2014 - April R3 Journal Review
Jabre P et al. Family Presence during Cardiopulmonary Resuscitation. N Engl J Med. 2013; 368:1008-1017.
This was a multicenter, randomized, controlled trial comparing if family presence during CPR would decrease the likelihood of PTSD related symptoms for family members. Fifteen prehospital emergency medicine units in France participated in the study from November 2009 through October 2011. The prehospital units consisted of an ambulance driver, a nurse, and a senior emergency physician as the minimum. After simple randomization, eight of the units were assigned to intervention arm and seven to the control. Units assigned to the intervention arm systematically asked family members whether they wished to be present during the resuscitation that occurred on scene. For units that were assigned to the control, family members were not routinely given the option to be present. For those involved in observing the CPR, a communication guide was used to help introduce the relative to the resuscitation scene and when required to help with the announcement of death. Only one family member was evaluated for the study (first degree relative in the following order, spouse, parent, offspring, sibling). Relatives were excluded if there were communication barriers with the relative and in which resuscitation was not attempted. Ninety days after resuscitation, a trained psychologist, who was blinded to the study groups, asked enrolled relatives to answer a structured questionnaire by telephone. Relatives were asked to complete the impact of event scale and hospital anxiety depression scale. The primary end point was the proportion of relatives with PTSD related symptoms with an IES score >30 on day 90. Secondary end points included the effect of family presence on medical efforts at resuscitation, the well-being of the health care team and the occurrence of medicolegal claims. Overall, 211 of 266 (79%) witnessed CPR in the treatment group compared to 131 of 304 (43%) in the control group. The intention-to-treat analysis demonstrated that the frequency of PTSD related symptoms with the IES score was significantly higher in the control group than the intervention group. It was found that relatives who did not witness CPR tend to have higher rates of anxiety and depression. Secondary end point analysis showed that family witnessed CPR did not affect resuscitation characteristics, patient survival or level of emotional stress in the medical team and did not result in medicolegal claims. Overall family presence in CPR resuscitation was associated with positive results on psychological variables. Limitations of the study included that the study was conducted only in France which may preclude generalizing the findings to other EMS systems outside of this area. Another limitation was that trial took place in patient’s homes and did not evaluate in hospital cardiac arrests such as the ED. Despite the limitations the results of the study are promising that the presence of family members during resuscitations are beneficial and may play a major role in caring for the patient.
Mahajan P et al. Procalcitonin as a Marker of Serious Bacterial Infections in Febrile Children Younger than 3 Years Old. Acad Emerg Med. 2014; 21:171-179.
This was a prospective, multicenter study on a convenience sample of well-appearing children younger than 36 months who presented to one of 4 emergency departments for evaluation of fever of unknown origin between May 2004 and December 2005 that aimed to identify potential use of procalcitonin serum levels as markers of serious bacterial infections (SBIs) in an effort to improve efficiency and reduce iatrogenic injury in these febrile young patients who most commonly have simple viral infections (the majority of these types of cases). The investigators collected rectal temp, medical history, birth history, use of antipyretics, and any previous recent vaccinations but did not standardize further data collection – it was left up to each individual EM physician to collect blood, urine, CSF fluid, CXR, etc as he/she deemed necessary. Children were excluded if they were ‘toxic’ appearing, had recently received antibiotics, were recently vaccinated, had obvious etiology of fever, were premature at birth, or guardians did not consent. In all, 226 patients were enrolled most of whom were non-white but otherwise of similar demographics. Thirty children had SBI. The sensitivities of WBC count and procalcitonin were 57 and 53% respectively. The positive LR of procalcitonin (PCT) for SBI was the highest among the different variables (WBC, ANC, % bands, etc) at 5.39. PCT also had the largest area under the curve. Age, PCT level, and absolute band count were the three variables that were independently predictive of SBI using multivariable analysis. Ultimately PCT did better than WBC count or ANC or absolute band count but only by a small margin and moreover, the sensitivity of this test is barely above 50% - a negative result will not reassure the physician that the patient’s presentation is due to viral illness and not SBI. This study was limited by the non-standard approach to the febrile child evaluation and data collection as mentioned earlier. Also, there were ultimately very few children with bacteremia. The children presented to academic emergency centers only and as such it may be difficult to generalize to all children given the unique characteristics of children who present to academic centers. It is however, very much applicable to UCD EM as we were one of the four centers involved in this research.