| 1. |
- Djalali, Ahmadreza, et al.
(författare)
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Facilitators and obstacles in pre-hospital medical response to earthquakes : a qualitative study
- 2011
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - Stockholm : Karolinska Institutet, Dept of Clinical Science, Intervention and Technology. - 1757-7241.
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Earthquakes are renowned as being amongst the most dangerous and destructive types of natural disasters. Iran, a developing country in Asia, is prone to earthquakes and is ranked as one of the most vulnerable countries in the world in this respect. The medical response in disasters is accompanied by managerial, logistic, technical, and medical challenges being also the case in the Bam earthquake in Iran. Our objective was to explore the medical response to the Bam earthquake with specific emphasis on pre-hospital medical management during the first days. METHODS: The study was performed in 2008; an interview based qualitative study using content analysis. We conducted nineteen interviews with experts and managers responsible for responding to the Bam earthquake, including pre-hospital emergency medical services, the Red Crescent, and Universities of Medical Sciences. The selection of participants was determined by using a purposeful sampling method. Sample size was given by data saturation. RESULTS: The pre-hospital medical service was divided into three categories; triage, emergency medical care and transportation, each category in turn was identified into facilitators and obstacles. The obstacles identified were absence of a structured disaster plan, absence of standardized medical teams, and shortage of resources. The army and skilled medical volunteers were identified as facilitators. CONCLUSIONS: The most compelling, and at the same time amenable obstacle, was the lack of a disaster management plan. It was evident that implementing a comprehensive plan would not only save lives but decrease suffering and enable an effective praxis of the available resources at pre-hospital and hospital levels.
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| 2. |
- Djalali, Ahmadreza, et al.
(författare)
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Hospital incident command system (HICS) performance in Iran : decision making during disasters
- 2012
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - Stockholm : Karolinska Institutet, Dept of Clinical Science and Education, Södersjukhuset. - 1757-7241.
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Tidskriftsartikel (refereegranskat)abstract
- Background: Hospitals are cornerstones for health care in a community and must continue to function in the face of a disaster. The Hospital Incident Command System (HICS) is a method by which the hospital operates when an emergency is declared. Hospitals are often ill equipped to evaluate the strengths and vulnerabilities of their own management systems before the occurrence of an actual disaster. The main objective of this study was to measure the decision making performance according to HICS job actions sheets using tabletop exercises. Methods: This observational study was conducted between May 1st 2008 and August 31st 2009. Twenty three Iranian hospitals were included. A tabletop exercise was developed for each hospital which in turn was based on the highest probable risk. The job action sheets of the HICS were used as measurements of performance. Each indicator was considered as 1, 2 or 3 in accordance with the HICS. Fair performance was determined as < 40%; intermediate as 41-70%; high as 71-100% of the maximum score of 192. Descriptive statistics, T-test, and Univariate Analysis of Variance were used. Results: None of the participating hospitals had a hospital disaster management plan. The performance according to HICS was intermediate for 83% (n = 19) of the participating hospitals. No hospital had a high level of performance. The performance level for the individual sections was intermediate or fair, except for the logistic and finance sections which demonstrated a higher level of performance. The public hospitals had overall higher performances than university hospitals (P = 0.04). Conclusions: The decision making performance in the Iranian hospitals, as measured during table top exercises and using the indicators proposed by HICS was intermediate to poor. In addition, this study demonstrates that the HICS job action sheets can be used as a template for measuring the hospital response. Simulations can be used to assess preparedness, but the correlation with outcome remains to be studied.
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| 3. |
- Forberg, Jakob L, et al.
