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Prediction of the Risk of Sepsis by Using Analysis of Plasma Glucose and Serum Lactate in Ambulance Services: A Prospective Study
- Agnes Olander, Carl Magnusson, Annelie J. Sundler, Anders Bremer, Henrik Andersson, Johan Herlitz, Christer Axelsson, Magnus Andersson Hagiwara
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue 2 / April 2023
- Published online by Cambridge University Press:
- 08 February 2023, pp. 160-167
- Print publication:
- April 2023
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Introduction:
The early recognition of patients with sepsis is difficult and the initial assessment outside of hospitals is challenging for ambulance clinicians (ACs). Indicators that ACs can use to recognize sepsis early are beneficial for patient outcomes. Research suggests that elevated point-of-care (POC) plasma glucose and serum lactate levels may help to predict sepsis in the ambulance service (AS) setting.
Study Objective:The aim of this study was to test the hypothesis that the elevation of POC plasma glucose and serum lactate levels may help to predict Sepsis-3 in the AS.
Methods:A prospective observational study was performed in the AS setting of Gothenburg in Sweden from the beginning of March 2018 through the end of September 2019. The criteria for sampling POC plasma glucose and serum lactate levels in the AS setting were high or intermediate risk according to the Rapid Emergency Triage and Treatment System (RETTS), as red, orange, yellow, and green if the respiratory rate was >22 breaths/minutes. Sepsis-3 were identified retrospectively. A primary and secondary analyses were carried out. The primary analysis included patients cared for in the AS and emergency department (ED) and were hospitalized. In the secondary analysis, patients who were only cared for in the AS and ED without being hospitalized were also included. To evaluate the predictive ability of these biomarkers, the area under the curve (AUC), sensitivity, specificity, and predictive values were used.
Results:A total of 1,057 patients were included in the primary analysis and 1,841 patients were included in the secondary analysis. In total, 253 patients met the Sepsis-3 criteria (in both analyses). The AUC for POC plasma glucose and serum lactate levels showed low accuracy in predicting Sepsis-3 in both the primary and secondary analyses. Among all hospitalized patients, regardless of Sepsis-3, more than two-thirds had elevated plasma glucose and nearly one-half had elevated serum lactate when measured in the AS.
Conclusions:As individual biomarkers, an elevated POC plasma glucose and serum lactate were not associated with an increased likelihood of Sepsis-3 when measured in the AS in this study. However, the high rate of elevation of these biomarkers before arrival in hospital highlights that their role in clinical decision making at this early stage needs further evaluation, including other endpoints than Sepsis-3.
Prehospital Identification of Patients with a Final Hospital Diagnosis of Stroke
- Elin Andersson, Linda Bohlin, Johan Herlitz, Annelie J. Sundler, Zoltán Fekete, Magnus Andersson Hagiwara
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- Journal:
- Prehospital and Disaster Medicine / Volume 33 / Issue 1 / February 2018
- Published online by Cambridge University Press:
- 10 January 2018, pp. 63-70
- Print publication:
- February 2018
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Introduction
the early phase of stroke, minutes are critical. Since the majority of patients with stroke are transported by the Emergency Medical Service (EMS), the early handling and decision making by the EMS clinician is important.
ProblemThe study aim was to evaluate the frequency of a documented suspicion of stroke by the EMS nurse, and to investigate differences in the clinical signs of stroke and clinical assessment in the prehospital setting among patients with regard to if there was a documented suspicion of stroke on EMS arrival or not, in patients with a final hospital diagnosis of stroke.
MethodsThe study had a retrospective observational design. Data were collected from reports on patients who were transported by the EMS and had a final diagnosis of stroke at a single hospital in western Sweden (630 beds) in 2015. The data sources were hospital and prehospital medical journals.
ResultsIn total, 454 patients were included. Among them, the EMS clinician suspected stroke in 52%. The findings and documentation on patients with a suspected stroke differed from the remaining patients as follows:
a) More frequently documented symptoms from the face, legs/arms, and speech;
b) More frequently assessments of neurology, face, arms/legs, speech, and eyes;
c) More frequently addressed the major complaint with regard to time and place of onset, duration, localization, and radiation;
d) Less frequently documented symptoms of headache, vertigo, and nausea; and
e) More frequently had an electrocardiogram (ECG) recorded and plasma glucose sampled.
