Prehospital Emergency Care最新文献

The National Governors Association (NGA) Center for Best Practices, in partnership with the National Association of State Emergency Medical Services Officials (NASEMSO), supported five states-Kentucky, Ohio, South Carolina, Vermont, and Wisconsin-in developing and implementing action plans to expand the role of EMS to help prevent overdose events and support individuals with substance use disorders. States undertook initiatives such as pilot programs for EMS-initiated buprenorphine, development of statewide naloxone leave-behind programs, and changes to EMS protocols that enable agencies and clinicians to use evidence-informed best and promising practices that utilize harm reduction strategies and provide opportunities for linkages to treatment.

Objectives: End-tidal carbon dioxide (EtCO₂) monitoring is widely used as a surrogate for the partial pressure of carbon dioxide (PCO₂) in critically ill patients receiving manual or mechanical ventilation in prehospital, emergency, and critical care settings. Specific targets for ETCO₂ are a key component of Emergency Medical Services (EMS) protocols, especially for specific patient groups such as those with traumatic brain injury. However, the correlation between EtCO₂ and venous or arterial PCO₂ is uncertain. We aimed to assess the correlation between EtCO₂ and PCO₂ in intubated patients undergoing critical care transport (CCT), and in specific subgroups of patients.

Methods: We performed a retrospective review of patients undergoing emergency transport by a multi-state CCT agency. Patients were included if they had an advanced airway and both an EtCO₂ and PCO₂ reading within 5 min of each other. We obtained data on patient demographics, transport characteristics, medical categories, vital signs, lab values, and specific interventions. We performed univariable and multivariable binary logistic regression to assess the association between delta PCO₂ and these characteristics.

Results: We included 6,459 patients (mean age 58.4 years [SD 18.5], 57.1% male), of which a subset of 551 patients had multiple EtCO₂-PCO₂ measurements within 5 min. The median (IQR) initial delta PCO₂ was 12.9 mmHg (7.1, 21.9). 3,967 (61.4%) patients had a delta PCO₂ >10 mmHg and 1,843 (28.5%) had a delta PCO₂ >20 mmHg. We identified an independent association between delta PCO₂ >10 mmHg and age, male sex, interfacility transport, venous sampling site, respiratory rate, hypotension, hypoxia, and thoracostomy. In patients with multiple blood gas measurements, 76% had delta PCO₂ >10 mmHg over the duration of the transport.

Conclusions: We identified substantial differences between EtCO₂ and PCO₂ across patients with medical and traumatic conditions undergoing critical care transport. The PCO₂ assessment should be strongly considered as part of ventilatory management in patients encountered in emergency and critical care settings.

Objectives: Trauma-induced coagulopathy remains a significant contributor to mortality in severely injured patients. Fibrinogen is essential for early hemostasis and is recognized as the first coagulation factor to fall below critical levels, compromising the coagulation cascade. Recent studies suggest that early administration of fibrinogen concentrate is feasible and effective to prevent coagulopathy. We conducted a scoping review to characterize the existing quantity of literature and to explore the usage of prehospital fibrinogen concentrate products in improving clinical outcomes in trauma patients.

Methods: A search strategy was developed and underwent Peer Review of Electronic Search Strategies (PRESS) review in consultation with an information specialist. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Scopus from inception to May 6, 2024. English studies evaluating prehospital civilian and military usage of fibrinogen concentrate in trauma patients were included. Studies were assessed by three independent reviewers for meeting inclusion and exclusion criteria. A hand search of the reference lists of included articles was conducted to identify additional studies meeting inclusion criteria. Clinical endpoints regarding fibrinogen were extracted and synthesized.

Results: The literature search returned 1,301 articles with six studies meeting the inclusion criteria. Five studies (83%) were conducted in civilian settings and one study (17%) was conducted in a military setting. Of the included studies, two related studies (29%) utilized a randomized control trial design. We identified five outcomes that compared fibrinogen concentrate to a placebo group. The outcomes included thromboembolic events, clotting time, maximum clot firmness, clot stability at emergency department (ED) admission, and fibrinogen concentration at ED admission. Apart from thromboembolic events, all other reported outcomes showed statistically significant differences in group comparisons, determined using p values. The four (67%) non-clinical studies underscored the robustness, practicality, and degree of fibrinogen concentrate utilization in military environments and retrieval services.

Conclusions: Preliminary research suggests that prehospital fibrinogen concentrate administration in traumatic bleeding patients is both feasible and effective, improving clotting parameters. While implementing a time-saving and proactive approach with fibrinogen holds potential for enhancing trauma care, the current evidence is limited. Further studies in this novel field are warranted.

