Prehospital Emergency Care最新文献

Objectives: Pulseless electrical activity (PEA) arrest, which includes pseudo-PEA, is increasingly common and survival remains dismal. We hypothesized that mechanical chest compressions synchronized to native cardiac contractions improve coronary perfusion pressure (CPP) during pseudo-PEA resuscitation.

Methods: We developed a model of pseudo-PEA by infusing high dose esmolol intravenously into anesthetized, intubated, and central arterial and venous catheterized swine to a goal of 45 mm Hg mean arterial blood pressure (MAP). We performed a randomized unblinded repeated crossover trial by administering alternating synchronized and unsynchronized chest compressions for 52 s preceded by 8 s breaks consecutively 4 times. We repeated the protocol approximately 4 times with 1 min breaks. Synchronized compressions were provided 1:1 with native contractions during systole and unsynchronized compressions were provided at 100 beats per minute (BPM). We measured average CPP, MAP, and heartrate (HR) for 5 beats immediately preceding the chest compression onset and for 30 s 10 s after compression onset. We computed the difference in continuous CPP during compressions compared to the immediately preceding baseline for each interval. We developed a mixed linear model with outcome average CPP during compressions minus baseline, fixed variable compression type, and random variable animal.

Results: We included 6 animals. Mean baseline HR was 76.0 BPM, MAP 49.9, and CPP 36.2. Chest compressions increased CPP from baseline an average 1.7 mm Hg when unsynchronized and 5.6 mm Hg synchronized. The adjusted difference was 4.0 mm Hg (95% CI 2.4-5.5).

Conclusions: Synchronized chest compressions increased CPP 4.0 mm Hg (135%) more than unsynchronized compressions despite a lower compression rate in medication-induced pseudo-PEA. Further refinement and eventual application to patients suffering pseudo-PEA arrest appear warranted.

Objectives: Low titer O⁺ whole blood (LTO + WB) has been shown to improve outcomes in trauma patients and use is increasingly common. Studies on prehospital use and efficacy have been published throughout the literature, but few of these fully address the risks of transfusion reactions and other side effects. The focus of this study is to look at prehospital LTO + WB transfusions in trauma patients and review for transfusion reactions.

Methods: This was a retrospective review of consecutive trauma patients who received prehospital LTO + WB over a 4.5-year period. We used EMS agency transfusion records and institutional blood bank data from two urban level I trauma centers for records on blood transfusion reactions. Excluded from the study were patients declared dead on arrival to the hospital, patients transfused for non-traumatic complaints, patients for whom hospital records were unavailable, and any transfusion reaction that occurred more than 10 days after the prehospital transfusion. Descriptive statistics were used for data analysis.

Results: Of 1126 prehospital transfusions 572 met inclusion criteria. There were 2 (0.35%) suspected transfusion reactions, none of which were determined to be hemolytic reactions. There was 1 febrile non-hemolytic reaction on hospital day 1 and there was 1 allergic reaction with hives and shortness of breath that occurred on hospital day 1.

Conclusions: Prehospital LTO + WB is safe to use and has a similar rate of transfusion reaction as when given in-hospital. Concerns about transfusion reactions caused by LTO + WB should not preclude its use prehospital. Regardless of the low incidence of transfusion reactions, prehospital personnel should be trained in their recognition and management. Limitations include retrospective study design and the inability to distinguish transfusion reactions from prehospital LTO + WB versus reaction to blood products transfused at the trauma center.

Objectives: Emergency ambulance services are an essential component of rapid treatment of prehospital ST-segment elevation myocardial infarction (STEMI). The effectiveness and safety of prehospital fibrinolysis in older STEMI patients is unknown. This study investigated the effectiveness and safety of paramedic-administered prehospital fibrinolysis in STEMI patients ≥ 75 years of age who were identified by paramedics in Queensland, Australia.

Methods: Included were STEMI patients ≥ 75 years of age who were identified by paramedics in Queensland (Australia), and received prehospital fibrinolysis with tenecteplase or did not receive this treatment due to age being the sole contraindication, between 2010 and 2023. Patient characteristics, outcomes, and safety profiles were compared between the two groups, as well as between patients receiving full-dose and half-dose of tenecteplase.

