Prehospital Emergency Care最新文献

Objectives: Patients receiving extracorporeal membranous oxygenation (ECMO) support often have fragile conditions that make them susceptible to physiological deterioration during interhospital transport (IHT). This study aimed to assess the safety of IHT for ECMO-supported patients, utilizing a dedicated critical care transport team.

Methods: A retrospective analysis was conducted on patients who underwent IHT while receiving ECMO support in a metropolitan city between January 2016 and April 2024. The primary outcome was the occurrence of abnormal physiologic parameters during IHT, including hypotension (mean arterial pressure <65 mmHg), desaturation (pulse oximetry <90%), tachycardia (heart rate >120/min), and bradycardia (heart rate <50/min).

Results: A total of 151 patients were included in the study, with 96 (59.6%) on Veno-arterial (VA)-ECMO and 55 (40.4%) on veno-venous (VV)-ECMO. Of these, 37.1% had experienced cardiac arrest prior to ECMO initiation. The median transport time from departure at the referring hospital to arrival at the receiving hospital was 25 minutes (interquartile range, 19-37 minutes). Several adverse events occurred during transport, including ECMO console shutdown in 8.9% of cases (n = 10 spontaneous shutdowns, n = 3 due to human error), all of which were appropriately managed by the trained transport team. Physiological parameters remained stable between the start and end of IHT, with a significant reduction in the prevalence of tachycardia (p < 0.01).

Conclusions: Interhospital transport for ECMO-supported patients by a dedicated critical care transport team is safe. These findings support the implementation of specialized transport systems to facilitate the safe transfer of critically ill patients receiving ECMO support.

Objectives: Chest pain is the most common reason for 9-1-1 calls in the United States. Triage of these patients to a local hospital vs tertiary care facility can be challenging. Our objective was to determine whether a cardiovascular telehealth program that connects rural paramedics with emergency physicians could avoid interfacility transfers in patients with chest pain.

Methods: We conducted a pilot prospective cohort study of adult patients with chest pain who underwent prehospital telehealth evaluation in a single emergency medical services (EMS) system (2/2021-11/2023). A paramedic completed a structured assessment of each patient, then connected with an emergency physician to complete a telehealth call. The physician reviewed the patient's electrocardgram (ECG), discussed the case with the paramedic, and met with the patient to determine risk for emergent conditions. Transport destination was guided by the following framework: local clinic (during operating hours) for stable low-risk patients, local community hospital for stable moderate-risk patients, and tertiary care center for high-risk patients, an ischemic ECG, or instability. The primary outcome was avoided interfacility transfers. Secondary outcomes included transport destination, avoided emergency department (ED) visits, and patient satisfaction assessed with the Short Assessment of Patient Satisfaction (SAPS) score.

Results: During the study, 112 patients were accrued, of which 45.5% (51/112) were female and 9.8% (11/112) were non-white with a mean age of 60 ± 17 years. Among these patients, 67.8% (76/112) were triaged to the local hospital, 19.6% (22/112) to a tertiary care center, 2.7% (3/112) to the clinic, and 9.8% (11/112) refused transport. Telehealth triage resulted in in 9 out of 112 patients (8.0%; 95% CI 5.0-13.0%) adjudicated as likely to have avoided subsequent interfacility transfer and avoided ED visits in 2 out of 112 patients (1.8%, 95% CI 0.0-4.3%). Mean SAPS score was 23.4 (±2.8), consistent with strong overall satisfaction with telehealth calls.

Conclusions: Among rural patients with chest pain, an EMS telehealth program was associated with avoided interfacility transfers and strong patient satisfaction.

Objectives: This study aims to characterize the national prehospital trends in primary supraglottic airway use in non-cardiac arrest patients with various methods, including rapid sequence airway (RSA), defined as administration of a sedative and paralytic to facilitate supraglottic airway (SGA) placement. We compared this SGA-first practice to other methods of prehospital airway management.

Methods: This was a retrospective analysis of a national emergency medical services (EMS) database containing 9-1-1 calls over a five-year period. Only ALS-level calls were included. We compared the incidence of SGA- and tracheal-intubation-first attempts by paramedics. We excluded interfacility transfers, patients in or near cardiac arrest, and surgical airways before intubation.

Results: There were 355,511 encounters with endotracheal tube (ETT) or SGA placement, of which 316,392 patients were excluded, most commonly for cardiac arrest and peri-cardiac arrest, leaving 36,058 (92%) managed with tracheal intubation first and 3,061 (8%) managed with a SGA first. Trauma was the primary reason for encounter for approximately 28% of both groups. SGA-first approaches increased over the five-year period from 3.5% to 8.7% of invasive airway attempts. The type of SGA changed substantially over the study period, with use of the iGel increasing (42% to 82%), and the King LTSD decreasing (50% to 14%). Neuromuscular blocking agents were used in 74% of encounters.

Conclusions: Among prehospital patients not in cardiac arrest, supraglottic airway devices comprise 8% of initial advanced airway management, with increasing use over time. Placement is usually facilitated by use of a sedative and neuromuscular blocking agent.

Objectives: On November 28, 2017, the fire at the Guadeloupe University Hospital created an exceptional health care crisis, due to the loss of critical care units, operating rooms, and emergency department at the island's main hospital. Large-scale air medical evacuations were organized to the University Hospital of Martinique, another nearby French island. This unprecedented event posed unique challenges in terms of feasibility and risks inherent to these emergency medical evacuations of critically ill patients.

Methods: It was a retrospective, observational, monocentric study, including all patients with initial medical care provided in Guadeloupe archipelago, Saint-Martin and Saint-Barthelemy islands and which required medical evacuation to the Martinique University Hospital during the following 6 wk after fire at the Guadeloupe University Hospital.

