TOP 10 PUBLIKACÍ 2018: EMERGENCY MEDICINE

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1 TOP 10 PUBLIKACÍ 2018: EMERGENCY MEDICINE MUDr. Anatolij Truhlář, Ph.D., FERC Zdravotnická záchranná služba Královéhradeckého kraje, Hradec Králové Klinika anesteziologie, resuscitace a intenzivní medicíny, Univerzita Karlova v Praze, Lékařská fakulta v Hradci Králové, Fakultní nemocnice Hradec Králové

2 Potenciální střet zájmů Fotografie: Jaromír Chalabala

3 Obsah sdělení Přednemocniční aplikace plazmy Moore HB et al. COMBAT. The Lancet 2018 Sperry JL et al. PAMPer trial. NEJM 2018 Zajištění dýchacích cest při KPR Benger JR et al. AIRWAYS-2 trial. JAMA 2018 Wang HE et al. PART trial. JAMA 2018 Jabre P et al. CAAM trial. JAMA 2018 Kim SY et al. Resuscitation 2018 [in press] Farmakoterapie KPR Perkins GD et al. Paramedic 2 trial. NEJM 2018 Pravidla pro nezahájení KPR Druwé P. REAppropriate. Resuscitation 2018 Shibahashi K. TOR rule. Resuscitation 2018 ERC Guidelines 2017 update Perkins GD et al. Resuscitation 2018

4 Život ohrožující krvácení Ilustrační fotografie: Boston 15. dubna 2013 Ilustrační fotografie: Truhlář A. 2018

5 Současné možnosti léčby I, II, VII, IX, X, XII

6 Přednemocniční transfuze STAT MedEvac, Center for Emergency Medicine, University of Pittsburgh

7 Přednemocniční aplikace plazmy Moore HB et al. The Lancet 19 July 2018 Sperry JL et al. NEJM 26 July 2018

8 Přednemocniční aplikace plazmy COMBAT (Control of Major Bleeding After Trauma Trial) Use of prehospital plasma was NOT associated with survival benefit PAMPer trail (Prehospital Air Medical Plasma) Moore HB et al. The Lancet 19 July 2018 Prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombintime ratio than standard-care resuscitation Sperry JL et al. NEJM 26 July 2018

9 Přednemocniční aplikace plazmy COMBAT (Control of Major Bleeding After Trauma Trial) Pragmatic, randomised, single-centre trial Paramedic division for Denver city Denver Health Medical Center 144 pts in haemorrhagic shock (SBP 70 mm Hg or mm Hg plus HR 108 per min) 125 pts analyzed, age 33 years [IQR 25-47] n=65 plasma (treatment) vs. n=60 normal saline (control) median time from Time injury to arrival at hospital: 28 min [IQR 22 34] vs. 24 min [19 31] Transport times: plasma 19 min [IQR 16 23] vs. control 16 min [14 22] Mortality within 28 days: plasma 15 % vs. control 10 % (p=0,37) Study was stopped for futility Moore HB et al. The Lancet 19 July 2018

10 Přednemocniční aplikace plazmy PAMPer trail (Prehospital Air Medical Plasma) Pragmatic, multicenter, cluster-randomized, superiority trial at the University of Pittsburgh air medical transport from the scene OR from an outside referral ED (approx. 22 %) to the trauma center 501 pts in haemorrhagic shock (SBP 70 mm Hg or mm Hg plus HR 108 per min) age 45 years n=230 plasma (treatment) vs. n=271 standard care (control) Transport times: plasma 42 min [IQR 34 53] vs. control 40 min [33 51] Mortality at 30 days: plasma 23,2 % vs. control 33,9 % (p=0,03) Lower median prothrombin time ratio in plasma group (p<0,001) Sperry JL et al. NEJM 26 July 2018

11 Přednemocniční aplikace plazmy PAMPer trail (Prehospital Air Medical Plasma) Sperry JL et al. NEJM 26 July 2018

12 Přednemocniční aplikace plazmy COMBAT (Control of Major Bleeding After Trauma Trial) Most patients in trauma centre within 30 min of injury Ground transportation in an urban area Short time to mechanical haemorrhage control and the immediate availability of plasma in the hospital might explain the absence of benefit PAMPer trail (Prehospital Air Medical Plasma) Even small volume of plasma resulted in a robust mortality benefit Reduction in bleeding or coagulopathy, inflammatory response or endothelial dysfunction of trauma Differences in the volume of prehospital crystalloid solution and in the percentage of patients who received red-cell transfusion Moore HB et al. The Lancet 19 July 2018 Sperry JL et al. NEJM 26 July 2018

13 Zajištění dýchacích cest při KPR Benger JR et al. JAMA 2018

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15 Zajištění dýchacích cest při KPR Wang HE et al. JAMA 2018

