Publications by authors named "Bentley J Bobrow"

119 Publications

Feasibility and outcomes from an integrated bridge treatment program for opioid use disorder.

J Am Coll Emerg Physicians Open 2021 Apr 31;2(2):e12417. Epub 2021 Mar 31.

Department of Emergency Medicine McGovern Medical School The University of Texas Health Science Center at Houston Houston Texas USA.

Objective: With a significant proportion of individuals with opioid use disorder not currently receiving treatment, it is critical to find novel ways to engage and retain patients in treatment. Our objective is to describe the feasibility and preliminary outcomes of a program that used emergency physicians to initiate a bridge treatment, followed by peer support services, behavioral counseling, and ongoing treatment and follow-up.

Methods: We developed a program called the Houston Emergency Opioid Engagement System (HEROES) that provides rapid access to board-certified emergency physicians for initiation of buprenorphine, plus at least 1 behavioral counseling session and 4 weekly peer support sessions over the course of 30 days. Follow-ups were conducted by phone and in person to obtain patient-reported outcomes. Primary outcomes included percentage of patients who completed the 30-day program and the percentage for successful linkage to more permanent ongoing treatment after the initial program.

Results: There were 324 participants who initiated treatment on buprenorphine from April 2018 to July 2019, with an average age of 36 (±9.6 years) and 52% of participants were males. At 30 days, 293/324 (90.43%) completed the program, and 203 of these (63%) were successfully connected to a subsequent community addiction medicine physician. There was a significant improvement (36%) in health-related quality of life.

Conclusion: Lack of insurance is a predictor for treatment failure. Implementation of a multipronged treatment program is feasible and was associated with positive patient-reported outcomes. This approach holds promise as a strategy for engaging and retaining patients in treatment.
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http://dx.doi.org/10.1002/emp2.12417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011614PMC
April 2021

Prevalence and charges of opioid-related visits to U.S. emergency departments.

Drug Alcohol Depend 2021 04 3;221:108568. Epub 2021 Feb 3.

School of Biomedical Informatics, The University of Texas Health Science Center at Houston, 7000 Fannin Street, Houston TX 77030, United States.

Objective: An overwhelming responsibility for responding to the opioid epidemic falls on hospital emergency departments (ED). We sought to examine the overall prevalence rate and associated charges of opioid-related diagnoses and overdoses. Although charge data do not necessarily represent cost, they are proxy indicators of resource utilization and burden.

Methods: We conducted a retrospective study of the National Emergency Department Sample (NEDS) dataset, the largest all-payer ED database in the United States. We queried using specific relevant ICD-10 codes to estimate the number of adult ED visits for both opioid poisonings and other opioid-related diagnoses during 2016 and 2017, which was the most recent publicly available data. Prevalence rates and financial charges were calculated by year and odds ratios were used to examine differences.

Results: Of approximately 234 million adult visits to EDs across 2016 and 2017, 2.88 million (1.23%) were related to opioids, with overdoses comprising nearly 27.5% and visits for other opioid-related diagnoses totaling 72.5%. As the primary diagnosis, opioids were responsible for 37% of all ED visits across both years. Total opioid-related visits for the two years accounted for $9.57 billion in ED charges, or $4.78 billion annually, with Medicaid and Medicare responsible for 66% of all charges.

Conclusion And Relevance: Approximately one of every 80 visits to the ED were opioid-related, leading to financial charges approaching $5 billion per year. Since both prevalence and the economic burden of opioid-related visits are high, targeted interventions to address this epidemic's impact on healthcare systems should be a national priority.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108568DOI Listing
April 2021

Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids).

Ann Emerg Med 2021 02 11;77(2):139-153. Epub 2020 Nov 11.

Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ.

Study Objective: We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury.

Methods: The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders.

Results: There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+).

Conclusion: Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
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http://dx.doi.org/10.1016/j.annemergmed.2020.09.435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855946PMC
February 2021

A sentinel COVID-19 case in Houston, Texas: Informing frontline emergency department screening and preparedness.

J Am Coll Emerg Physicians Open 2020 Apr 19;1(2):92-94. Epub 2020 Apr 19.

McGovern Medical School at University of Texas Health Science Center at Houston (UTHealth) Memorial Hermann Health System Houston Texas USA.