Fluid resuscitation choices in prehospital trauma care are limited, with most Emergency Medical Services (EMS) agencies only having access to crystalloids. Which solution to use, how much to administer, and judging the individual risks and benefits of giving or withholding fluids remains an area of uncertainty. To address the role of crystalloid fluids in prehospital trauma care, we reviewed the available relevant literature and developed recommendations to guide clinical care. The topic of prehospital blood product administration is covered elsewhere.NAEMSP recommends:Isotonic crystalloid solutions should be the preferred fluids for use in prehospital trauma management. Specific choice of isotonic crystalloid solutions may be driven by medication compatibility and other operational issues.Permissive hypotension is reasonable in patients without traumatic brain injury (TBI).Avoiding or correcting hypotension in polytrauma patients with TBI may be a higher priority than restricting fluid use.Large volume crystalloid resuscitation should be generally avoided.Developing processes to administer warmed intravenous (IV) fluids is reasonable. • Risks of IV fluid use, or restriction, in trauma resuscitation should be weighed against possible benefits.• Strategies to reduce the need for IV fluids should be considered.• A standard trauma resuscitation curriculum for prehospital providers should be developed to improve evidence-based delivery of IV fluids in trauma.

This prologue to the NAEMSP Prehospital Trauma Compendium describes the rationale for and the process used in developing the compendium manuscripts. It also provides a summary of other contemporary works discussing additional elements of prehospital trauma care including hemorrhage control, airway and ventilation management, pain management, care for traumatic brain injury, and trauma triage.

Objectives: Pain management in the potentially austere search and rescue (SAR) and emergency medical services (EMS) environments can be challenging. Intravenous (IV) and intramuscular (IM) routes of administration may be less practical. This study assesses the efficacy and safety of the sublingual sufentanil tablet (SST) in prehospital settings and hypothesizes that its use will reduce pain while maintaining a reasonable safety profile.

Methods: This was a retrospective case analysis examining patient records from Teton County Search and Rescue, Grand Teton National Park EMS, and Jackson Hole Fire/EMS from 2021-2023, based on the criteria that they were administered SST in a prehospital setting. Cases in which SST was used were examined to assess patient characteristics, injury classification, patient reported pain scale before and after SST, other medications administered, and vital signs.

Results: Seventy patients met the inclusion criteria. Six individuals were excluded due to missing one or more of the key variables, and the analysis was carried out with the remaining (N = 64 cases). The mean pain score decreased from 8.0 ± 1.9 before medication administration to 5.5 ± 2.5 after administration, reflecting a statistically significant difference of 2.6 ± 2.1 (p < 0.001). The results also revealed statistically significant reductions in heart rate (HR) and systolic blood pressure (SBP) following SST administration (mean HR dropped by 4.2 ± 9.1 beats/min, p = 0.004, and mean SBP dropped by 11.1 ± 21.8 mmHg, p = 0.01). Changes in vital signs, although statistically significant, were not clinically significant and did not necessitate additional monitoring or intervention in any patients.

Conclusions: Our study demonstrated that SST administration led to a significant reduction in pain scores and exhibited a favorable safety profile regarding vital signs, including SBP, HR, respiratory rate (RR), and O₂ saturation. These findings support the utilization of SST for pain management in the prehospital setting, particularly in austere environments where traditional routes of administration may be impractical.

Objectives: Previous research demonstrated that the numerical Cincinnati Prehospital Stroke Scale (CPSS) identifies large vessel occlusion (LVO) at similar rates compared to dedicated LVO screening tools. We aimed to compare numerical CPSS to additional stroke scales using a national Emergency Medical Services (EMS) database.

Methods: Using the ESO Data Collaborative, the largest EMS database with linked hospital data, we retrospectively analyzed prehospital patient records from 2022. Each EMS record was linked to corresponding emergency department (ED) and inpatient records through a data exchange platform. Prehospital CPSS was compared to the Cincinnati Stroke Triage Assessment Tool (C-STAT), the Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and the Balance Eyes Face Arm Speech Time (BE-FAST). The optimal prediction cut points for LVO screening were determined by intersecting the sensitivity and specificity curves for each scale. To compare the discriminative abilities of each scale among those diagnosed with LVO, we used the area under the receiver operating curve (AUROC).

Results: We identified 17,442 prehospital records from 754 EMS agencies with ≥ 1 documented stroke scale of interest: 30.3% (n = 5,278) had a hospital diagnosis of stroke, of which 71.6% (n = 3,781) were ischemic; of those, 21.6% (n = 817) were diagnosed with LVO. CPSS score ≥ 2 was found to be predictive of LVO with 76.9% sensitivity, 68.0% specificity, and AUROC 0.787 (95% CI 0.722-0.801). All other tools had similar predictive abilities, with sensitivity/specificity/AUROC of: C-STAT 62.5%/76.5%/0.727 (0.555-0.899); FAST-ED 61.4%/76.1%/0.780 (0.725-0.836); BE-FAST 70.4%/67.1%/0.739 (0.697-0.788).

Conclusions: The less complex CPSS exhibited comparable performance to three frequently employed LVO detection tools. The EMS leadership, medical directors, and stroke system directors should weigh the complexity of stroke severity instruments and the challenges of ensuring consistent and accurate use when choosing which tool to implement. The straightforward and widely adopted CPSS may improve compliance while maintaining accuracy in LVO detection.