16 Přednemocniční aplikace plazmy PART trail (Pragmatic Airway Resuscitation Trial) Multicenter pragmatic cluster-crossover clinical trial 3004 adults with OHCA and anticipated need for advanced airway 27 EMS agencies randomized to initial use of LT (n=1505) vs. ETI (n=1499) 72-hour survival: 18,3 % in the LT group vs 15,4 % in the ETI group (p=0,04) Rates of initial airway success were 90,3 % with LT and 51,6 % with ETI Favorable neurological status at discharge 7,1 % vs. 5,0 % (p=0,02) Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with initial ETI Wang HE et al. JAMA 2018

17 Zajištění dýchacích cest při KPR Jabre P et al. JAMA 2018

18 Zajištění dýchacích cest při KPR CAAM trail (20 center v Belgii a Francii: lékařský systém, 20 min to ALS) Is bag-mask ventilation non-inferior to ETI for initial airway management during advanced resuscitation of patients with OHCA? n=2043 patients (70 % witnessed OHCA, 50 % bystander CPR, 16 % VF) Favorable neurological function at 28 days was present in 4,3 % in the bag-mask group vs. 4,2 % in the ETI group (p=0,11) Difference did not meet the non-inferiority margin of 1 % Higher ROSC if ETI (+3 %), no higher hospital admission or survival Airway management failure 6,4 % BMV vs. 2,8 % ETI (p<0,001) Regurgitation 15,2 % BMV vs. 7,5 % ETI (p<0,001) Jabre P et al. JAMA 2018

19 Zajištění dýchacích cest při KPR ERC guidelines: ETI should be performed only by highly skilled rescuers (?) How much experience with ETI is required for rescuers to perform successful ETI quickly without complications including serious chest compression interruption (interruption time <10 s) or oesophageal intubation during CPR? Kim SY et al. Resuscitation 2018 [in press]

20 Zajištění dýchacích cest při KPR Clinical observation study using review of CPR video clips in an urban ED 110 ETIs during CPR recorded (1st attempt success 68,2 %) Success rate improved and the time to successful ETI decreased with increasing experience 90% success rate for qualified ETI (<60 s) required 137 experiences of ETIs 90% success rate for highly qualified ETI (<30 s) required at least 243 experiences of ETIs Conclusions: more than 240 experiences were required to achieve a 90% success rate of highly qualified ETI (<30 s without complications) Kim SY et al. Resuscitation 2018 [in press]

21 Farmakoterapie KPR Perkins GD et al. NEJM 2018

22 Farmakoterapie KPR Perkins GD et al. NEJM 2018

23 Farmakoterapie KPR Perkins GD et al. NEJM 2018

24 Perkins GD et al. NEJM 2018

25 Perkins GD et al. NEJM 2018

26 Severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]) Perkins GD et al. NEJM 2018

27 Rozhodování o nezahajování KPR Druwé P et al. Resuscitation 2018

28 Rozhodování o nezahajování KPR What is prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in EDs and EMS? Cross-sectional survey conducted in 288 centres in 24 countries 4018 participating clinicians incl. CZ (n=292) 3150 (78,4 %) perceived their last CPR attempt as appropriate 548 (13,6 %) were uncertain 320 (8,0 %) perceived inappropriateness Perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [ ]; P <.0001), a non-witnessed arrest (2.68 [ ]; P <.0001), in older patients (2.94 [ ]; P <.0001, for patients>79 years) and in case of a poor first physical impression of the patient (3.45 [ ]; P <.0001) Need for objective indicators of poor prognosis! Druwé P et al. Resuscitation 2018

29 Rozhodování o nezahajování KPR Observational study evaluated data from OHCA cases in a prospectively collected nationwide Japanese database (n= ) 3 factors strongly associated with unfavourable neurological outcomes at 1 month after OHCA: unshockable initial rhythm (adjusted odds ratio [aor]: 6.09, 95% confidence interval [CI]: ), unwitnessed by bystanders (aor: 5.27, 95% CI: ), and age of 73 years (adjusted OR: 2.34, 95% CI: ) New TOR rule: PPV of 0,996 (95% CI: ) for unfavourable outcome Shibahashi K et al. Resuscitation 2018

30 ERC Guidelines 2017 update

31 ERC Guidelines 2017 update Všichni pacienti s NZO by měli být léčeni kompresemi hrudníku Umělé dýchání může mít ve vybraných situacích přidanou hodnotu Děti Srdeční zástavy nekardiální etiologie Delší dojezdový čas ZZS Změna věkové hranice pro použití pediatrického algoritmu na 18 let Změna výukových materiálů až od roku 2020

32 Jak interpretovat výsledky studií v EM?

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