Aims The aim of this study was to investigate the effect of contact-to-balloon time on mortality in ST-segment elevation myocardial infarction (STEMI) patients with and without haemodynamic instability. Methods and results Using data from the prospective, multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial, we assessed the prognostic relevance of first medical contact-to-balloon time in n = 12 675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA). For patients treated within 60 to 180 min from the first medical contact, we found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-min treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to haemodynamically stable patients (0.34, P < 0.0001). Conclusions In patients with CS, the time elapsing from the first medical contact to primary PCI is a strong predictor of an adverse outcome. This patient group benefitted most from immediate PCI treatment, hence special efforts to shorten contact-to-balloon time should be applied in particular to these high-risk STEMI patients. Clinical Trial Registration NCT00794001.

/pdf/impact-of-treatment-delay-on-mortality-in-st-segment-sub83ds0nf.pdf

Impact of treatment delay on mortality in ST-segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT-STEMI trial.

OBJECTIVE To examine the association between antibiotic timing and deep infection of type III open tibia fractures. DESIGN Retrospective prognostic study. SETTING Level 1 Trauma Center. PATIENTS The study population included 137 patients after exclusions for missing data (13), nonreconstructible limbs (9), and/or absence of 90-day outcome data (3). INTERVENTION An observational study of antibiotic timing. MAIN OUTCOME MEASUREMENT Deep infection within 90 days. RESULTS Age, smoking, diabetes, injury severity score, type IIIA versus 3B/C injury, and time to surgical debridement were not associated with infection on univariate analysis. Greater than 5 days to wound coverage (P < 0.001) and greater than 66 minutes to antibiotics (P < 0.01) were univariate predictors of infection. Multivariate analysis found wound coverage beyond 5 days [odds ratio, 7.39; 95% confidence interval (CI), 2.33-23.45; P < 0.001] and antibiotics beyond 66 minutes (odds ratio, 3.78; 95% CI, 1.16-12.31; P = 0.03) independently predicted infection. Immediate antibiotics and early coverage limited the infection rate (1 of 36, 2.8%) relative to delay in either factor (6 of 59, 10.2%) or delay in both factors (17 of 42, 40.5%). CONCLUSIONS Time from injury to antibiotics and to wound coverage independently predict infection of type III open tibia fractures. Both should be achieved as early as possible, with coverage being dependent on the condition of the wound. Given the relatively short therapeutic window for antibiotic prophylaxis (within an hour of injury), prehospital antibiotics may substantially improve outcomes for severe open fractures. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection.

BackgroundParamedics routinely perform multiple time-sensitive decisions in dynamic environments, often with limited information and equipment. Paramount to patient safety, how paramedics make judgements and decisions within their uncertain environment is important. The primary aim of this review was to identify, examine and synthesise the published literature on how paramedics working in the out-of-hospital environment use judgement and make decisions.MethodsDatabases Medline, PubMed, CINAHL, Embase were searched and common themes pertaining to paramedic decision-making were identified. Full text original research articles that focussed on how paramedics perform decision-making in the out-of-hospital environment were included. Papers excluded were non-English; those examining emergency medical technicians, nurse- or physician-led ambulances; paramedics operating in hospital or clinic-based environment; and studies of purely paramedic student populations. Data were managed using the ‘preview, question, read, summarise’ approach.ResultsA total of 362 abstracts and titles were reviewed; six were found to address the research aim. Of those six, four were qualitative in approach, one quantitative and one was mixed-methods. Overall, paramedics displayed the application of subconscious (intuitive) and conscious (analytical) thought processes – consistent with dual-process theory – with experience and formal education influencing factors. Paramedics gathered cues, problem solved, critically analysed, reasoned and displayed aptitude at rapid clinical impressions in critically ill patients with minimal information. Expert paramedics collected, processed and utilised information differently to novices portraying an interconnectedness of conscious and sub-conscious processing.ConclusionParamedic judgement and decision-making is complex and multifaceted with multiple layers of knowledge interwoven. Implications for practice include better cognitive performance; educational course structure guidance; encouraging implementation of routine reflection and feedback, thus promoting continued improvement and better patient outcomes. Despite its importance, research was lacking.