In December 2019, a cluster of severe pneumonia cases of unknown cause was reported in Wuhan, Hubei province, China. A novel strain of coronavirus belonging to the same family of viruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) was identified. In February 2020, cases began being identified in the United States. We describe a sentinel COVID-19 patient in Houston, Texas, who first presented on March 1, 2020. The patient did not meet criteria for a Person Under Investigation (PUI) as recommended by the Centers for Disease Control and Prevention (CDC) at the time. This case has broad implications for emergency department screening and preparedness for COVID-19 and other future infectious diseases.
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http://dx.doi.org/10.1002/emp2.12068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493469PMC
April 2020

Emergency medicine: the finest hour in our time.

J Am Coll Emerg Physicians Open 2020 May 12. Epub 2020 May 12.

Department of Emergency Medicine McGovern Medical School at UTHealth Houston Texas USA.

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http://dx.doi.org/10.1002/emp2.12088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273048PMC
May 2020

Out-of-hospital cardiac arrest across the World: First report from the International Liaison Committee on Resuscitation (ILCOR).

Resuscitation 2020 07 6;152:39-49. Epub 2020 Apr 6.

Kyoto University Health Service, Kyoto, Japan. Electronic address:

Background: Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.

Methods: We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.

Results: Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0-97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1-79.0% in all registries and 2.0-37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1-20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8-18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%.

Conclusion: This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.
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http://dx.doi.org/10.1016/j.resuscitation.2020.02.044DOI Listing
July 2020

Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association.

Circulation 2020 03 24;141(12):e686-e700. Epub 2020 Feb 24.

Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.
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http://dx.doi.org/10.1161/CIR.0000000000000744DOI Listing
March 2020

Effect of team-based cardiopulmonary resuscitation training for emergency medical service providers on pre-hospital return of spontaneous circulation in out-of-hospital cardiac arrest patients.

Resuscitation 2019 11 21;144:60-66. Epub 2019 Sep 21.

Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.

Objective: This study aimed to assess whether team-based cardiopulmonary resuscitation (CPR) training for emergency medical service (EMS) providers improved the pre-hospital return of spontaneous circulation (ROSC) rates of non-traumatic adult out-of-hospital cardiac arrest (OHCA) patients.

Methods: This was a before-and-after study an evaluating educational intervention for community EMS providers, which was conducted in Gyeonggi province, South Korea. Team-based CPR training was conducted from January to March 2016 for every level 1 and level 2 EMS provider in the study area. Non-traumatic EMS treated OHCA patients from July to December 2015 and from July to December 2016 were enrolled and used for the analysis. The primary outcome was pre-hospital ROSC rates before and after the training period. A multivariable logistic regression model with an interaction term (period × dispatch type) was used to determine the adjusted odds ratios (aORs) according to the dispatch type (single vs. multi-tiered).

Results: Of the 2125 OHCA cases included, 1072 (50.4%) and 1053 (49.6%) were categorized in the before- and after-training groups, respectively, and the pre-hospital ROSC rates were 6.6% and 12.6%, respectively. In the multivariable logistic regression analysis, the aOR for pre-hospital ROSC was 2.07 (95% CI, 1.32-3.25) in the after-training period. In the interaction model (period × type of dispatch), the aORs for pre-hospital ROSC were 2.00 (95% CI, 1.01-3.98) and 2.13 (95% CI, 1.20-3.79) in the single- and multi-tiered dispatch groups, respectively, during the after-training period.

Conclusion: Team-based CPR training for EMS providers in a large community EMS system improved the pre-hospital ROSC rates of OHCA patients.
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http://dx.doi.org/10.1016/j.resuscitation.2019.09.014DOI Listing
November 2019

Prehospital Protocols Reducing Long Spinal Board Use Are Not Associated with a Change in Incidence of Spinal Cord Injury.

Prehosp Emerg Care 2020 May-Jun;24(3):401-410. Epub 2019 Aug 14.