In addition to the 52% of patients who had a documented initial suspicion of stroke, seven percent of the patients had an initial suspicion of transitory ischemic attack (TIA) by the EMS clinician, and a neurologist was approached in another 10%.
ConclusionAmong 454 patients with a final diagnosis of stroke who were transported by the EMS, an initial suspicion of stroke was not documented in one-half of the cases. These patients differed from those in whom a suspicion of stroke was documented in terms of limited clinical signs of stroke, a less extensive clinical assessment, and fewer clinical investigations.
,Andersson E ,Bohlin L ,Herlitz J ,Sundler AJ ,Fekete Z .Andersson Hagiwara M Prehospital Identification of Patients with a Final Hospital Diagnosis of Stroke . Prehosp Disaster Med.2018 ;33 (1 ):63 –70 .
On-Scene and Final Assessments and Their Interrelationship Among Patients Who Use the EMS on Multiple Occasions
- Julia Tärnqvist, Erik Dahlén, Gabriella Norberg, Carl Magnusson, Johan Herlitz, Anneli Strömsöe, Christer Axelsson, Magnus Andersson Hagiwara
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- Journal:
- Prehospital and Disaster Medicine / Volume 32 / Issue 5 / October 2017
- Published online by Cambridge University Press:
- 08 May 2017, pp. 528-535
- Print publication:
- October 2017
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Introduction
The use of Emergency Medical Services (EMS) is increasing. A number of patients call repeatedly for EMS. Early studies of frequent callers show that they form a heterogenous group.
ProblemThere is a lack of research on frequent EMS callers. There is furthermore a lack of knowledge about characteristics and the prehospital assessment of the patients who call for EMS on several occasions. Finally, there is a general lack of knowledge with regard to the association between the prehospital assessment by health care providers and the final diagnosis.
MethodPatients in Skaraborg in Western Sweden, who used the EMS at least four times in 2014, were included, excluding transport between hospitals. Information on the prehospital assessment on-scene and the final diagnosis was collected from the EMS and hospital case records.
ResultsIn all, 339 individual patients who used the EMS on 1,855 occasions were included, accounting for five percent of all missions. Fifty percent were women. The age range was 10-98 years, but more than 50.0% were in the age range of 70-89 years.
The most common emergency signs and symptoms (ESS) codes on the scene were dyspnea, chest pain, and abdominal pain. The most common final diagnosis was chronic obstructive pulmonary disease (eight percent).
Thirteen percent of all cases had a final diagnosis defined as a potentially life-threatening condition. Among these, 22.0% of prehospital assessments were retrospectively judged as potentially inappropriate.
Forty-nine percent had a defined final diagnosis not fulfilling the criteria for a potentially life-threatening condition. Among these cases, 30.0% of prehospital assessments were retrospectively judged as potentially inappropriate.
Conclusion:Among patients who used EMS on multiple occasions, the most common symptoms on-scene were dyspnea, chest pain, and abdominal pain. The most common final diagnosis was chronic obstructive pulmonary disease. In 13.0%, the final diagnosis of a potentially life-threatening condition was indicated. In a minority of these cases, the assessment on-scene was judged as potentially inappropriate.
,Tärnqvist J ,Dahlén E ,Norberg G ,Magnusson C ,Herlitz J ,Strömsöe A ,Axelsson C .Andersson Hagiwara M On-Scene and Final Assessments and Their Interrelationship Among Patients Who Use the EMS on Multiple Occasions . Prehosp Disaster Med.2017 ;32 (5 ):528 –535 .
The Early Chain of Care in Patients with Bacteraemia with the Emphasis on the Prehospital Setting
- Christer Axelsson, Johan Herlitz, Anders Karlsson, Henrik Sjöberg, Maria Jiménez-Herrera, Angela Bång, Anders Jonsson, Anders Bremer, Henrik Andersson, Martin Gellerstedt, Lars Ljungström
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- Journal:
- Prehospital and Disaster Medicine / Volume 31 / Issue 3 / June 2016
- Published online by Cambridge University Press:
- 30 March 2016, pp. 272-277
- Print publication:
- June 2016
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Purpose
There is a lack of knowledge about the early phase of severe infection. This report describes the early chain of care in bacteraemia as follows: (a) compare patients who were and were not transported by the Emergency Medical Services (EMS); (b) describe various aspects of the EMS chain; and (c) describe factors of importance for the delay to the start of intravenous antibiotics. It was hypothesized that, for patients with suspected sepsis judged by the EMS clinician, the delay until the onset of antibiotic treatment would be shorter.