Results: In total, 86 patients received prehospital fibrinolysis and 83 did not. Patients receiving prehospital fibrinolysis were slightly younger (median 77 versus 81 years, p < 0.001). There was no statistically significant difference in mortality rates at 24 hours (risk difference [RD] prehospital fibrinolysis versus no prehospital fibrinolysis 2.1%, 95% confidence interval [CI] -5.6 to 9.8%, p = 0.41), 30 days (RD -0.3%, 95% CI -9.6 to 9.0%, p = 0.58), and one year (RD -1.7%, 95% CI -12.1 to 8.7%, p = 0.46) between the two groups. There was no statistically significant difference in functional outcomes on discharge (RD for favourable functional outcome 8.8%, 95% CI -6.0 to 23.6%, p = 0.25). No intracranial or major non-intracranial haemorrhage was observed in the entire study sample. Patients receiving full-dose tenecteplase were younger, closer to a hospital capable of percutaneous coronary intervention, in metropolitan areas, and had shorter time from symptom onset to tenecteplase than those receiving half-dose.

Conclusions: This study was the first that investigated the effectiveness and safety of paramedic-administered fibrinolysis in older patients with STEMI. No intracranial or major non-intracranial haemorrhage was recorded for the study sample. There was no association between prehospital fibrinolysis and mortality or functional outcomes.

Objectives: To explore the long-term effect of intelligent first-aid training based on virtual reality (VR) technology on cardiopulmonary resuscitation (CPR) skill proficiency.

Methods: The convenience sampling method was used to select a total of 100 non-medical volunteers from Nanchang, China, and this cohort was randomized to either the VR training group (VR group) or the traditional simulation scenario training group (traditional group). Relevant data were collected for comparative analysis. Participants were evaluated by measuring mean chest compression depth, chest compression pauses time, the proportion of compressions with correct compression depth, mean chest compression rate, and mean ventilation volume.

Results: After initial training, the 2 groups of participants showed similar results in terms of chest compression depth and chest compression rate. There were significant differences in chest compression pauses time, proportion of compressions with correct compression depth and ventilation volume (p < 0.001). Long-term follow-up (12 months) after training showed that both groups of participants showed differences in the above indicators (p < 0.001). After training, the VR group had higher pass proportions for mean chest compression rate (p = 0.047) and mean ventilation volume (p = 0.043) than the traditional group. After training, the VR group had higher pass proportion for mean chest compression depth (p < 0.001), mean chest compression rate (p < 0.001), and mean ventilation volume (p < 0.001) than the traditional group.

Conclusions: Training with VR can significantly improve CPR knowledge and skill levels and help learners master and maintain high-quality CPR skills.

Noninvasive ventilation has been used as a pre-oxygenation strategy for rapid sequence intubation in the emergency department and the intensive care unit, yet, limited research has examined its use in the transport setting. These case reports discuss the use of noninvasive ventilation via a Hamilton T1 ventilator (Hamilton Medical) during transport by an air medical crew for pre-oxygenation before intubation in two cases. In both cases, a noninvasive, bilevel-positive airway pressure mode with a backup rate was used to achieve adequate airway pressures while allowing for a two-handed seal by one emergency medical services clinician as the other prepared the equipment and medications. This method of pre-oxygenation in a space and resource-limited setting was associated with first-pass success without hypoxia in both cases. This adds another method of pre-oxygenation to facilitate safe intubation in similar settings.

Objectives: While ambulance transport decisions guided by artificial intelligence (AI) could be useful, little is known of the accuracy of AI in making patient diagnoses based on the pre-hospital patient care report (PCR). The primary objective of this study was to assess the accuracy of ChatGPT (OpenAI, Inc., San Francisco, CA, USA) to predict a patient's diagnosis using the PCR by comparing to a reference standard assigned by experienced paramedics. The secondary objective was to classify cases where the AI diagnosis did not agree with the reference standard as paramedic correct, ChatGPT correct, or equally correct.

