Prehospital Emergency Care最新文献

Objectives: Early hospital transport may benefit out-of-hospital cardiac arrest (OHCA) patients with shockable rhythms who are refractory to defibrillation, particularly in settings with limited advanced on-scene interventions. However, its impact in emergency medical service (EMS) systems with limited advanced cardiac life support (ACLS) capabilities remain unclear. This study aimed to assess the association between intra-arrest transport and survival outcomes in OHCA patients with initial shockable rhythms who remained in refractory shockable rhythms despite the first defibrillation attempt.

Methods: Using a nationwide OHCA registry from a country with an intermediate prehospital service level where interventions such as prehospital anti-arrhythmic drugs or double sequential defibrillation are not feasible, adult medical OHCA patients with initial shockable rhythms who failed the first defibrillation between January 1, 2015, and December 31, 2022 were analyzed. The primary outcome was good neurological recovery. Time-dependent propensity score matching was performed to assess the association between intra-arrest transport and survival outcomes. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated, and stratified analyses were performed based on matched time intervals after the first defibrillation.

Results: Of 10,246 eligible patients, 8,131 underwent intra-arrest transport. After 1:1 time-dependent propensity score matching, 2,332 patients each in the intra-arrest transport and on-scene resuscitation groups were included. In the matched cohort, intra-arrest transport was not associated with good neurological recovery (11.7% and 11.5% in the intra-arrest transport and on-scene resuscitation groups, respectively; RR (95% CI) 0.97 (0.91-1.07)). In the stratified analyses based on matched time intervals after the first defibrillation, intra-arrest transport within 5 minutes after the first defibrillation was associated with poorer neurological outcomes (RR (95% CI) 0.86 (0.77-0.97)).

Conclusions: In an EMS setting with a limited-service level, intra-arrest transport showed no benefit for OHCA patients with an initial shockable rhythm who remained in refractory shockable rhythms despite the first defibrillation attempt. High-quality on-scene management is crucial before the initiation of hospital transport. Further research is needed to develop integrated systems ensuring effective prehospital and hospital care.

Objectives: Neonates, infants 30 days of age or younger are understudied in prehospital emergencies. Our objective was to describe prehospital assessment and care for patients <30 days of age at the San Diego-Tijuana Point of Entry (POE). Additional objectives included describing assessments, care, frequency, and level of care for newborns brought to the border by Mexican ambulances.

Methods: This was a retrospective analysis from January 1, 2014, to January 01, 2020, of all 9-1-1 calls involving patients <30 days of age at the San Diego POEs. The 9-1-1 responses to newly delivered patients were "newborns". Patients who were not immediately post-delivery were "neonates." Patient demographics, response intervals, clinician interventions, and dispositional data were collected from electronic patient records. Descriptive statistics were applied.

Results: A total of 57 patients <30 days of age were included. With 27 newborn patients, 15 were delivered by emergency medical services (EMS) personnel (27, 55.6%). Initial appearance, pulse, grimace, activity, and respiration (APGAR) scores were 8-10 in 44.4% and 5-7 in 29.6%. Procedures included newborn care (88.9%), advanced life support (ALS) assessment (63.0%), and warming (59.3%). There were five patients that had stimulation, 7 received oxygen, and 3 received Bag-Valve-Mask (BVM) ventilation. No serial heart rates were documented. Regarding 30 neonates, the predominant method of transport to the POE was Mexican ambulance (n 16, 53.3%). Medications administered included oxygen (n 16, 53.3%) and albuterol/ipratropium (n 1, 3.3%). Procedures included ALS assessment (n 19, 63.3%), pulse oximetry (n 22, 73.3%), and 3-lead electrocardiogram (n 8, 26.7%). Three patients (10%) received BVM. Mexican Ambulances brought 16 neonates. A physician or nurse was present in 37.5% of transfers, 50% were incubated, 25% intubated, 37.5% on supplemental oxygen, and 71% had preexisting intravenous access. These were not interfacility transfers but were 9-1-1 activations by U.S. border agents; and 14 neonates did not arrive via Mexican ambulance. Their complaints were respiratory distress (n 7, 50%) and Brief Resolved Unexplained Episode (n 4, 28.6%).

Conclusions: We found that 9-1-1 transports at the San Diego-Tijuana POE for patients <30 days were few and involved resuscitation, neonates in Mexican ambulances with specialized equipment, physicians, and unfamiliar medications. Neonates arriving via private transport had respiratory distress and BRUE.