Many emergency medical services (EMS) agencies have de-emphasized or eliminated the use of long spinal boards (LSB) for patients with possible spinal injury. We sought to determine if implementation of spinal motion restriction (SMR) protocols, which reduce LSB use, was associated with an increase in spinal cord injury (SCI). This retrospective observational study includes EMS encounters from January 1, 2013 to December 31, 2015 submitted by SMR-adopting ground-based agencies to a state EMS database with hospital discharge data. Encounters were excluded if SMR implementation date was unknown, occurred during a 3-month run-in period, or were duplicates. Study samples include patients with traumatic injury (TI), possible spinal trauma (P-ST), and verified spinal trauma (V-ST) using hospital discharge ICD-9/10 diagnosis codes. The incidence of SCI before and after implementation of SMR was compared using Chi-squared and logistic regression. From 1,005,978 linked encounters, 104,315 unique encounters with traumatic injury and known SMR implementation date were identified with 51,199 cases of P-ST and 5,178 V-ST cases. The incidence of SCI in the pre-SMR and post-SMR interval for each group was: TI, 0.20% vs. 0.22% (p = 0.390); P-ST, 0.40% vs. 0.45% (p = 0.436); and V-ST, 4.04% vs. 4.37% (p = 0.561). Age and injury severity adjusted odds ratio of SCI in the highest risk cohort of patients with V-ST was 1.097 after SMR implementation (95% CI 0.818-1.472). In this limited study, no change in the incidence of SCI was identified following implementation of SMR protocols. Prospective evaluation of this question is necessary to evaluate the safety of SMR protocols.
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http://dx.doi.org/10.1080/10903127.2019.1645923DOI Listing
August 2019

Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study.

JAMA Surg 2019 07 17;154(7):e191152. Epub 2019 Jul 17.

Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix.

Importance: Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival.

Objective: To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI.

Design, Setting, And Participants: The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019.

Interventions: Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension.

Main Outcomes And Measures: Primary: survival to hospital discharge; secondary: survival to hospital admission.

Results: Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02).

Conclusions And Relevance: Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines.

Trial Registration: ClinicalTrials.gov identifier: NCT01339702.
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http://dx.doi.org/10.1001/jamasurg.2019.1152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506902PMC
July 2019

Key components of a community response to out-of-hospital cardiac arrest.

Nat Rev Cardiol 2019 07;16(7):407-416

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death worldwide, with substantial geographical, ethnic and socioeconomic disparities in outcome. Successful resuscitation efforts depend on the 'chain of survival', which includes immediate recognition of cardiac arrest and activation of the emergency response system, early bystander cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, rapid defibrillation, basic and advanced emergency medical services and integrated post-cardiac arrest care. Well-orchestrated telecommunicator CPR programmes can improve rates of bystander CPR - a critical link in the chain of survival. High-performance CPR by emergency medical service providers includes minimizing interruptions in chest compressions and ensuring adequate depth of compressions. Developing local, regional and statewide systems with dedicated high-performing cardiac resuscitation centres for post-resuscitation care can substantially improve survival after OHCA. Innovative digital tools for recognizing cardiac arrest where and when it occurs, notifying potential citizen rescuers and providing automated external defibrillators at the scene hold the promise of improving survival after OHCA. Improved implementation of the chain of survival can save thousands of lives each year.
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http://dx.doi.org/10.1038/s41569-019-0175-4DOI Listing
July 2019

Key components of a community response to out-of-hospital cardiac arrest.

Nat Rev Cardiol 2019 07;16(7):407-416

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death worldwide, with substantial geographical, ethnic and socioeconomic disparities in outcome. Successful resuscitation efforts depend on the 'chain of survival', which includes immediate recognition of cardiac arrest and activation of the emergency response system, early bystander cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, rapid defibrillation, basic and advanced emergency medical services and integrated post-cardiac arrest care. Well-orchestrated telecommunicator CPR programmes can improve rates of bystander CPR - a critical link in the chain of survival. High-performance CPR by emergency medical service providers includes minimizing interruptions in chest compressions and ensuring adequate depth of compressions. Developing local, regional and statewide systems with dedicated high-performing cardiac resuscitation centres for post-resuscitation care can substantially improve survival after OHCA. Innovative digital tools for recognizing cardiac arrest where and when it occurs, notifying potential citizen rescuers and providing automated external defibrillators at the scene hold the promise of improving survival after OHCA. Improved implementation of the chain of survival can save thousands of lives each year.
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http://dx.doi.org/10.1038/s41569-019-0175-4DOI Listing
July 2019

Quantification of ventilation volumes produced by compressions during emergency department cardiopulmonary resuscitation.

Am J Emerg Med 2018 09 30;36(9):1640-1644. Epub 2018 Jun 30.

Department of Emergency Medicine, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, United States of America. Electronic address:

Background: Clinical investigations have shown improved outcomes with primary compression cardiopulmonary resuscitation strategies. It is unclear whether this is a result of passive ventilation via chest compressions, a low requirement for any ventilation during the early aspect of resuscitation or avoidance of inadvertent over-ventilation.