Methods: This diagnostic accuracy study used a zero-shot learning model and greedy decoding. A convenience sample of PCRs from paramedic students was analyzed by an untrained ChatGPT-4 model to determine the single most likely diagnosis. A reference standard was provided by an experienced paramedic reviewing each PCR and giving a differential diagnosis of three items. A trained prehospital professional assessed the ChatGPT diagnosis as concordant or non-concordant with one of the three paramedic diagnoses. If non-concordant, two board-certified emergency physicians independently decided if the ChatGPT or the paramedic diagnosis was more likely to be correct.

Results: ChatGPT-4 diagnosed 78/104 (75.0%) of PCRs correctly (95% confidence interval: 65.3-82.7%). Among the 26 cases of disagreement, judgment by the emergency physicians was that in 6/26 (23.0%) the paramedic diagnosis was more likely to be correct. There was only one case of the 104 (0.96%) where transport decisions based on the AI guided diagnosis would have been potentially dangerous to the patient (under-triage).

Conclusions: In this study, overall accuracy of ChatGPT to diagnose patients based on their emergency medical services PCR was 75.0%. In cases where the ChatGPT diagnosis was considered less likely than paramedic diagnosis, most commonly the AI diagnosis was more critical than the paramedic diagnosis-potentially leading to over-triage. The under-triage rate was <1%.

Objectives: To systematically review the effectiveness and harms of interventions to promote resistance and resilience regarding mental health and occupational stress issues among emergency medical service (EMS) clinicians.

Methods: We registered the systematic review prospectively on PROSPERO (CRD42023465325). We searched Medline, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, journals, and websites for studies published from January 1, 2001, through June 30, 2024. We conducted duplicate screening of titles and abstracts followed by full texts of potentially relevant abstracts. We included studies of EMS clinicians in high-income countries that evaluated interventions targeting resistance or resilience regarding mental health or occupational stress issues. We assessed the risk of bias and evaluated strength of evidence (SoE) using standard methods.

Results: We included 7 studies (1 randomized controlled trial, 1 controlled trial with a waitlist control, 4 pre-post studies, and 1 prospective cohort [single group] study) that evaluated a total of 425 EMS clinicians. We deemed 5 of the 7 studies to have high risk of bias, 1 moderate risk, and 1 low risk. No meta-analysis was feasible because of heterogeneity in the interventions evaluated across studies. Mindfulness-building interventions targeting resistance and resilience among EMS clinicians were associated with reduced burnout at up to 6 months of follow-up (low SoE). The evidence was insufficient regarding the impacts of interventions targeting both resistance and resilience on anxiety and depression. No conclusions are possible for resistance-only or resilience-only interventions. No studies reported on the effectiveness of any interventions in reducing hospitalizations, post-traumatic stress disorder, substance use, suicidality, or withdrawals from the workforce. No studies reported on unintended harms of interventions.

Conclusions: Given the sparse evidence identified in this systematic review, evidence-based options to improve mental health outcomes for EMS clinicians are very limited. Future research is urgently needed to inform strategies to address the many mental health and occupational stress issues that face the EMS clinician workforce.

Objectives: To systematically review the (1) incidence, prevalence, and severity of mental health issues and occupational stress issues among emergency telecommunicators, and (2) effectiveness and harms of interventions to promote resistance and resilience regarding these issues.

Methods: We searched Medline, Embase, CENTRAL, and CINAHL, ClinicalTrials.gov, journals, and websites from January 1, 2001, through June 30, 2024. We conducted duplicate screening of titles and abstracts followed by full-texts of potentially relevant records. We included studies of telecommunicators in high-income countries that reported the incidence/prevalence/severity of mental health issues and occupational stress issues or evaluated interventions targeting resistance/resilience regarding these issues. We excluded studies of telecommunicators in training during the study. We assessed the risk of bias using study design-specific tools, conducted meta-analyses using random-effects models, and evaluated strength of evidence (SoE) per Agency for Healthcare Research and Quality methods. We registered the systematic review prospectively in PROSPERO (CRD42023465325).