Objectives: Use of supraglottic airways by emergency medical services (EMS) clinicians has increased for patients of all ages. However, data are limited on real-world use in the prehospital setting, including success rates, complications, and paramedic experience. The objective of this study was to determine frequency of successful i-gel^® insertion and associated complications, and to describe paramedic perception of i-gel^® use.

Methods: This was a prospective study of i-gel^® use in adult patients at four fire-based EMS Provider Agencies in Los Angeles (LA) County from June to September 2021. All paramedics received asynchronous and hands-on training prior to implementation. The i-gel^® was indicated for adult patients in respiratory and/or cardiac arrest of any etiology, as directed by LA County protocols. Patients were included if a paramedic attempted i-gel^® placement at any point. After transition of care, paramedics completed a web-based questionnaire and contacted an on-call EMS physician investigator to discuss the case. Further data were abstracted from the EMS electronic patient care record. The primary outcome was successful placement of i-gel^® based on adequate ventilation post insertion confirmed with capnography. Secondary outcomes were frequency of complications and paramedic perceived ease of placement and of ventilation with i-gel^® measured on a 5-point Likert scale. Descriptive statistics were reported.

Results: Of the 102 adult patients, 55 (54%) were female and the median age was 69 years (IQR 53-79). The majority 91 (89%) of the patients had a paramedic impression of non-traumatic cardiac arrest. Placement was successful in 90 (88%) patients overall with 85 (83%) i-gel^® insertions successful on the first attempt. Complications included: 28 (28%) cases with regurgitation/emesis, bleeding (8, 8%), hypoxia (7, 7%), and dislodgement (5, 5%). Among cases of successful i-gel^® placement, the majority of paramedics rated both ease of placement and ease of ventilation as "very easy" (69% and 78%, respectively) or "somewhat easy" (23% and 9%).

Conclusions: Paramedics were successful in 88% of i-gel^® insertion attempts with the most common complication being regurgitation/emesis. Paramedics rated the ease of placement and ease of ventilation of the i-gel^® device as "very easy" or "somewhat easy" in the vast majority of cases.

Objectives: Emergency medical services (EMS) frequently respond to patients with opioid-related overdoses but often lack the infrastructure and capacity to provide resources and support to individuals who decline transportation to the emergency department. Post-overdose response teams pair EMS clinicians with other first responders or substance use treatment professionals to provide outreach, harm reduction materials, and recovery resources. We aimed to explore the experiences of post-overdose patients and team members to better inform a prehospital care intervention and outcomes for patients with opioid use disorder.

Methods: This exploratory case study was part of a larger program evaluation of the Rapid Response Emergency and Addiction Crisis Team (RREACT) and describes the barriers and facilitators to accessing substance use recovery resources from the perspective of former patients (n = 8, called program alumni) and RREACT team members (n = 19) in Columbus, OH, USA. Semi-structured interviews were conducted between October 2019 and August 2020. We used inductive thematic analysis to identify key themes by participant group. Themes were compared for similarities and differences. Member checking with team members, peer debriefing, and triangulation of data were used to increase the trustworthiness of the findings.

Results: Four overall themes were identified: fear, relationships, resources, and stigma. For program alumni, the fear of withdrawal symptoms was categorized as a barrier to treatment, while the fear of death was a facilitator. Positive relationships between alumni and RREACT team members, among team members, and between RREACT and the community facilitated treatment entry. Additional facilitators of the RREACT intervention were resources in terms of their immediate response and ability to navigate systems. Barriers to RREACT's work included substance use stigma, a lack of appropriate and available treatment services, services only accepting particular insurers, and treatment services for special populations.

Conclusions: An EMS-led post-overdose response team provided recovery resources and linkage to treatment by meeting patients in times of desperation, employing non-judgmental personnel, and removing complex barriers. These findings are important to leveraging EMS in expanded roles as part of the larger public health response to opioid overdose.

Objectives: Benzodiazepines are the treatment for seizures in prehospital settings, but fail in up to 40% of cases, leading to benzodiazepine refractory status epilepticus (BRSE). Early treatment of BRSE is essential to prevent neurological damage and death. Ketamine, an N-methyl-D-aspartate receptor antagonist used by emergency medical services (EMS) for a variety of indications, has potential as a safe, effective prehospital treatment for BRSE. However, safety and efficacy data for early treatment of patients with seizures are limited.

Methods: We retrospectively analyzed patients treated by EMS clinicians with ketamine for BRSE at a single urban ground-based EMS system between September 1, 2021, and December 1, 2023. Ketamine dose and route, patient characteristics, and airway interventions are described. Data were gathered from EMS records.