Objectives: To quantify whether chest compressions with guideline-compliant depth (>2 in) produce measurable and substantial ventilation volumes during emergency department resuscitation of out-of-hospital cardiac arrest.

Methods: This was a prospective, convenience sampling of adult non-traumatic out-of-hospital cardiac arrest patients receiving on-going cardiopulmonary resuscitation in an academic emergency department from June 1, 2011 to July 30, 2013. Cardiopulmonary resuscitation quality files were analyzed using R-Series defibrillator/monitors (ZOLL Medical) and ventilation data were measured using a Non-Invasive Cardiac Output monitor (Philips/Respironics, Wallingford, CT).

Results: cardiopulmonary resuscitation quality data were analyzed from 21 patients (17 males, median age 59). The median compression depth was 2.2 in (IQR = 1.9, 2.5) and the median chest compression fraction was 88.4% (IQR = 82.2, 94.1). We were able to discern 580 ventilations that occurred during compressions. The median passive tidal volume recorded during compressions was 7.5 ml (IQR 3.5, 12.6). While the highest volume recorded was 45.8 ml, 81% of the measured tidal volumes were <20 ml.

Conclusion: Ventilation volume measurements during emergency department cardiopulmonary resuscitation after out-of-hospital cardiac arrest suggest that chest compressions alone, even those meeting current guideline recommendations for depth, do not provide physiologically significant tidal volumes.
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http://dx.doi.org/10.1016/j.ajem.2018.06.057DOI Listing
September 2018

Time to Compress the Time to First Compression.

J Am Heart Assoc 2018 04 27;7(9). Epub 2018 Apr 27.

Arizona Emergency Medicine Research Center, University of Arizona College of Medicine, Tucson, AZ

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http://dx.doi.org/10.1161/JAHA.118.009247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015283PMC
April 2018

Association between coronary angiography with or without percutaneous coronary intervention and outcomes after out-of-hospital cardiac arrest.

Resuscitation 2018 06 13;127:21-25. Epub 2018 Mar 13.

The Arizona Department of Health Services Bureau of Emergency Medical Services and Trauma System, Phoenix, AZ, United States; Arizona Emergency Medicine Research Center, The University of Arizona College of Medicine, Tucson, AZ, United States; The University of Arizona Sarver Heart Center, Tucson, AZ, United States. Electronic address:

Aim: The aim of our study was to assess the impact of coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) without ST-elevation (STE).

Methods: Prospective observational study of adult (age ≥ 18) OHCA of presumed cardiac etiology from 1/01/2010-12/31/2014 admitted to one of 40 recognized cardiac receiving centers within a statewide resuscitation network.

Results: Among 11,976 cases, 1881 remained for analysis after exclusions. Of the 1230 non-STE cases, 524 (43%) underwent CAG with resultant PCI in 157 (30%). Survival in non-STE cases was: 56% in cases without CAG; 82% in cases with CAG but without PCI; and 78% in those with PCI (p < 0.0001). In cases without STE the aOR for survival with CAG alone was 2.34 (95% CI 1.69-3.24) and for CAG plus PCI was 1.98 (95% CI 1.26-3.09). The aOR for CPC 1/2 with CAG alone was 6.89 (95% CI 3.99-11.91) and for CAG plus PCI was 2.95 (95% CI 1.59-5.47). After propensity matching, CAG was associated with an aOR for survival of 2.10 (95% CI 1.30-3.55) and for CPC 1/2 it was 5.06 (95% CI 2.29-11.19).

Conclusion: In OHCA without STE, CAG was strongly and independently associated with survival regardless of whether PCI was performed. The association between CAG and positive outcomes remained after propensity matching.
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http://dx.doi.org/10.1016/j.resuscitation.2018.03.023DOI Listing
June 2018

Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association.

Circulation 2018 05 26;137(21):e645-e660. Epub 2018 Feb 26.

The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a national process to develop and implement evidence-based guidelines for cardiac resuscitation systems of care. Significant experience has been gained with implementing these systems, and new evidence has accumulated. This update describes recent advances in the science of cardiac resuscitation systems and evidence of their effectiveness, as well as recent progress in dissemination and implementation throughout the United States. Emphasis is placed on evidence published since the original recommendations (ie, including and since 2010).
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http://dx.doi.org/10.1161/CIR.0000000000000557DOI Listing
May 2018

Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial.

