Prehospital Emergency Care最新文献

Objectives: High sensitivity cardiac troponin (hs-cTn) measures are used in the emergency department (ED) to evaluate patients with acute chest pain. Prehospital hs-cTn measurement could facilitate earlier rule-out of myocardial infarction (MI). The objective of this study is to assess the performance of prehospital blood draw for hs-cTnI measure alone, in combination with hs-cTnI measured at ED arrival, and incorporating the Myocardial Ischemic Injury Index (MI³) machine learning algorithm to rule-out index MI.

Methods: We conducted a pilot prospective observational cohort study among adult emergency medical services (EMS) patients with acute, non-traumatic chest pain. Two third-service EMS agencies and two tertiary care EDs in North Carolina participated. Demographics and initial ECG findings were collected. Blood was obtained prehospital and on ED arrival for hs-cTnI measurement. The clinical outcome was adjudicated index visit MI. Efficacy (percentage of patients with index MI ruled-out) and negative predictive value (NPV) for index MI were determined for the following strategies: 1) a very-low single prehospital hs-cTnI, 2) serial hs-cTnI change (delta) at the prehospital and arrival timepoints, 3) MI³ incorporating prehospital hs-cTnI alone and 4) MI³ incorporating prehospital and arrival hs-cTnI.

Results: Of the 75 patients enrolled, 53.3% (40/75) were women, 32.0% (24/75) were Black patients, and the mean age was 62.2 ± 15.7 years. Index MI occurred in 8.0% (6/75). Prehospital hs-cTnI below the limit of quantification (≤2.7ng/L) had an efficacy of 46.7% (35/75) with an NPV of 100% (95%CI 90.0%-100%) for index MI. A prehospital and arrival hs-cTnI delta ≤3 had an efficacy of 84.3% (43/51) with an NPV of 97.7% (95%CI 87.7-99.9%) for index MI. The standard low-risk MI³ threshold <1.6 with a single prehospital hs-cTnI had an efficacy and NPV for index MI of 76.0% (57/75) and 96.5% (95%CI 87.9-99.6), respectively. Finally, the standard low-risk MI³ threshold incorporating both prehospital and arrival hs-cTnI had an efficacy of 70.6% (36/51) and NPV of 100% (95%CI 90.3-100%) for index MI.

Conclusions: Strategies using prehospital blood for hs-cTnI measurement alone and MI³ with prehospital and arrival hs-cTnI safely identified a large percentage of patients ruled-out, warranting further investigation in a larger trial.

Objectives: Paramedics in rural and wilderness environments often face prolonged transport intervals and limited resources, increasing the value of diagnostic tools like point-of-care ultrasound (POCUS). This is a prospective, quasi-experimental study with a one-group pretest-posttest design to assess the feasibility and utility of implementing extended focused assessment with sonography in trauma (eFAST) and limited cardiac ultrasound exams in these austere settings.

Methods: Twenty-four paramedics from a National Park Service unit and a local emergency medical services (EMS) agency underwent a blended POCUS training program, including asynchronous modules and hands-on instruction. Knowledge, attitudes, and practices (KAP) were assessed via pre/post-training surveys and tests, with a delayed knowledge test administered at four months. Scan utility was evaluated via post-scan hand-off surveys.

Results: Participants demonstrated a 44% increase in knowledge scores immediately post-training (p < 0.0001), with good knowledge retention at four months post-training. Although KAP scores showed minimal change, qualitative feedback reflected strong enthusiasm for and perceived utility of prehospital POCUS. Twenty-two scans were performed during routine patient care. Four scans (18.2%) were deemed clinically meaningful by receiving physicians, influencing diagnosis and transport decisions.

Conclusions: Point of care ultrasound training for paramedics in rural and wilderness EMS settings is feasible, well-received, and results in successful use of POCUS for patient care and transport decision-making. Broader implementation and research may provide further insight to EMS clinician satisfaction, diagnostic accuracy and impact on patient outcomes in austere environments.

Objectives: Prehospital blood transfusion by emergency medical services (EMS) is associated with improved outcomes in trauma patients, but little is known about the statewide protocols that influence the availability and use of prehospital blood. This study aimed to describe statewide EMS protocols regarding field-initiated prehospital blood and blood product transfusion across the U.S.

