Prehospital Emergency Care最新文献

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.

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.

Objectives: To examine the association of community-level social drivers of health with variability in the documentation of prehospital 12-lead electrocardiogram (ECG) for patients with suspected acute coronary syndrome (ACS).

Methods: This retrospective observational cohort study was conducted using the 2021 ESO Data Collaborative with de-identified records from more than 1,300 emergency medical services (EMS) agencies in the United States. We included 9-1-1 ground responses for adults ≥35 years with a prehospital clinical impression of ACS who were transported to the hospital. Social vulnerability index (SVI) was linked at the Census tract of the scene encounter and grouped in quartiles with the highest quartile representing communities of greatest vulnerability. The primary outcome was documentation of prehospital 12-lead ECG performance. Multivariable logistic regression models were used to examine the association of SVI with prehospital 12-lead ECG documentation of performance.

Results: Among 34,388 EMS encounters for patients with suspected ACS, 73% were between the ages of 45-79 years old, 49% were female, and 18% were Black. Most calls occurred in the South (64%), with a paramedic crew (90%), and 29% were in rural settings. Compared to communities in the least vulnerable quartile, Q2 (OR 0.86, 95%CI 0.78-0.95, p = 0.004), Q3 (OR 0.64, 95%CI 0.58-0.71, p < 0.001), and Q4 (OR 0.63, 95%CI 0.57-0.70, p < 0.001) quartiles were associated with reduced odds of ECG documentation. The relationship persisted after adjusting for factors associated with 12-lead ECG documentation.

Conclusions: Higher community social vulnerability was significantly associated with lower odds of prehospital ECG for patients with suspected ACS, suggesting that additional resources focused on these communities may be needed to address these inequities.

Objectives: Needle thoracostomy (NT) is a time-sensitive procedure infrequently performed by EMS clinicians with variable success rates. Our primary objective was to evaluate the accuracy of NT site selection by paramedics using ThoraSite^® compared to traditional anatomic landmarks (ALs). Secondarily, we assessed paramedic-rated confidence and ease of ThoraSite^® use.

Methods: We conducted a randomized, two-arm crossover study including fire-based paramedics. Emergency physician investigators determined a NT placement zone for live human models in three size groups, confirming with ultrasound and demarcating the zone with "invisible" ultraviolet ink. Following training, paramedics performed NT site selection on the models using ThoraSite^® and ALs by placing a sticker at the selected insertion site. Accuracy of placement was confirmed with ultraviolet flashlight. If placement was outside the demarcated zone (DZ), we identified underlying structures with ultrasound. We evaluated the effect of approach on placement accuracy and time-to-NT placement using linear models with covariates of paramedic, approach, and model size. For the outcome of accuracy, we used a log link function. For time-to-NT, we log-transformed the values for the parametric analysis allowing interpretation of the coefficients as percent differences. We compared paramedic confidence in performing the NT procedure and perceived ease of procedure using a 5-point Likert scale.

Results: There were 112 paramedics that performed 223 ThoraSite^® and 223 landmark attempts with 383 correct placements within the DZ: 198 attempts using ThoraSite^® compared to 185 with ALs, odds ratio (OR) 1.91 (95%CI 1.01-3.62), p = 0.04. Placement accuracy by model size followed similar trends. Incorrect placement over critical structures occurred in 1 ThoraSite^® and 3 AL attempts. The mean time for NT site selection was 14.3s (SD = 7.11) using ThoraSite^® and 18.7s (SD = 7.40) using ALs (p < 0.01). Overall procedural confidence improved with training. However, there was no statistically significant difference in the change in confidence with ThoraSite^® as compared to ALs (OR = 1.55 95%CI = 0.89-2.72). Paramedics rated ease of NT placement significantly higher using ThoraSite^® (median = 5, IQR = 4-5) compared to ALs (median = 4, IQR = 4-5; p < 0.01).

Conclusions: ThoraSite^® was associated with increased odds of NT site selection in the DZ, reduced time-to-NT site selection, and increased self-rated ease reported by paramedics.

Objectives: To evaluate the agreement between bystander cardiopulmonary resuscitation (B-CPR) documented by emergency medical services (EMS) personnel in the Birmingham Cardiac Arrest Registry to Enhance Survival (CARES) and B-CPR identified through 9-1-1 audio review.

Methods: We conducted a retrospective observational analysis of adult non-traumatic out-of-hospital cardiac arrest (OHCA) cases in Birmingham from January 1 to December 31, 2023. We excluded EMS-witnessed events, those in nursing homes, health care facilities, jails/prisons, or involving patients who were conscious during the 9-1-1 call. The provision of B-CPR was classified as "yes" or "no" in CARES based on EMS documentation and compared to B-CPR status determined through review of the corresponding 9-1-1 audio by a single reviewer. Agreement between sources was assessed using percent agreement, Cohen's kappa, Gwet's AC, and McNemar's test.