Ann Intern Med 2018 04 27;168(7):471-480. Epub 2018 Feb 27.

Whatley Health Services, Tuscaloosa, Alabama (R.B., T.T.B., C.S.E., D.H.T.).

Background: Chronic pain is common and challenging to treat. Although cognitive behavioral therapy (CBT) is efficacious, its benefit in disadvantaged populations is largely unknown.

Objective: To evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care.

Design: Randomized controlled trial. (ClinicalTrials.gov: NCT01967342).

Setting: Community health centers serving low-income patients in Alabama.

Patients: Adults (aged 19 to 71 years) with mixed chronic pain.

Interventions: CBT and EDU delivered in 10 weekly 90-minute group sessions.

Measurements: Self-reported, postintervention pain intensity (primary outcome) and physical function and depression (secondary outcomes).

Results: 290 participants were enrolled (70.7% of whom were women, 66.9% minority group members, 72.4% at or below the poverty level, and 35.8% reading below the fifth grade level); 241 (83.1%) participated in posttreatment assessments. Linear mixed models included all randomly assigned participants. Members of the CBT and EDU groups had larger decreases in pain intensity scores between baseline and posttreatment than participants receiving usual care (estimated differences in change scores-CBT: -0.80 [95% CI -1.48 to -0.11]; P = 0.022; EDU: -0.57 [CI, -1.04 to -0.10]; P = 0.018). At 6-month follow-up, treatment gains were not maintained in the CBT group but were still present in the EDU group. With regard to physical function, participants in the CBT and EDU interventions had greater posttreatment improvement than those receiving usual care, and this progress was maintained at 6-month follow-up. Changes in depression (secondary outcome) did not differ between either the CBT or EDU group and the usual care group.

Limitations: Participants represented a single health care system. Self-selection bias may have been present.

Conclusion: Simplified group CBT and EDU interventions delivered at low-income clinics significantly improved pain and physical function compared with usual care.

Primary Funding Source: Patient-Centered Outcomes Research Institute.
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http://dx.doi.org/10.7326/M17-0972DOI Listing
April 2018

2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Circulation 2018 01 6;137(1):e7-e13. Epub 2017 Nov 6.

Cardiopulmonary resuscitation is a lifesaving technique for victims of sudden cardiac arrest. Despite advances in resuscitation science, basic life support remains a critical factor in determining outcomes. The American Heart Association recommendations for adult basic life support incorporate the most recently published evidence and serve as the basis for education and training for laypeople and healthcare providers who perform cardiopulmonary resuscitation.
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http://dx.doi.org/10.1161/CIR.0000000000000539DOI Listing
January 2018

Multistate 5-Year Initiative to Improve Care for Out-of-Hospital Cardiac Arrest: Primary Results From the HeartRescue Project.

J Am Heart Assoc 2017 Sep 22;6(9). Epub 2017 Sep 22.

University of Washington, Seattle, WA.

Background: The HeartRescue Project is a multistate public health initiative focused on establishing statewide out-of-hospital cardiac arrest (OHCA) systems of care to improve case capture and OHCA care in the community, by emergency medical services (EMS), and at hospital level.

Methods And Results: From 2011 to 2015 in the 5 original HeartRescue states, all adults with EMS-treated OHCA due to a presumed cardiac cause were included. In an adult population of 32.8 million, a total of 64 988 OHCAs-including 10 046 patients with a bystander-witnessed OHCA with a shockable rhythm-were treated by 330 EMS agencies. From 2011 to 2015, the case-capture rate for all-rhythm OHCA increased from an estimated 39.0% (n=6762) to 89.2% (n=16 103; <0.001 for trend). Overall survival to hospital discharge was 11.4% for all rhythms and 34.0% in the subgroup with bystander-witnessed OHCA with a shockable rhythm. We observed modest temporal increases in bystander cardiopulmonary resuscitation (41.8-43.5%, <0.001 for trend) and bystander automated external defibrillator application (3.2-5.6%, <0.001 for trend) in the all-rhythm group, although there were no temporal changes in survival. There were marked all-rhythm survival differences across the 5 states (8.0-16.1%, <0.001) and across participating EMS agencies (2.7-26.5%, <0.001).