Methods: This was a cross-sectional analysis of publicly available statewide EMS protocols pertaining to field-initiated blood or blood product use during ground transport by advanced life support (ALS) clinicians. We excluded protocols specific to critical care or interfacility transport. We used a standardized data collection tool to compare clinical indications, blood product type, and considerations for pediatrics and biologically female patients who may bear children in the future. Descriptive statistics were used to describe the protocols.

Results: We identified 31 states and the District of Columbia with publicly available statewide EMS protocols. Thirteen (42%) of these protocols allowed for field-initiated prehospital blood transfusion. There was variability regarding recommendations for transfusion indications and the details of administration in the protocols. All protocols allowed for transfusion in traumatic emergencies, and nine (69%) allowed for transfusion in medical emergencies. Three (23%) protocols specifically recommended low titer group O whole blood, and three (23%) protocols allowed transfusion during cardiac arrest. Nine (69%) protocols allowed for transfusion in pediatric patients. Only four (31%) protocols included special considerations for transfusing blood to biologically female patients.

Conclusions: While most statewide EMS protocols in the US did not include field-initiated blood transfusion, the protocols that do exist vary widely. With the increasing implementation of prehospital blood programs, these findings suggest an opportunity to provide more robust evidence-based guidelines for prehospital blood transfusion to improve patient care and outcomes.

Laryngeal tube suction (LTS) is widely used by emergency medical technicians for airway management in patients with out-of-hospital cardiac arrest, but reports of serious complications are limited. Here, we report a rare case of out-of-hospital cardiac arrest in which an LTS was inserted during resuscitation, and perforation of the posterior pharyngeal wall was confirmed by forensic autopsy. The present case is notable because the perforation site was directly visualized during an autopsy while the device remained in place. The case highlights important findings from both the emergency education and forensic perspectives. While the LTS offers the advantage of rapid blind insertion, it carries the risk of fatal complications, such as perforations or deviations from the insertion path. To prevent such perforations from occurring, some essential measures are required, including appropriate device size selection, recognition of resistance during insertion, and confirmation via capnography. Emergency medical personnel should be mindful of these risks during their clinical practice.

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.

Objectives: Injury mechanisms play a critical role in determining the need for advanced airway management during prehospital trauma care. While prior studies have examined airway interventions in the context of physiological compromise or specific clinical conditions, few have evaluated how airway device use varies across trauma mechanisms (e.g., falls, motor vehicle collisions). Understanding which injury types are most associated with airway placement, and which airway devices are most commonly used, can help emergency medical service (EMS) clinicians anticipate airway needs and inform trauma system preparedness.

Methods: We analyzed 2023 data from the National Emergency Medical Services Information System (NEMSIS) to evaluate 9-1-1 trauma activations with documented advanced airway device placement (endotracheal intubation [ETI], supraglottic airway [SGA], and cricothyrotomy [Cric]). Injury causes were categorized based on clinically relevant categories derived from the 20 most common ICD-10 trauma codes. Airway use was described by patient age, sex, urbanicity, incident location, EMS system response, scene, and transport times. Age-stratified airway use rates (per/1,000 trauma activations) were calculated for pediatric (≤15), adult (16-64), and geriatric (≥65) patients.

Results: Among 5,716,650 trauma activations in 2023, 18,628 (3.6 per/1,000) involved advanced airway placement: ETI-only (13,452; 72.2%), SGA-only (3,544; 19.0%), Cric-only (110; 0.6%), and multiple airways (1,522; 8.2%). Patients were primarily male (75.0%) with a median age of 48 years (IQR: 30-66), found in urban areas (81.2%), on street/highway (40.0%) locations, with over half experiencing out-of-hospital cardiac arrest (55.8%). Falls (29.0%) and motor vehicle collisions (MVCs) (21.0%) accounted for the largest frequency of airway placements, while firearm-related injuries (51.9/1,000) and motorcycle accidents (16.1/1,000) had the highest airway use rates across all age groups. Cricothyrotomy was most commonly performed in firearm-related trauma (39.1%). Among patients with scene and transport times <60 minutes, median scene and transport times differed across airway types.

Conclusions: Advanced airway placement occurred in approximately 4 of every 1,000 EMS trauma activations. While falls and MVCs were the most frequent injury types, firearm-related injuries and motorcycle accidents had the highest incidence of airway use. These findings highlight high-risk scenarios for airway intervention and may inform EMS training, triage, and airway preparedness strategies.