(författare)
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An artificial neural network to safely reduce the number of ambulance ECGs transmitted for physician assessment in a system with prehospital detection of ST elevation myocardial infarction
- 2012
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 20:1, s. 1-9
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Tidskriftsartikel (refereegranskat)abstract
- Background: Pre-hospital electrocardiogram (ECG) transmission to an expert for interpretation and triage reduces time to acute percutaneous coronary intervention (PCI) in patients with ST elevation Myocardial Infarction (STEMI). In order to detect all STEMI patients, the ECG should be transmitted in all cases of suspected acute cardiac ischemia. The aim of this study was to examine the ability of an artificial neural network (ANN) to safely reduce the number of ECGs transmitted by identifying patients without STEMI and patients not needing acute PCI. Methods: Five hundred and sixty ambulance ECGs transmitted to the coronary care unit (CCU) in routine care were prospectively collected. The ECG interpretation by the ANN was compared with the diagnosis (STEMI or not) and the need for an acute PCI (or not) as determined from the Swedish coronary angiography and angioplasty register. The CCU physician's real time ECG interpretation (STEMI or not) and triage decision (acute PCI or not) were registered for comparison. Results: The ANN sensitivity, specificity, positive and negative predictive values for STEMI was 95%, 68%, 18% and 99%, respectively, and for a need of acute PCI it was 97%, 68%, 17% and 100%. The area under the ANN's receiver operating characteristics curve for STEMI detection was 0.93 (95% CI 0.89-0.96) and for predicting the need of acute PCI 0.94 (95% CI 0.90-0.97). If ECGs where the ANN did not identify a STEMI or a need of acute PCI were theoretically to be withheld from transmission, the number of ECGs sent to the CCU could have been reduced by 64% without missing any case with STEMI or a need of immediate PCI. Conclusions: Our ANN had an excellent ability to predict STEMI and the need of acute PCI in ambulance ECGs, and has a potential to safely reduce the number of ECG transmitted to the CCU by almost two thirds.
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| 4. |
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| 5. |
- Brizzi, Marco, et al.
(författare)
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Early do-not-resuscitate orders in intracerebral haemorrhage; frequency and predictive value for death and functional outcome. A retrospective cohort study
- 2012
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 20
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: In former studies from North America early Do-Not-Resuscitate orders (DNR orders) in patients with intracerebral haemorrhage (ICH) had negative prognostic impact on mortality. The influence of DNR orders on functional outcome and whether DNR orders are grounded on relevant patient characteristics is unknown. We aimed to determine the frequency and predictive factors of DNR-orders and its association to prognosis, in ICH patients, in Scandinavia. Methods: In 197 consecutive ICH patients admitted to Skane University Hospital, Malmo, Sweden, between January 2007 and June 2009, information of the presence of DNR orders within 48 hours, clinical and radiological characteristics was retrieved by review of patient medical journal and computed tomography scans. Determinants of DNR-orders, one-month case fatality and bad functional outcome (modified Rankin Scale, grade 4-6) were assessed by logistic regression analysis. Results: DNR orders were made in 41% of the cases. After adjustment for confounding factors, age >= 75 years (Odds Ratio (95% confidence interval) 4.2(1.8-9.6)), former stroke (5.1(1.9-3.1)), Reaction Level Scale grade 2-3 and 4 (7.0(2.8-17.5) and (4.1(1.2-13.5), respectively) and intraventricular haemorrhage (3.8(1.6-9.4)) were independent determinants of early DNR orders. Independent predictors of one-month case fatality was age >= 75 years (3.7(1.4-9.6)) volume >= 30 ml (3.5(1.3-9.6)) and DNR orders (3.5(1.5-8.6)). Seizure (6.0(1.04-34.2) and brain stem hemorrhage (8.0(1.1-58.4)) were related to bad functional outcome, whereas early DNR order was not (3.5(0.99-12.7)). Conclusions: Well known prognostic factors are determinants for DNR orders, however DNR orders are independently related to one-month case fatality. In addition to improvements of the local routines, we welcome a change of attitude with an enhanced awareness of the definition of, and a more careful approach with respect to DNR orders.
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| 6. |
- Calcagnile, Olga, et al.
(författare)
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S100B levels are affected by older age but not by alcohol intoxication following mild traumatic brain injury
- 2013
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 21
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Biomarkers of brain damage and head injury are potentially useful tools in the management of afflicted patients. Particularly S100B has received much attention and has been adapted into clinical guidelines. Alcohol intoxication and higher age (65 years and over) have been used as risk factors for serious complications following head injury. The effect of these factors on S100B levels has not been fully established in a relevant patient cohort. Methods: We prospectively included 621 adult patients with mild traumatic brain injury (TBI) and S100B sampling. Mild TBI was defined as Glasgow Come Scale 14-15 with loss of consciousness and/or amnesia, but without high-risk factors for intracranial complications. These patients would normally require CT scanning according to local and most international guidelines. S100B was sampled within 3 hours following trauma. Results: 280 patients (45%) were intoxicated by alcohol. Alcohol intoxication had no effect on S100B levels (p = 0.65) and the performance of S100B remained unchanged in these patients. 115 patients (22%) were 65 years or older with elevated S100B levels being more common in this group compared to patients under 65 (p = 0.029). Although the sensitivity of S100B was unchanged in older patients, the specificity was poorer. Conclusion: S100B can be used reliably in mild TBI patients with alcohol intoxication. The clinically utility of S100B in older patients may be limited by very poor specificity leading to only a small decrease in CT scanning.
