Prehospital Emergency Care最新文献

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.

Objectives: Patients living in residential aged care homes (RACH) frequently experience acute health episodes prompting contact with emergency medical services (EMS). To improve health care access and reduce unnecessary emergency department (ED) presentations, a referral pathway to the Victorian Virtual ED (VVED) was introduced to EMS secondary triage (comprehensive telephone-based assessment of lower acuity cases). This study evaluates the impact of the pathway on referral outcomes, ED diversion, and patient safety indicators.

Methods: A retrospective cohort study of patients living in RACH who underwent EMS secondary triage in Victoria, Australia was conducted. Data were compared between an 18-month pre-implementation period and an 18-month post-implementation period following the introduction of the referral pathway. Descriptive analyses, interrupted time-series and multivariable logistic regression were used to assess changes in referral outcomes, ED diversion, and recontact within 72 hours.

Results: A total of 59,546 secondary triage cases from RACH were included. Referrals to alternate care pathways increased from 6.8% pre-implementation to 11.2% post-implementation, largely driven by referrals to the VVED (6.7%), while ED diversion also increased (18.7% to 28.9%). Interrupted time-series analysis showed introduction of the VVED pathway was associated with an increase in referrals to alternate care pathways (IRR: 1.349 (95%CI:1.182, 1.539)). In the post-implementation period, referral to the VVED was associated with increased age (AOR 1.12 (95%CI: 1.04,1.20), per 10 year increase), metropolitan event location (AOR 1.18 (95%CI: 1.04,1.34), compared with regional location), out-of-hours calls (AOR 1.55 (95%CI:1.39,1.72), compared with calls between 0800 and 1700), complaints of external injury (AOR 1.50 (95%CI:1.13, 1.98) compared with generally unwell), and lower acuity care timeframes (AOR 19.13 (95%CI:15.01, 24.39) compared with recommendation for immediate care). Seventy-two-hour recontact to EMS increased, from 3.1% to 3.5% (p = 0.002) while lights and sirens transports to ED remained stable (2.5%).

Conclusions: The introduction of the VVED referral pathway to secondary triage was associated with increased use of alternate care pathways and a significant increase in ED diversion for RACH residents. Specific patient and call time characteristics were associated with VVED referral, suggesting the VVED has a targeted role in meeting access needs out of hours and for select clinical presentations.

Objectives: The objective of this study was to assess the prevalence and characteristics of hospice and palliative care (HPC) protocols in emergency medical services (EMS) systems across the United States (U.S.), including both statewide and city-level protocols.

Methods: We conducted a cross-sectional review of publicly available EMS protocols from all 50 U.S. states and the District of Columbia, as well as the 50 most populous U.S. cities. Protocols were obtained between July and November 2024 using the centralized platform EMSProtocols.org and supplemental public sources. Protocols were included if they referenced hospice or palliative care-related terms ("hospice," "palliative," "comfort care," "end-of-life," "terminal illness"). Hospice protocols were included only if the term "hospice" appeared explicitly. Data were abstracted using a standardized form developed around several best-practice protocol features informed by the 2023 National Association of EMS Physicians and the American Academy of Hospice and Palliative Medicine joint position statement. Descriptive statistics were used to analyze the prevalence and content of identified protocols.

Results: Of 101 jurisdictions reviewed, 62 EMS protocols were available for analysis (31 statewide and 31 city-level). Among these, 24.2% (15/62) included a hospice protocol and 25.8% (16/62) included a palliative care protocol. Among hospice protocols, 80.0% included orders for pain medication, 80.0% addressed general symptom management, 73.3% recommended contacting hospice agencies, and 86.7% included guidance on transport decisions. Among hospice protocols, 33.3% permitted EMS clinicians to administer medications from hospice emergency kits. Only one palliative care protocol addressed naloxone use, advising against its routine administration in end-of-life symptom management.

Conclusions: Across the U.S., HPC protocols remain inconsistently integrated into EMS systems. Fewer than one in four reviewed protocols included any HPC-specific guidance, and most lacked comprehensive components recommended by national guidelines. Broader adoption of HPC protocols and alignment with expert recommendations may improve the delivery of compassionate, goal-concordant care to a growing population of seriously ill patients in the out-of-hospital setting.

Objectives: Los Angeles County initiated an extracorporeal cardiopulmonary resuscitation (eCPR) program to transport patients with refractory shockable out-of-hospital cardiac arrest (OHCA) to dedicated eCPR-capable centers (ECCs). The impact of an eCPR program on patients with OHCA who do not receive eCPR has not been described.

Methods: We measured the association between EMS unit participation in the program and survival-to-hospital discharge for patients with OHCA who did not receive eCPR, treated between July 2019 and September 2023. Six of the 29 EMS agencies participated in the program, which included eCPR protocol development, hands-on scenario-based training on the eCPR protocol and application of the mechanical compression device (MCD) on a manikin, and provision of MCDs. Because the deployment model for one agency differed from others (MCDs on supervisor units, no paramedic hands-on training), we prespecified a subgroup analysis excluding that agency.

Results: We analyzed 30,855 patients with EMS-treated OHCA: 7% had a shockable rhythm, 32% were treated by a pilot unit pre-implementation, 24% by a pilot unit post-implementation, and 44% were treated by a unit that never participated in the eCPR pilot. Treatment by a pilot unit post-implementation was not associated with a significant difference in the odds of survival-to-discharge compared to pre-implementation (1.14 95%CI 0.99-1.34) in the primary analysis but was associated with it in the subgroup analysis (1.61 95%CI 1.37-1.95). Similar results were found for neurologic outcome at discharge.

Conclusions: Implementation of an eCPR program is not associated with worse outcomes for patients with OHCA who did not receive eCPR and may be associated with benefit depending on implementation.

