthcare facilities – less than one per month on average. This fascinating service covers vast distances, low population density, and a high number of indigenous people.
Aeromedical retrieval for critical clinical conditions: 12 years of experience with the Royal Flying Doctor Service, Queensland, Australia
J Emerg Med. 2009 May;36(4):363-8
http://www.ncbi.nlm.nih.gov/pubmed/18814993