Wildland fire in the United States has evolved into a sustained public health emergency with direct and escalating implications for emergency medical services (EMS). Once viewed primarily as a forestry issue, modern wildfire is now driven by climate change, decades of fuel accumulation, expansion of the wildland-urban interface, and ecosystem degradation. Fire seasons have lengthened into year-round events, generating substantial health impacts and placing severe strain on out-of-hospital systems. The population health consequences of wildfire exposure are extensive. Acute smoke inhalation increases asthma exacerbations, chronic obstructive pulmonary disease presentations, cardiovascular events, and premature mortality. Repeated or chronic exposure contributes to long-term pulmonary dysfunction, elevated malignancy risk, and behavioral health morbidity. Children, older adults, individuals with preexisting conditions, and socioeconomically disadvantaged communities experience disproportionate harm. Simultaneously, wildfires cause surges in EMS call volume while disrupting communications, transportation, and access to definitive care. Prehospital clinicians and responders also face significant occupational hazards, including extreme heat, prolonged particulate exposure, musculoskeletal trauma, behavioral health stressors, and an elevated risk of sudden cardiac death. As EMS agencies are increasingly tasked with austere fireground support, extended evacuations, and prolonged operations, the role of EMS physicians becomes critical. However, despite the scale of these challenges, prehospital physicians are often underrepresented in regional wildfire mitigation, preparedness, and resilience planning. National recommendations now call for a strategic shift from reactive suppression to proactive, interdisciplinary collaboration. Prehosptial physicians are uniquely positioned to integrate clinical care, disaster medicine, occupational health, and community preparedness. Their leadership is essential to ensure EMS integration into community wildfire protection plans; to strengthen occupational and mental health support for responders; to guide wildfire-specific training, triage, and protocol development; and to inform public education efforts. Prehospital physicians must also advocate for policies that incorporate out-of-hospital perspectives into resilience funding and mitigation initiatives. In summary, wildland fire is a chronic societal crisis with expanding health and EMS implications. Meeting this challenge requires prehospital physicians to broaden their roles as clinicians, educators, advocates, and policy leaders to support a more fire-adapted and resilient future.

Objectives: The Interfacility transportation of critically ill patients is a common practice in modern medical care. Transportation of patients may be necessary for clinical or hospital capacity issues. Patient transfers are typically conducted by specialized teams via ground emergency medical services (GEMS) using emergency medical vehicles (i.e. ambulances) or helicopter emergency medical services (HEMS) using rotary-wing air ambulances. The primary objective of this study is to compare the efficacy of HEMS and GEMS in terms of the duration of time-critical interfacility transfers.

Methods: This is a retrospective observational study of emergency interfacility transfer of critically ill adult patients in Qatar between 2018 and 2022. Data on patient demographics, facilities' locations, and multiple mission-related time parameters were collected from the Ambulance Service database and the hospitals' centralized electronic medical records and analyzed. Patients with non-emergency conditions, incomplete transfer data, or HEMS activation delays exceeding 30 minutes were excluded.

Results: Data of 518 emergency interfacility transfers (355 GEMS and 163 HEMS) was collected and analyzed. Patients' median age was 45 years old. For transfers shorter than 50 km, HEMS was used in 50.2% (109/217) of cases, while for transfers over 50 km, GEMS was used in 82.1% (247/301) of cases (p < 0.001). The GEMS transfers had a significantly shorter call-to-departure time by 21.9 minutes, whereas HEMS had a significantly shorter departure-to-arrival time by 23.6 minutes. However, the difference in total mission time was not significant (p > 0.05). In transfers less than 50 kilometers, HEMS had a longer call-to-departure time by 18.4 minutes and a shorter departure-to-arrival time by 12.3 minutes (both p < 0.001). Similar trends were observed in both short (<50 km) and long (>50 km) transfers.

Conclusions: Ground ambulance may offer a comparably as efficient option for emergency patient transfers over short and medium distances, as no significant difference was found in the total transfer times and clinical patient outcomes were not assessed. The results obtained in Qatar's context may not be universally generalizable. Helicopter ambulance may be advantageous when the patient needs to be transferred very quickly over a longer distance.