Objectives: Children make up 5-10% of emergency medical services (EMS) transports and are at risk for under-recognition and under-treatment of pain. Prior studies have identified enablers to pediatric analgesia including EMS pediatric analgesia education, agency leadership support, the availability of assistive guides and having positive relationships with online medical control. Prior barriers identified were intravenous (IV) line insertion pain, caregiver concerns, difficulty assessing pain, pain medication safety concerns, unfamiliarity with pediatrics, unwanted attention from authority figures and perceived superiority of hospital care. This study's objective was to evaluate enablers and barriers to prehospital analgesia for children presenting with traumatic pain after the introduction of intranasal (IN) fentanyl into EMS protocols.

Methods: Focus groups with EMS clinicians were used to elicit perspectives on pediatric analgesia. EMS clinicians discussed transports of children in pain, decision-making regarding analgesic administration, available resources to treat pain including EMS protocols, patient and family reactions, and ways to improve pediatric oligoanalgesia. Themes were explored until thematic saturation was reached using a deductive approach with open-ended yet structured questions.

Results: Enablers for pediatric analgesia included longer transports, desire to stabilize the patient, vital signs or injuries suggestive of severe pain, and clinician comfort with and availability of IN pain medication. Barriers to analgesia included concerns that the child was not stable enough for pain medication, avoiding masking symptoms prior to hospital arrival, lack of pediatric experience, lack of access to opiates in some ambulances, poor suspension in ambulances causing difficulty with IV access, patient refusal for an IV, caregivers' discomfort with opiates and caregivers' lack of knowledge of available prehospital medications. Focus group themes identified were that there was a lack of experience with pediatric patients, medical control was a helpful resource and training that approximated real-world situations was important.

Conclusions: New enablers for pediatric analgesia identified were longer transports and EMS clinician comfort with IN pain medications. While many barriers to pediatric analgesia persist, new barriers identified were poor suspension in ambulances causing difficulty with IV access and caregivers' lack of knowledge of available prehospital medications. Additional EMS pediatric training and experience may improve pediatric oligoanalgesia.

Objectives: The epidemic of opioid use disorder (OUD) remains pervasive in the United States. In an effort to increase the availability and timeliness of medications for opioid use disorder (MOUD), several agencies in the United States (US) offer buprenorphine by prehospital providers to selected patients, though published data remains limited. We describe the preliminary safety and feasibility of training all paramedics within a single agency to administer buprenorphine in the field without online medical control to simultaneously treat opioid withdrawal and initiate MOUD.

Methods: Using data from an ongoing quality assurance (QA) database, cases were retrospectively reviewed. Inclusion criteria included administration of buprenorphine by paramedics; cases were excluded if administered prior to EMS arrival on scene (i.e., the patient was given buprenorphine by a bystander or took their own). Data were entered into a REDCap database as part of the ongoing QA process. The primary reported outcome was administration of buprenorphine without complications. Complications were defined as any adverse effects from the administration of medication, including but not limited to new or worsening opioid withdrawal symptoms.

Results: In total, 121 patients met inclusion criteria, 82 were treated for naloxone-induced withdrawal and 39 for withdrawal due to opioid cessation. There were no cases of precipitated withdrawal or worsening of patient condition observed. Adverse effects were limited to three cases of nausea and vomiting post-administration, all of which were present prior to buprenorphine administration. No patients met the primary outcome of adverse effects from medication administration.

Conclusions: In a single prehospital system, the use of buprenorphine appears to be a feasible and safe strategy for treating patients experiencing acute opioid withdrawal.

Objectives: The combination of broad conditional applicability and ease of data collection make some general risk scores an attractive tool for clinical decision making under acute care conditions. To date, general risk scores have demonstrated moderate levels of accuracy for key outcomes, but there are no definitive general scores integrated universally into prehospital care. The objective of our study was to demonstrate a relationship between the Revised Trauma Score (RTS) and prehospital lifesaving interventions (LSI) and downstream hospital mortality among a large, diverse, multi-year cohort of critical care transport patients. We hypothesized that the RTS is associated with mortality and prehospital LSI generally across all conditions, including non-trauma.

Methods: We conducted a retrospective observational study using a pre-established cohort of sequentially enrolled patients from a regional air medical service between the years 2012 and 2021. Pediatric patients, non-transports, and those transported to hospitals outside the regional health system were excluded from the study. Both trauma and non-trauma patients were included in this study. We performed logistic regressions to evaluate the association between RTS and the outcomes of LSI and hospital mortality, while controlling for age, sex, and medical category. Graphs were constructed to plot RTS against prehospital LSI and survival percentage.

Results: Our final patient cohort was 62,424 patients. 58.4% of all patients required a prehospital LSI. Non-trauma cases made up 69.7% of the patient population. The Revised Trauma Score was inversely proportional with both prehospital LSI and mortality. The logistic regression model yielded an odds ratio (OR) of 0.55 (95% CI 0.54 - 0.56) for the association between RTS and death. Additionally, when the components of RTS were associated with mortality, they each showed a statistically significant OR. The Revised Trauma Score was also associated with prehospital LSI (OR 0.10; 95% CI 0.03 - 0.33).

Conclusions: In a large helicopter EMS cohort of both trauma and non-trauma patients, the RTS was inversely associated with prehospital LSI and hospital mortality. The generalized utility of RTS demonstrated in our study warrants further investigation of this measure as a broader triage tool.