Results: Forty-two patients aged 8 months to 79 years, were included. Ketamine was administered intramuscularly in 22 with an average dose of 3.3 mg/kg, and intravenously or intraosseous in 20, with an average dose of 2.2 mg/kg. Ketamine stopped seizures in 38 patients (90.5%). Transient hypoxia occurred in 9 patients (22%). Respirations were supported with bag-valve-mask ventilation in 13 patients (31%), a supraglottic airway in three (7%), and one patient was endotracheally intubated (2.4%).

Conclusions: Ketamine appears safe and effective for prehospital treatment of BRSE. Monitoring and intervention for respiratory complications appears necessary, but rates of these complications are consistent with expected rates from seizures and appropriate benzodiazepine dosing. These findings support ketamine's use in EMS for BRSE. Larger prospective studies are needed to confirm safety and efficacy.

Objectives: Although earlier antibiotics are known to be beneficial in sepsis, very few emergency medical services (EMS) agencies have protocols for prehospital antibiotics for sepsis. Therefore, we sought to assess how well a large EMS agency that uses prehospital antibiotics for sepsis adheres to its sepsis protocol (when initiated), and to determine how soon antibiotics are typically given.

Methods: We conducted a retrospective chart review of patients identified as "sepsis alerts" by EMS clinicians from a single EMS system in Florida, USA. The prehospital sepsis protocol dictated that EMS clinicians initiate a "sepsis alert" if the patient had a suspected infection and at least 2 of the following 3 criteria based on the sequential (sepsis-related) organ failure assessment (qSOFA) score: altered mental status, respiratory rate > 22 breaths per minute or end-tidal CO2 < 25 mmHg, or systolic blood pressure < 100 mmHg. Per protocol, patients meeting sepsis criteria were supposed to receive intravenous ceftriaxone and intramuscular gentamicin. We reviewed the charts of sepsis alert patients to determine demographic information, clinical characteristics, sepsis protocol compliance, and when patients received antibiotics.

Results: Between June 1, 2023, and June 30, 2024, there were 1308 patients for whom a prehospital sepsis alert was initiated. Median age was 80.0 years (IQR: 72 to 87.5), and 48.5% had hypotension (systolic blood pressure < 100 mmHg). Of the 1308 sepsis alert patients, review of documentation confirmed that 1301 (99.5%) had a suspected infection with at least 2 sepsis alert criteria. In total, 1264 (96.6%) received at least 1 antibiotic (either ceftriaxone or gentamicin) prior to hospital arrival. The median time from 9-1-1 call to first antibiotic administration was 26 minutes (IQR: 21 to 31 minutes). The first antibiotic was given a median of 11 minutes (IQR: 7 to 16 minutes) prior to hospital arrival.

Conclusions: For patients in whom a sepsis alert was initiated, EMS clinicians adhered to the sepsis protocol and administered antibiotics prior to hospital arrival in 97% of cases. Patients received their first antibiotic a median of approximately 26 minutes after 9-1-1 call and 11 minutes prior to hospital arrival.

Objectives: Vital signs are a critical component in the assessment of the injured child. We compared vital sign abnormalities among injured children in the prehospital setting to those in the emergency department (ED) and evaluated the predictive value of each for the presence of major trauma.

Methods: We performed a multi-agency and multicenter retrospective study of injured children within a county-based emergency medical services (EMS) system between 2010-2021, including injured children (<18 years) transported to the hospital. We compared prehospital vital signs for heart rate (HR), respiratory rate (RR), and systolic blood pressure (SBP) in the prehospital and ED setting. Using the Standard Triage Assessment Tool to define major trauma, we constructed multivariable models to evaluate the association of prehospital and ED vital sign abnormalities for major trauma.

Results: We included 21,298 encounters (median age 13 years, IQR 6-16), with major trauma was present in 3,606 (16.9%). In the prehospital setting, abnormal vital signs were reported in 25.7% for HR, 14.6% for RR, and 24.3% for SBP. ED measurements recorded a higher proportion of abnormal HR (28.2%) and RR (21.3%), and slightly lower proportion with abnormal SBP (21.8%). Cohen's Kappa was fair for HR (0.27) and SBP (0.20), but slight for RR (0.09). Prehospital vital signs most strongly associated with major trauma included tachypnea (odds ratio [OR] 2.7, 95% confidence interval (CI 2.4-3.1) and bradypnea (OR 1.7, 95% CI 1.4-1.9). ED vital signs most strongly associated with major trauma included hypotension (OR 2.4, 95% CI 2.1-2.7) and tachypnea (OR 1.8, 95% CI 1.6-2.0). Prehospital and ED vital signs demonstrated similar performance in predicting major trauma (area under the receiver operator characteristic curve (AUROC 0.63); 95% CI 0.61-0.64 for prehospital; 0.63; 95% CI, 0.61-0.64 for ED). When combining prehospital and ED vital signs into a single model, predictive power increased (AUROC 0.66, 95% CI 0.65-0.67).