/pdf/paramedic-judgement-decision-making-and-cognitive-processing-3w54tyub9e.pdf

Paramedic judgement, decision-making and cognitive processing: a review of the literature

Lower mortality with pre-hospital electrocardiogram triage by telemedicine support in high risk acute myocardial infarction treated with primary angioplasty: Preliminary data from the Bari-BAT public Emergency Medical Service 118 registry.

Background Emergency medical services (EMS) transportation is associated with shorter door-to-balloon (DTB) time in patients with ST-segment elevation myocardial infarction (STEMI). In addition to EMS transportation, prehospital notification of STEMI by EMS to receiving hospital might be able to further shorten DTB time. We evaluated the impact of STEMI notification on DTB time as well as infarct size. Methods We performed a retrospective analysis of consecutive patients with anterior wall STEMI who underwent emergent coronary angiography. We excluded patients who presented with cardiac arrest and those who were transferred from non–percutaneous coronary intervention–capable hospitals. Mode of transportation were categorized into the 3 groups: (1) EMS transport with STEMI notification, (2) EMS transport without STEMI notification, and (3) self-transport. Baseline characteristics, laboratory data, left ventricular ejection fraction (LVEF), and DTB time were compared among the 3 groups. Results A total of 148 patients were included in the final analysis. Of the 148 patients, 56 patients arrived by EMS transport with STEMI notification, 56 patients arrived by EMS transport without STEMI notification, and 36 patients arrived by self-transport. Patients who arrived by EMS transport with STEMI notification had the shortest DTB time among the 3 groups. Patients who arrived by EMS transport with STEMI notification had smaller infarct size, as indicated by lower peak creatine kinase value and higher LVEF, compared with those who arrived by EMS transport without STEMI notification. Conclusion Emergency medical services transport with STEMI notification was associated with shorter DTB time and smaller infarct size in patients with anterior wall STEMI.

STEMI notification by EMS predicts shorter door-to-balloon time and smaller infarct size

Background: Mortality in ST elevation myocardial infarction (STEMI) is strongly predicted by the time from first medical contact to reperfusion. The aim of this study was to examine the impact of pre-hospital diagnosis by paramedics in the field on the door-to-balloon (DTB) times of patients with ST elevation myocardial infarction undergoing primary percutaneous intervention. Methods: Paramedics in the field identified patients with ST elevation myocardial infarction on a 12-lead electrocardiograph, activated the cardiac catheter laboratory team from the field and initiated therapy with anticoagulants and antiplatelet agents in the pre-hospital setting. This cohort of patients was compared to a similar group of patients without pre-hospital diagnosis and notification. The primary outcome measure was DTB times. A secondary end point was mortality at 30 days and mortality at six months. Results: A total of 281 patients, mean age of 61.1. ±. 12.9 years underwent primary percutaneous intervention with pre-hospital notification occurring in 63 cases. DTB times were lower in those with pre notification than in those without pre-hospital notification (40.4 vs. 75.6. minutes, p. <. 0.001). This represented a 47.6% shorter DTB time. A non-statistically significant mortality reduction at one month and six months was observed in the pre-hospital notification group (1.6 versus 4.3%, p= 0.307 and 1.6 versus 6.4%, p= 0.203, respectively). Conclusion: Pre-hospital intervention at our centre had a powerful effect in reducing the time to reperfusion in patients with STEMI undergoing primary percutaneous intervention.

Pre-hospital ambulance notification and initiation of treatment of ST elevation myocardial infarction is associated with significant reduction in door-to-balloon time for primary PCI

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Pre-hospital ambulance notification and initiation of treatment of ST elevation myocardial infarction is associated with significant reduction in door-to-balloon time for primary PCI