Results: We included 31 studies (29 cross-sectional studies, 1 pre-post study, and 1 randomized controlled trial) that evaluated a total of 6,621 participants. Research Question 1 (30 studies): No study reported on incidence of any outcome. During routine practice, prevalence estimates were: any depression 15.5%, suicidal ideation 12.4%, suicide plans 5.7%, suicide attempts 0.7%, alcohol abuse 15.5%, high/extreme peri-traumatic distress 5%, high secondary traumatic stress 16.3%, and acute stress disorder 17% (low SoE for each). In terms of severity, on average, depressive symptoms and stress were mild/low to moderate, burnout was mild to severe (moderate SoE); peri-traumatic distress was moderate, and secondary traumatic stress was mild (low SoE). After critical incidents, the prevalence of high and medium general stress was 39.7% and 28.2%, respectively (low SoE). In terms of severity, on average, burnout and general stress were moderate (low SoE). Research Question 2 (2 studies): The evidence was insufficient regarding the impacts of interventions on anxiety, depression, posttraumatic stress disorder, and alcohol use.

Conclusions: The prevalence and severity of mental health and occupational stress issues in the emergency telecommunicator workforce merits greater attention. Much more research is needed regarding the effectiveness of interventions for strengthening the resistance and resilience of the workforce.

Objectives: While epinephrine is widely used for medical cardiac arrests, there is a knowledge gap regarding its utility for traumatic arrests. Traumatic arrests result from hypovolemia, hypoxia, or anatomic impairment of cardiac function such that the inotropic and vasoconstrictive effects of epinephrine may be ineffective or harmful. We hypothesized that epinephrine does not improve survival among patients with traumatic cardiac arrest.

Methods: This was a multicenter retrospective cohort study of trauma patients sustaining prehospital cardiac arrest who were treated at seven level I and II trauma centers over 6 years (2011-2017), ascertained via trauma registry data and chart abstraction. The primary outcome was survival to hospital discharge; patients treated with or without epinephrine were compared. Multivariable analyses were performed using Poisson regression. Time to event analyses were conducted using Cox proportional hazard models.

Results: We included 1631 adult and pediatric trauma patients with prehospital cardiac arrest. Prehospital epinephrine was administered to 844 (52%). The median age was 35 years, 335 (21%) were female, 712 (44%) sustained blunt trauma, and 58 (4%) had a shockable initial rhythm. Survival to hospital discharge was significantly lower in the prehospital epinephrine cohort compared to the no epinephrine cohort in univariable analysis [43/844 (5%) vs. 125/787 (16%), p < 0.001]. Among patients with blunt mechanism, survival was significantly lower in the prehospital epinephrine cohort [12/382 (3%) vs. 54/330 (16%), p < 0.001]. Among patients with penetrating mechanism, survival was not statistically different [10/276 (4%) with epinephrine vs. 22/374 (6%) without, p = 0.19]. In multivariable analyses adjusting for age, sex, mechanism, and initial rhythm, epinephrine was associated with lower likelihood of survival in the overall and blunt cohorts; there was no significant difference in the penetrating cohort (overall aRR 0.33, 95% CI 0.23-0.46; blunt aRR 0.20, 95% CI 0.11-0.37; penetrating aRR 0.62, 95% CI 0.30-1.28). Adjusted and unadjusted time to event analyses across each of these cohorts showed that epinephrine was associated with either statistically inferior or indistinct hazard ratios.

Conclusions: Epinephrine was not associated with improved survival following traumatic cardiac arrest, and in multiple subanalyses, it was associated with inferior outcomes. These results may inform prehospital traumatic arrest protocols.

Pediatric trauma patients have unique physiology and anatomy that impact the severity and patterns of injury. There is a need for updated, holistic guidance for Emergency Medical Services (EMS) clinicians and medical directors to optimize prehospital pediatric trauma guidelines based on evidence and best practice. This is especially pertinent to pediatric severe and inflicted trauma, where prehospital evaluation and management determine the overall quality of care and patient outcomes. This position statement addresses the prehospital evaluation and management of pediatric severe and inflicted trauma and is based on a thorough review and analysis of the current literature.