Basic ProceduresAll patients in the Municipality of Gothenburg (Sweden) with a positive blood culture, when assessed at the Laboratory of Bacteriology in the Municipality of Gothenburg, from February 1 through April 30, 2012 took part in the survey.
Main Findings/ResultsIn all, 696 patients fulfilled the inclusion criteria. Their mean age was 76 years and 52% were men. Of all patients, 308 (44%) had been in contact with the EMS and/or the emergency department (ED). Of these 308 patients, 232 (75%) were transported by the EMS and 188 (61%) had “true pathogens” in blood cultures. Patients who were transported by the EMS were older, included more men, and suffered from more severe symptoms and signs.
The EMS nurse suspected sepsis in only six percent of the cases. These patients had a delay from arrival at hospital until the start of antibiotics of one hour and 19 minutes versus three hours and 21 minutes among the remaining patients (P =.0006). The corresponding figures for cases with “true pathogens” were one hour and 19 minutes versus three hours and 15 minutes (P =.009).
ConclusionAmong patients with bacteraemia, 75% used the EMS, and these patients were older, included more men, and suffered from more severe symptoms and signs. The EMS nurse suspected sepsis in six percent of cases. Regardless of whether or not patients with true pathogens were isolated, a suspicion of sepsis by the EMS clinician at the scene was associated with a shorter delay to the start of antibiotic treatment.
,Axelsson C ,Herlitz J ,Karlsson A ,Sjöberg H ,Jiménez-Herrera M ,Bång A ,Jonsson A ,Bremer A ,Andersson H ,Gellerstedt M .Ljungström L The Early Chain of Care in Patients with Bacteraemia with the Emphasis on the Prehospital Setting . Prehosp Disaster Med.2016 ;31 (3 ):272 –277 .
A Description of the Prehospital Phase of Aortic Dissection in Terms of Early Suspicion and Treatment
- Christer Axelsson, Thomas Karlsson, Katarina Pande, Kristin Wigertz, Per Örtenwall, Joakim Nordanstig, Johan Herlitz
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- Journal:
- Prehospital and Disaster Medicine / Volume 30 / Issue 2 / April 2015
- Published online by Cambridge University Press:
- 10 February 2015, pp. 155-162
- Print publication:
- April 2015
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Purpose
Aortic dissection is difficult to detect in the early phase due to a variety of symptoms. This report describes the prehospital setting of aortic dissection in terms of symptoms, treatment, and suspicion by the Emergency Medical Service (EMS) staff.
Basic ProceduresAll patients in the Municipality of Gothenburg, Sweden, who, in 2010 and 2011, had a hospital discharge diagnosis of aortic dissection (international classification of disease (ICD) I 71,0) were included. The exclusion criteria were: age < 18 years of age and having a planned operation. This was a retrospective, descriptive study based on patient records. In the statistical analyses, Fisher's exact test and the Mann-Whitney U test were used for analyses of dichotomous and continuous/ordered variables.
Main findingsOf 92 patients, 78% were transported to the hospital by the EMS. The most common symptom was pain (94%). Pain was intensive or very intensive in 89% of patients, with no significant difference in relation to the use of the EMS. Only 47% of those using the EMS were given pain relief with narcotic analgesics. Only 12% were free from pain on admission to the hospital. A suspicion of aortic dissection was reported by the EMS staff in only 17% of cases. The most common preliminary diagnosis at the dispatch center (31%) and by EMS clinicians (52%) was chest pain or angina pectoris. In all, 79% of patients were discharged alive from the hospital (75% of those that used the EMS and 95% of those that did not).
ConclusionAmong patients who were hospitalized due to aortic dissection in Gothenburg, 78% used the EMS. Despite severe pain in the majority of patients, fewer than half received narcotic analgesics, and only 12% were free from pain on admission to the hospital. In fewer than one-in-five patients was a suspicion of aortic dissection reported by the EMS staff.