Conclusions: We identified poor correlation between prehospital and ED vital signs. In both settings, vital sign abnormalities were associated with major trauma. The combined use of prehospital and ED vital signs improved predictive value for major trauma, suggesting potential for future integration into trauma triage tools.

Aim: Each year, more than 100,000 Americans die from an overdose. Most of these deaths are attributed to high-potency opioids, including fentanyl. People who use drugs face multiple barriers to treatment including access, knowledge of options, and adverse medical experiences. In 2022, Worcester County, Massachusetts saw a sharp increase in overdose deaths. In response, our team, based in Central Massachusetts developed and implemented an Opioid Response Specialist (ORS) Program, under the auspices of a mobile addiction service which has been operating in our area since 2021.

Methods: The Mobile Addiction Service is composed of physicians and advanced practice providers to facilitate low-barrier access to medications for opioid use disorder (MOUD) and harm reduction resources and the ORS service includes two care givers with emergency medical services (EMS) experience, currently also working as paramedics in the area. A model curriculum for the ORS role was developed and then the pilot testing of this role within the existing mobile addiction service was performed. These specialists were trained to the paramedic level and added extensive experience with overdose reversal, phlebotomy, wound care, and additional touch points with high-risk patients to the mobile service.

Results: As a result, we saw increases in naloxone and clean syringe distribution, and hepatitis C and human immunodeficiency virus screening. The integration of these personnel within the mobile addiction service also facilitated the uptake of opioid use disorder treatment interventions by our city's EMS which resulted in further improvements to city-wide naloxone distribution and the use of buprenorphine/naloxone after overdose reversal.

Conclusions: Based on our initial work, the concept of an ORS, especially when embedded with a mobile addiction service, has the potential to improve access to harm reduction as well as form the basis of a training program to extend the skills and scope of personnel with a background in EMS practice.

Objectives: To examine the impact of migration across the United States southern land border on the mental health of emergency medical services (EMS) clinicians in the border region.

Methods: We conducted 67 in-depth interviews with fire-based EMS clinicians in three communities. Interviews took place from June 23 to 27, 2024. We conducted thematic analysis using inductive, latent coding in NVivo 14© software.

Results: Primary themes identified were that EMS clinicians were emotionally impacted by helping migrants, that calls to provide care to migrants often led EMS clinicians to feel overwhelmed, and that EMS clinicians have developed support systems and coping mechanisms for the mental health impacts of their job.

Conclusions: Given the complex environment of the border region and the uniqueness of migrant-related emergency calls, EMS clinicians in the border region need greater mental health support.

Objectives: Emergency medical services (EMS) clinicians often do not achieve sufficient levels of physical activity. We investigate behavioral determinants that influence participation in physical activity among EMS clinicians.

Methods: We enrolled EMS clinicians from a North Carolina third-service EMS agency in 2023. A trained qualitative investigator conducted twenty virtual, 30-minute, individual, semi-structured interviews using an interview guide developed by experts in physical activity behaviors, EMS, and qualitative research. Interviews were guided by the Theoretical Domains Framework and Capability Opportunity Motivation Behavior Change Model. Structured interviews were digitally recorded and transcribed verbatim by a professional transcription service. Transcriptions were verified against audio for accuracy and de-identified. A codebook was established using a hybrid inductive/deductive approach, and thematic analysis was performed.

Results: The 20 participants had a median age of 31 years (IQR 27-34), of which 65% (13/20) were female. Several key themes emerged that represent opportunities for behavioral intervention. First, physical activity is often viewed as a process requiring high inhibitory self-regulation and is often paired with highly restrictive behaviors, which likely leads to existing poor behavioral habits. Existing confidence in being physically active was often tied to goal setting and mastery experiences, suggesting an opportunity to leverage specific and achievable goal setting, self-monitoring, and feedback. Further, EMS clinicians often struggle with incorporating physical activity amid work and life demands in a practical, sustainable way. They also identified a lack of available time, resources, and organizational support. High-quality social networks are foundational behavior change components and were often lacking among participants.

Conclusions: Behavioral determinants of physical inactivity included a theme of negative implicit associations around physical activity among some participants and need for achievable goal setting, self-monitoring, and building positive social support networks. Further investigation is needed to develop and test toolsets to improve physical activity behaviors among EMS clinicians.