Conclusions: In the initial 5 years, the HeartRescue Project developed a population-based OHCA registry and improved statewide case-capture rates and some processes of care, although there were no early temporal changes in survival. The observed survival variation across states and EMS systems presents a future challenge to elucidate the characteristics of high-performing systems with the goal of improving OHCA care and survival.
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http://dx.doi.org/10.1161/JAHA.117.005716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5634254PMC
September 2017

Description of Abnormal Breathing Is Associated With Improved Outcomes and Delayed Telephone Cardiopulmonary Resuscitation Instructions.

J Am Heart Assoc 2017 Aug 29;6(9). Epub 2017 Aug 29.

Arizona Department of Health Services, Phoenix, AZ.

Background: Emergency 9-1-1 callers use a wide range of terms to describe abnormal breathing in persons with out-of-hospital cardiac arrest (OHCA). These breathing descriptors can obstruct the telephone cardiopulmonary resuscitation (CPR) process.

Methods And Results: We conducted an observational study of emergency call audio recordings linked to confirmed OHCAs in a statewide Utstein-style database. Breathing descriptors fell into 1 of 8 groups (eg, gasping, snoring). We divided the study population into groups with and without descriptors for abnormal breathing to investigate the impact of these descriptors on patient outcomes and telephone CPR process. Callers used descriptors in 459 of 2411 cases (19.0%) between October 1, 2010, and December 31, 2014. Survival outcome was better when the caller used a breathing descriptor (19.6% versus 8.8%, <0.0001), with an odds ratio of 1.63 (95% confidence interval, 1.17-2.25). After exclusions, 379 of 459 cases were eligible for process analysis. When callers described abnormal breathing, the rates of telecommunicator OHCA recognition, CPR instruction, and telephone CPR were lower than when callers did not use a breathing descriptor (79.7% versus 93.0%, <0.0001; 65.4% versus 72.5%, =0.0078; and 60.2% versus 66.9%, =0.0123, respectively). The time interval between call receipt and OHCA recognition was longer when the caller used a breathing descriptor (118.5 versus 73.5 seconds, <0.0001).

Conclusions: Descriptors of abnormal breathing are associated with improved outcomes but also with delays in the identification of OHCA. Familiarizing telecommunicators with these descriptors may improve the telephone CPR process including OHCA recognition for patients with increased probability of survival.
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http://dx.doi.org/10.1161/JAHA.116.005058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5634247PMC
August 2017

Telephone cardiopulmonary resuscitation is independently associated with improved survival and improved functional outcome after out-of-hospital cardiac arrest.

Resuscitation 2018 01 25;122:135-140. Epub 2017 Jul 25.

Bureau of EMS & Trauma System, Arizona Department of Health Services, Phoenix, AZ, United States; Arizona Emergency Medicine Research Center, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States.

Aim Of Study: This study aims to quantify the relative impact of Dispatcher-Initiated Telephone cardiopulmonary resuscitation (TCPR) on survival and survival with favorable functional outcome after out-of-hospital cardiac arrest (OHCA) in a population of patients served by multiple emergency dispatch centers and more than 130 emergency medical services (EMS) agencies.

Methods: We conducted a retrospective, observational study of EMS-treated adult (≥18 years) patients with OHCA of presumed cardiac origin in Arizona, between January 1, 2011, and December 31, 2014. We compared survival and functional outcome among three distinct groups of OHCA patients: those who received no CPR before EMS arrival (no CPR group); those who received BCPR before EMS arrival and prior to or without telephone CPR instructions (BCPR group); and those who received TCPR (TCPR group).

Results: In this study, 2310 of 4391 patients met the study criteria (median age, 62 years; IQR 50, 74; 1540 male). 32.8% received no CPR, 23.8% received Bystander-Initiated CPR and 43.4% received TCPR. Overall survival was 11.5%. Using no CPR as the reference group, the multivariate adjusted odds ratio for survival at hospital discharge was 1.51 (95% confidence interval [CI], 1.04, 2.18) for BCPR and 1.64 (95% CI, 1.16, 2.30) for TCPR. The multivariate adjusted odds ratio of favorable functional outcome at discharge was 1.58 (95% CI 1.05, 2.39) for BCPR and 1.56 (95% CI, 1.06, 2.31) for TCPR.

Conclusion: TCPR is independently associated with improved survival and improved functional outcome after OHCA.
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http://dx.doi.org/10.1016/j.resuscitation.2017.07.016DOI Listing
January 2018

In reply.