. ,Axelsson C ,Karlsson T ,Pande K ,Wigertz K ,Örtenwall P ,Nordanstig J .Herlitz J A Description of the Prehospital Phase of Aortic Dissection in Terms of Early Suspicion and Treatment . Prehosp Disaster Med.2015 ;30 (2 ):1 -8
44 - In-hospital resuscitation
- from Part IV - Therapy of sudden death
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- By Mary Ann Peberdy, Department of Medicine and Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA, Johan Herlitz, Division of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden, Michelle Cretikos, Simpson Centre for Health Services Research, University of New South Wales, Sydney, Australia
- Edited by Norman A. Paradis, University of Colorado, Denver, Henry R. Halperin, The Johns Hopkins University School of Medicine, Karl B. Kern, University of Arizona, Volker Wenzel, Douglas A. Chamberlain, Cardiff University
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- Book:
- Cardiac Arrest
- Published online:
- 06 January 2010
- Print publication:
- 18 October 2007, pp 782-791
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Summary
Introduction
In-hospital resuscitation practices have changed very little despite significant advances in resuscitation science. Unlike pre-hospital providers, hospital personnel have been slow to focus on resuscitation practices and even slower to adopt evolving science and technology to improve outcomes. Consequently, there has been no improvement in survival over time for hospitalized patients suffering a cardiorespiratory arrest, where overall survival remains approximately 18%.
Hospitalized patients have different comorbidities from persons who arrest outside of the hospital. In a large series of cardiorespiratory arrests occurring in hospitalized patients in the United States, many arrest patients had electrocardiographic or oximetry monitoring, an invasive airway, or were receiving an intravenous vasoactive drug prior to their arrest, suggesting that this population has varying degrees of underlying instability. Nevertheless, to stop here and suggest that survival will always be poor because the patients are “sick” and cannot be expected to do well leads to a self-fulfilling prophecy. Although the hospitalized patient population may inherently be more acutely ill, the hospital also has potential resources that far outweigh those in the pre-hospital setting.
Different strategies may be necessary to improve survival in the hospital environment. One of the most significant changes that must occur is within the hospital culture. Attention needs to be focused on the science of resuscitation, and on the process of care delivery. The importance of administrative and organizational support is paramount to achieving success. Traditionally, hospitals focus only on the arrest event itself when planning their resuscitation practices. Little attention is given to prevention or the specific care the patient receives after return of spontaneous circulation (ROSC).
10 - The methodology of clinical resuscitation research
- from Part II - Basic science
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- By Johan Herlitz, Department of Cardiology, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden, Anouk van Alem, Department of Cardiology, Academic Medical Center, Room B2-238, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands, Volker Wenzel, Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria, Karl Wegscheider, Institute for Statistics and Econometry, University of Hamburg, Von-Melle-Park 5, 20146 Hamburg, Germany
- Edited by Norman A. Paradis, University of Colorado, Denver, Henry R. Halperin, The Johns Hopkins University School of Medicine, Karl B. Kern, University of Arizona, Volker Wenzel, Douglas A. Chamberlain, Cardiff University
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- Book:
- Cardiac Arrest
- Published online:
- 06 January 2010
- Print publication:
- 18 October 2007, pp 206-215
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Summary
This chapter is designed to provide a comprehensive, systematic account of the methods of conducting clinical research in resuscitation, in particular, how to set up and carry out a comprehensive and meaningful clinical trial. We will follow the natural conduct of a study, from designing the protocol through data collection to evaluation and interpretation. As an example of some of the difficulties and also the satisfactions of a job well done, in the Appendix we present Professor Wenzel's personal description of the trials and tribulations of determining the role of vasopressin in treatment for cardiac arrest.
Study design
Study objectives
Clinical research in cardiac arrest has developed slowly during the last few decades as compared with other disciplines. The objectives of completed, scheduled, or planned studies can roughly be divided into three categories: (1) epidemiology, i.e., collection of information on prevalence, chance and risks of clinical conditions that require resuscitation attempts; for example, anecdote in the Appendix, elevated endogenous vasopressin levels in survivors of cardiac arrest were found in previous epidemiological studies; (2) evaluation of established treatments and algorithms for resuscitation that are practiced with or without proof of efficacy; for example, in the anecdote, historical data on CPR with vasopressin were available; (3) randomized clinical trials performed to collect evidence on the efficacy and safety of established or new interventions or therapeutic strategies following cardiac arrest; for example, the anecdote describes a randomized clinical trial performed to gain evidence on the efficacy of vasopressin as compared to the established epinephrine injections during out-of-hospital CPR.