Results: During the study period, 93 patients were included which corresponds to 2.2 patients transferred per day, with a highest transfers occurred during the first week (n = 30). Median age was 52 [22-64] years-old, and 54 were male (58.1%). All transfers were conducted by air 58 patients were admitted in ICU (62.3%) and diseases were mainly cardiovascular (n = 18, 19.4%), neurosurgery (n = 16, 17.2%) and pediatric (n = 15, 16.1%). Nine patients (9.7%) experienced complications or clinical deterioration during air transfer. Median length of hospital stay was 11 [7-17] days. Seven patients died during hospitalization (7.5%) and 81 patients (87.1%) returned in home territories after care in Martinique.

Conclusions: This event demonstrates the feasibility of conducting multiple air medical evacuations during a health crisis in a French overseas territory, with the appropriate medical and logistical resources for the safety and quality of care for evacuated patients.

We present the case of an 18-year-old male who was found unresponsive at home with profound cyanosis and shock. On-site suspicion of methemoglobinemia -suggested by chocolate-colored blood1 and refractory hypoxemia despite 100% oxygen - prompted early administration of methylene blue by emergency medical services. A second dose of methylene blue was given after patient's admission at the emergency department, resulting in a marked reduction in methemoglobin levels and rapid clinical improvement. This case highlights the importance of early recognition of toxicologic emergencies and timely administration of antidotes, including in the prehospital setting. It also underscores the need for ongoing education and training of healthcare professionals - especially first responders - on the identification and management of acute intoxications.

Objectives: Severe traumatic brain injury (TBI) is a leading cause of mortality among the pediatric population, and the impact of emergency medical services (EMS) prehospital times on patient survival remains unclear. The objective of this study was to determine associations between EMS time-on-scene and mortality during transport (i.e., dead-on-arrival [DOA] status) among pediatric patients with severe TBI. We also sought to investigate potential effects of social determinants of health on prehospital care practices.

Methods: This was a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program (2017-2022). Pediatric (<18 years old) patients with severe (Glasgow Coma Scale ≤8) TBI were included in our analyses. We constructed a hierarchical logistic regression model for associations with DOA status. Expecting a potential non-linear relationship between EMS time on scene and odds of presenting DOA, we trained a random forest model to predict survival probability as a function of time on scene and visualized the results with a locally estimated scatterplot smoothing (LOESS) plot. Secondary analyses were performed to investigate demographic associations with EMS time on scene and dispatch of a helicopter ambulance.

Results: Among 1,225 pediatric patients with severe TBI (median age, 13 years), 5.6% (N = 69) presented with DOA status. Longer EMS time on scene was associated with decreased odds of DOA (odds ratio [OR], 0.92; 95% CI, 0.85-0.99; P = 0.025). The LOESS plot revealed a non-linear relationship between EMS time on scene and survival probability, with EMS times associated with increasing survival up to approximately 12 minutes, then plateauing and subsequently decreasing. Black and Hispanic patients experienced shorter EMS scene times (P = 0.008 and P = 0.018, respectively), and all non-White patients had lower odds of air medical service dispatch (all P < 0.001).

Conclusions: Longer EMS time on scene, to a certain point, was associated with lower odds of presenting DOA among pediatric patients with severe TBI, potentially due to increased stabilization measures performed on scene. These results challenge the assumption that expedited transport to a trauma center alone optimizes patient outcomes. Moreover, racial disparities in EMS scene times and ambulance dispatch type highlight a need for further research into prehospital care practices.

Objectives: Prehospital notification is crucial for reducing door-to-reperfusion time in patients with acute ischemic stroke (AIS). However, evidence remains limited regarding the real-world effectiveness of smartphone-based prenotification systems, particularly when considering variations in system activation and utilization. In Daegu, a metropolitan city in South Korea, a mobile application-based prenotification system has been implemented to streamline acute stroke care. This study aims to analyze the effect of the pre-notification system on the reduction of treatment time delay in acute ischemic stroke.

Methods: This retrospective observational before-and-after study was conducted in Daegu, South Korea. The "before" period spanned December 2018 to November 2019, and the "after" period spanned December 2020 to November 2021. Patients diagnosed with AIS (first abnormal time < 6 h) who arrived at the emergency department via emergency medical service at five hospitals were included. Patients were divided into three groups based on the use of a smartphone application (FASTroke) before and after implementing the prehospital AIS notification system. Outcomes of time variables related to ischemic stroke management included scene-to-door time, Door-to-CT scan time (DTC), Door-to-intravenous thrombolysis time (DTI), and Door-to-endovascular thrombectomy time (DTE). The effect of FASTroke implementation on achieving the target time was analyzed through multivariable logistic regression analysis.

Results: Among the 553 patients included in the final analysis, 177 were managed using the FASTroke system. Compared to the before group, the group that used FASTroke during the after period had significantly shorter DTC (23.0-20.0 min, p < 0.001), DTI (42.5-36.0 min, p = 0.044), and DTE (95.5-87.0 min, p = 0.049). Time reduction was even greater with hospital preregistration, including DTC (14.0 min), DTI (33.0 min), and DTE (66.5 min). Logistic regression revealed that FASTroke use significantly increased the odds of achieving DTC < 20 min (adjusted odds ratio 1.971; 95% confidence interval (CI), 1.319-2.945) and DTE < 90 min (aOR 2.010; 95% CI, 1.014-3.985), with even higher odds in the preregistration subgroup.

Conclusions: The FASTroke system significantly improved in-hospital treatment timelines-DTC, DTI, and DTE-particularly through its preregistration feature.