Objectives: Delays in hospital management resulting from the failure of emergency medical services (EMS) to activate the stroke code (SC) diminish the probability of receiving acute stroke treatment, adversely affecting patient outcomes. This study aims to analyze the proportion and characteristics of patients eligible for SC not activated by EMS, within a contemporary cohort.

Methods: A retrospective cohort analysis was conducted on prehospital stroke patients from the Catalan SC registry from 2016 to June 2022, who were transported by ambulance. Patients were classified according to whether EMS activated SC or not. Baseline demographic characteristics, comorbidities, clinical episode details, and treatment timelines were analyzed.

Results: Among 34,331 subjects, 28,221 (82%) were transported by EMS, with SC activation occurring in 22,968 (81%) cases. Patients for whom SC was not activated presented with lower National Institutes of Health Stroke Scale scores and longer intervals from symptom onset. Large vessel occlusions were more frequent in EMS-activated patients (24% vs. 18%). The non-EMS-activated cohort exhibited a higher prevalence of posterior circulation occlusions. Despite the absence of initial SC activation, 28% of these patients ultimately received reperfusion therapy, albeit with significant delays compared to the EMS-activated group.

Conclusions: Most acute neurological patients who qualify for SC activation are accurately identified by EMS. However, a substantial proportion of patients are missed, leading to treatment delays. Enhancing the capacity of EMS to recognize the clinical heterogeneity of stroke presentations is essential for prompt SC activation and optimizing patient outcomes.

Objectives: Emergency medical services (EMS) clinicians report lack of training and experience with children, leading to discomfort and uncertainty regarding assessment and treatment. The Pediatric Assessment Triangle (PAT) was designed to provide a rapid and standardized approach. Despite widespread adoption, literature examining EMS implementation of PAT remains limited. We examined EMS use of PAT and assessment of clinical stability and the association between EMS use of PAT and prehospital interventions, EMS transport decisions (advanced life support [ALS] vs basic life support [BLS]), emergency department (ED) interventions, and ED disposition.

Methods: This was a retrospective cohort study of pediatric patients 0 to <15 years transported to a quaternary care pediatric ED via EMS between October 2022 and November 2023. Data were abstracted from EMS and ED electronic health records (EHRs) including PAT evaluation, demographics, EMS and ED interventions, and ED disposition. Data were analyzed using counts and percentages, logistic regression, chi-square, and McNemar's test.

Results: A total of 2929 patients were included. Most patients, 65.9%, had a PAT score of 0; for those with non-zero PATs, abnormalities in the appearance domain were most prevalent, 50.7%. A PAT score of 1 or higher was associated with transport via ALS (OR 67.9; 95% CI 32.0, 144.1) compared to a PAT of 0. Most patients, 62.2%, received an EMS intervention; the most common was diagnostics (blood glucose or electrocardiogram [EKG]). The EMS administered medications to 22% of patients. PAT scores of ≥2 were associated with double the odds of admission to the floor (OR 2.09; 95% CI 1.4, 3.0) and quadruple the odds of admission to ICU level of care/direct to surgery/expired (OR 4.9; 95% CI 2.9, 8.3); PATs abnormal for work of breathing only were associated with increased odds of admission to the floor (OR 2.5; 95% CI 1.8, 3.6).

Conclusions: This study suggests that EMS PAT assessment in the field appropriately reflects patient stability and may be associated with EMS intervention en-route. The EMS PAT scores demonstrate promise as an adjunct to ED assessment, alerting clinicians to increased likelihood of admission. The PAT has potential to serve as a practical mechanism for EMS feedback and quality improvement studies.

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 pre-existing 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.

Flecainide is an antiarrhythmic with several adverse effects, including dysrhythmias and hemodynamic collapse with an overdose fatality rate of 22.5% (1-3). Here we present a case of intentional flecainide ingestion leading to critical illness. Emergency medical services (EMS) was dispatched to a 17-year-old female after a witnessed flecainide ingestion. Arrival vitals were pulse 120, blood pressure 96/60, and Glasgow Coma Score 15. No initial electrocardiogram was performed. On arrival at the hospital, the patient quickly developed a seizure followed by cardiac arrest. Cardiopulmonary resuscitation was performed with return of spontaneous circulation (ROSC); ECG demonstrated a wide-complex tachycardia. Intubation was performed and norepinephrine started. The patient was also given sodium bicarbonate, lorazepam, levetiracetam, lidocaine, amiodarone, and lipid emulsion. The patient transferred to a pediatric center, where she developed pulseless ventricular tachycardia. After defibrillation and administration of calcium chloride and lipid emulsion, ROSC was achieved. Worsening hypotension and recurrent ventricular tachydysrhythmias led to the pursuit of extracorporeal membrane oxygenation (ECMO). Extracorporeal membrane oxygenation continued through day 5, and the patient was discharged on day 13. This case of an intentional flecainide overdose resulting in critical illness highlights several aspects of prehospital care. Clinician knowledge of the nature of illness, agent ingested, and magnitude of ingestion is critical to timely care. When patients decompensate, lack of access to this information can delay administration of decontamination agents, specific antidotes, and toxicology expert consultation. In this case, a prehospital electrocardiogram was not obtained. Given the rapid development of unstable tachydysrhythmias, having this information en route and on arrival at the emergency department may have expedited management. In all toxic ingestions, early electrocardiograms are paramount. Lastly, the patient may have benefited from direct transport to a pediatric center given it would have added only a few minutes' delay and the EMS crew was advanced life support-capable. In general, one cannot know whether a longer transfer time will result in critical decompensation. Nonetheless, one might consider certain presentations with capacity for critical illness requiring highly specialized care as an indication for direct transport.