Ann Emerg Med 2017 08;70(2):263-264

Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ; College of Public Health, University of Arizona, Tucson, AZ.

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http://dx.doi.org/10.1016/j.annemergmed.2017.03.015DOI Listing
August 2017

Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality.

Ann Emerg Med 2017 Oct 27;70(4):522-530.e1. Epub 2017 May 27.

College of Public Health, University of Arizona, Tucson, AZ.

Study Objective: Out-of-hospital hypotension has been associated with increased mortality in traumatic brain injury. The association of traumatic brain injury mortality with the depth or duration of out-of-hospital hypotension is unknown. We evaluated the relationship between the depth and duration of out-of-hospital hypotension and mortality in major traumatic brain injury.

Methods: We evaluated adults and older children with moderate or severe traumatic brain injury in the preimplementation cohort of Arizona's statewide Excellence in Prehospital Injury Care study. We used logistic regression to determine the association between the depth-duration dose of hypotension (depth of systolic blood pressure <90 mm Hg integrated over duration [minutes] of hypotension) and odds of inhospital death, controlling for significant confounders.

Results: There were 7,521 traumatic brain injury cases included (70.6% male patients; median age 40 years [interquartile range 24 to 58]). Mortality was 7.8% (95% confidence interval [CI] 7.2% to 8.5%) among the 6,982 patients without hypotension (systolic blood pressure ≥90 mm Hg) and 33.4% (95% CI 29.4% to 37.6%) among the 539 hypotensive patients (systolic blood pressure <90 mm Hg). Mortality was higher with increased hypotension dose: 0.01 to 14.99 mm Hg-minutes 16.3%; 15 to 49.99 mm Hg-minutes 28.1%; 50 to 141.99 mm Hg-minutes 38.8%; and greater than or equal to 142 mm Hg-minutes 50.4%. Log (the logarithm in base 2) of hypotension dose was associated with traumatic brain injury mortality (adjusted odds ratio 1.19 [95% CI 1.14 to 1.25] per 2-fold increase of dose).

Conclusion: In this study, the depth and duration of out-of-hospital hypotension were associated with increased traumatic brain injury mortality. Assessments linking out-of-hospital blood pressure with traumatic brain injury outcomes should consider both depth and duration of hypotension.
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http://dx.doi.org/10.1016/j.annemergmed.2017.03.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614805PMC
October 2017

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes.

Prehosp Emerg Care 2017 Sep-Oct;21(5):575-582. Epub 2017 May 8.

Introduction: Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures.

Methods: This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0-35.9°C [Low Temperature (LT)]; 36.0-37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group.

Results: 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT.

Conclusion: In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.
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http://dx.doi.org/10.1080/10903127.2017.1308609DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638643PMC
July 2018

Disparities in telephone CPR access and timing during out-of-hospital cardiac arrest.

Resuscitation 2017 06 23;115:11-16. Epub 2017 Mar 23.

Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Phoenix, AZ, United States; Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ, United States.

Aim: Spanish-only speaking residents in the United States face barriers to receiving potentially life-saving 911 interventions such as Telephone -cardiopulmonary resuscitation (TCPR) instructions. Since 2015, 911 dispatchers have placed an increased emphasis on rapid identification of potential cardiac arrest. The purpose of this study was to describe the utilization and timing of the 911 system during suspected out-of-hospital cardiac arrest (OHCA) by Spanish-speaking callers in Metropolitan Phoenix, Arizona.

Methods: The dataset consisted of suspected OHCA from 911 centers from October 10, 2010 through December 31, 2013. Review of audio TCPR process data included whether the need for CPR was recognized by telecommunicators, whether CPR instructions were provided, and the time elements from call receipt to initiation of compressions.

Results: A total of 3398 calls were made to 911 for suspected OHCA where CPR was indicated. A total of 39 (1.2%) were determined to have a Spanish language barrier. This averages to 18 calls per year with a Spanish language barrier during the study period, compared with 286 OHCAs expected per year among this population. The average time until telecommunicators recognized CPR need was 87.4s for the no language barrier group compared to 160.6s for the Spanish-language barrier group (p<0.001).Time to CPR instructions started was significantly different between these groups (144.4s vs 231.3s, respectively) (p<0.001), as was time to first compression, (174.4s vs. 290.9s, respectively) (p<0.001).