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| 7. |
- Cronberg, Tobias, et al.
(författare)
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A structured approach to neurologic prognostication in clinical cardiac arrest trials
- 2013
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 21
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Forskningsöversikt (refereegranskat)abstract
- Brain injury is the dominant cause of death for cardiac arrest patients who are admitted to an intensive care unit, and the majority of patients die after withdrawal of life sustaining therapy (WLST) based on a presumed poor neurologic outcome. Mild induced hypothermia was found to decrease the reliability of several methods for neurological prognostication. Algorithms for prediction of outcome, that were developed before the introduction of mild hypothermia after cardiac arrest, may have affected the results of studies with hypothermia-treated patients. In previous trials on neuroprotection after cardiac arrest, including the pivotal hypothermia trials, the methods for prognostication and the reasons for WLST were not reported and may have had an effect on outcome. In the Target Temperature Management trial, in which 950 cardiac arrest patients have been randomized to treatment at 33 degrees C or 36 degrees C, neuroprognostication and WLST-decisions are strictly protocolized and registered. Prognostication is delayed to at least 72 hours after the end of the intervention period, thus a minimum of 4.5 days after the cardiac arrest, and is based on multiple parameters to account for the possible effects of hypothermia.
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| 8. |
- Ekelund, Ulf, et al.
(författare)
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Patient throughput times and inflow patterns in Swedish emergency departments. A basis for ANSWER, A National SWedish Emergency Registry
- 2011
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 19
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Quality improvement initiatives in emergency medicine (EM) often suffer from a lack of benchmarking data on the quality of care. The objectives of this study were twofold: 1. To assess the feasibility of collecting benchmarking data from different Swedish emergency departments (EDs) and 2. To evaluate patient throughput times and inflow patterns. Method: We compared patient inflow patterns, total lengths of patient stay (LOS) and times to first physician at six Swedish university hospital EDs in 2009. Study data were retrieved from the hospitals' computerized information systems during single on-site visits to each participating hospital. Results: All EDs provided throughput times and patient presentation data without significant problems. In all EDs, Monday was the busiest day and the fewest patients presented on Saturday. All EDs had a large increase in patient inflow before noon with a slow decline over the rest of the 24 h, and this peak and decline was especially pronounced in elderly patients. The average LOS was 4 h of which 2 h was spent waiting for the first physician. These throughput times showed a considerable diurnal variation in all EDs, with the longest times occurring 6-7 am and in the late afternoon. Conclusion: These results demonstrate the feasibility of collecting benchmarking data on quality of care targets within Swedish EM, and form the basis for ANSWER, A National SWedish Emergency Registry.
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| 9. |
- Friberg, Hans
(författare)
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Neurological prognostication after cardiac arrest.
- 2008
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 16:1
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Tidskriftsartikel (refereegranskat)
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| 10. |
- Friberg, Hans, et al.
(författare)
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Submersion, accidental hypothermia and cardiac arrest, mechanical chest compressions as a bridge to final treatment: a case report
- 2009
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 17
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Tidskriftsartikel (refereegranskat)abstract
- Three young men were trapped in a car at the bottom of a canal at two meters depth, after losing control of their vehicle. They were brought up by rescue divers and found in cardiac arrest. One of three patients had return of spontaneous circulation (ROSC), at 47 min after the accident. This sole survivor had the longest submersion time of the three and he received continued mechanical chest compressions during transportation to the hospital. His temperature at admission was 26.9 degrees C, he was rewarmed to 33 degrees C and kept there for 24 h, followed by continued rewarming to normothermia. On day three, he woke up from coma and was discharged from the intensive care unit after one week. At follow-up six months later, he had a complete cerebral recovery but still had myoclonic twitches in the lower extremities. A mechanical device facilitates chest compressions during transportation and may be beneficial as a bridge to final treatment in the hospital. We recommend that comatose patients after submersion, accidental hypothermia and cardiac arrest are treated with mild hypothermia for 12-24 h.
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