Conclusions: Our study suggests that Hispanic callers under-utilize the 911 system, and when they do call 911, there are significant delays in initiating CPR.
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http://dx.doi.org/10.1016/j.resuscitation.2017.03.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5459486PMC
June 2017

Intensive care medicine research agenda on cardiac arrest.

Intensive Care Med 2017 Sep 11;43(9):1282-1293. Epub 2017 Mar 11.

Medical ICU, Cochin Hospital (AP-HP), Paris-Cardiovascular-Research-Centre, INSERM U970 (Sudden Death Expertize Centre), Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France.

Over the last 15 years, treatment of comatose post-cardiac arrest patients has evolved to include therapeutic strategies such as urgent coronary angiography with percutaneous coronary intervention (PCI), targeted temperature management (TTM)-requiring mechanical ventilation and sedation-and more sophisticated and cautious prognostication. In 2015, collaboration between the European Resuscitation Council (ERC) and the European Society for Intensive Care Medicine (ESICM) resulted in the first European guidelines on post-resuscitation care. This review addresses the major recent advances in the treatment of cardiac arrest, recent trials that have challenged current practice and the remaining areas of uncertainty.
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http://dx.doi.org/10.1007/s00134-017-4739-7DOI Listing
September 2017

Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold.

JAMA Surg 2017 Apr;152(4):360-368

Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona6Department of Child Health, The University of Arizona College of Medicine, Phoenix.

Importance: Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90 mm Hg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence.

Objective: To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists.

Design, Setting, And Participants: Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119 mm Hg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders.

Main Outcomes And Measures: The main outcome measure was in-hospital mortality.

Results: Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119 mm Hg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95% CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100 mm Hg as for a drop from 90 to 80 mm Hg, and so on throughout the range.

Conclusions And Relevance: We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119 mm Hg. Thus, in patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90 mm Hg are needed.
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http://dx.doi.org/10.1001/jamasurg.2016.4686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637731PMC
April 2017

The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury.

Ann Emerg Med 2017 01 28;69(1):62-72. Epub 2016 Sep 28.

College of Public Health, the University of Arizona, Tucson, AZ.

Study Objective: Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination.

Methods: All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out-of-hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: <10 years, out-of-hospital oxygen saturation ≤10%, and out-of-hospital systolic blood pressure <40 or >200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure <90 mm Hg) or hypoxia (saturation <90%) was assessed with multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, interhospital transfer, and trauma center.

Results: Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death.

Conclusion: In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.
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http://dx.doi.org/10.1016/j.annemergmed.2016.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5173421PMC
January 2017

Barriers to telephone cardiopulmonary resuscitation in public and residential locations.

Resuscitation 2016 12 10;109:116-120. Epub 2016 Aug 10.

Arizona Department of Health Services, Bureau of EMS and Trauma System, 150 North 18th Avenue, Phoenix, AZ 85007, United States; University of Arizona, Department of Emergency Medicine, Arizona Emergency Medicine Research Center, 714 East Van Buren St, Phoenix, AZ 85006, United States; University of Arizona College of Medicine Phoenix, 550 East Van Buren St, Phoenix, AZ 85004, United States.

Aim: Emergency medical telecommunicators can play a key role in improving outcomes from out-of-hospital cardiac arrest (OHCA) by providing instructions for cardiopulmonary resuscitation (CPR) to callers. Telecommunicators, however, frequently encounter barriers that obstruct the Telephone CPR (TCPR) process. The nature and frequency of these barriers in public and residential locations have not been well investigated. The aim of this study is to identify the barriers to TCPR in public and residential locations.

Methods: We conducted a retrospective study of audio recordings of EMS-confirmed OHCAs from eight regional 9-1-1 dispatch centers between January 2012 and December 2013.

Results: We reviewed 1850 eligible cases (public location OHCAs: N=223 and residential location OHCAs: N=1627). Telecommunicators less frequently encountered barriers such as inability to calm callers in public than in residential locations (2.1% vs 8.5%, p=0.002) or inability to place victims on a hard flat surface (13.9% vs 25.4%, p<0.001). However, the barrier where callers were not with patients was more frequently observed in public than in residential locations (11.8% vs 2.7%, p<0.001).

Conclusions: This study revealed that barriers to TCPR are distributed differently across public and residential locations. Understanding these differences can aid in the development of strategies to enhance bystander CPR and improve overall patient outcomes.
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http://dx.doi.org/10.1016/j.resuscitation.2016.07.241DOI Listing
December 2016
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