Results: Of 236 total cases, EMS documented a B-CPR rate of 12.3% whereas audio review indicated a B-CPR rate of 27.5%. Concordant classification occurred in 180 (76.3%) cases: 19 cases where both sources indicated B-CPR was performed and 161 where both indicated it was not. Discrepancies occurred in 56 cases (23.7%), including 46 instances where 9-1-1 audio identified B-CPR but EMS did not, and 10 where EMS documented B-CPR but audio review did not. Among the 46 audio-confirmed cases not captured by EMS, most involved B-CPR that ended before EMS arrival (e.g., B-CPR was discontinued by the caller), and 7 appeared to be EMS misclassifications. In the 10 cases where EMS documented B-CPR but audio did not, all involved calls that ended prior to EMS arrival without recognition of OHCA or B-CPR instruction. Overall agreement was fair to moderate: Cohen's kappa = 0.28 [95%CI 0.15, 0.42], Gwet's AC1 = 0.65 [95%CI 0.56, 0.75]), and McNemar's test showed significant asymmetry in classification, p < 0.001.

Conclusions: The provision of B-CPR differed in nearly 25% of OHCA cases when comparing EMS documentation with 9-1-1 audio review. Most discrepancies resulted from early termination of B-CPR by the caller prior to EMS arrival, while a smaller proportion appeared to reflect EMS misclassification. These findings underscore the importance of sustained telecommunicator CPR instruction through EMS arrival at the patient's side.

Objectives: To examine whether bystander cardiopulmonary resuscitation (BCPR) is associated with the time-dependent effects of epinephrine administration on neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients.

Methods: We conducted a retrospective cohort study using the All-Japan Utstein Registry from 2015 to 2019. Witnessed OHCA cases of presumed cardiac origin in patients aged 15-116 years who received epinephrine were included. Patients were stratified by initial cardiac rhythm (shockable or non-shockable) and categorized by time to epinephrine administration into early (0-19 min), intermediate (20-26 min), and late (27-56 min) groups. Multivariable logistic regression was performed to assess the association between BCPR and favorable neurological outcomes (CPC 1-2) at one month, adjusting for potential confounders. An interaction term between BCPR and epinephrine timing was included in the models to evaluate whether BCPR modified the time-dependent association between epinephrine administration and outcomes.

Results: Among 31,670 patients, 18.5% had shockable and 81.5% had non-shockable rhythms. In the shockable cohort, BCPR was significantly associated with favorable neurological outcomes overall (AOR 1.86, 95% CI 1.41-2.44), particularly in the early (AOR 1.75, 95% CI 1.30-2.34) and intermediate (AOR 2.84, 95% CI 1.75-4.61) groups. No significant interaction between BCPR and epinephrine timing was observed in this cohort. In the non-shockable cohort, BCPR was not independently associated with favorable outcomes across any time category. However, the interaction analysis indicated that the time-dependent effect of epinephrine differed slightly according to BCPR status (AOR for interaction 1.03, 95% CI 1.00-1.05, p = 0.03).

Conclusions: In shockable OHCA, BCPR was associated with improved outcomes, but no significant interaction with epinephrine timing was observed. In non-shockable OHCA, BCPR itself was not associated with outcomes, while the interaction analysis suggested a possible difference by BCPR status, indicating that the functional role of BCPR may vary depending on the initial rhythm.

Objectives: Sepsis is a life-threatening condition that results in significant morbidity and mortality, particularly when progressing to septic shock. Early detection and treatment, especially before hospital arrival, are crucial for improving outcomes. This review aimed to identify, assess, and summarize studies on the effectiveness of early detection methods and prehospital interventions in enhancing survival rates for patients with sepsis.

Methods: This descriptive systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. A comprehensive literature search was conducted across six electronic databases to identify relevant studies published up to November 2024. Studies were screened and independently reviewed by four reviewers, and bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Methodological Index for Non-Randomized Studies tool for observational studies.

Results: This review included 23 studies comprising 16,246 patients. Most of the studies were retrospective (57%), with RCTs (22%) and prospective observational studies (13%). Prehospital interventions-including antibiotic therapy (ABT), intravenous fluids, and norepinephrine-were associated with improved outcomes. Antibiotic therapy significantly reduced 30-day mortality. Norepinephrine improved survival, and early intravenous fluid administration lowered hospital mortality. The National Early Warning Score was superior to the quick Sequential Organ Failure Score in screening for sepsis (area under the receiver operating characteristic curve, 0.74 vs. 0.68). Emergency medical services (EMS) tools enhanced adherence to the 3-h sepsis bundle (80% vs. 44.2%).

Conclusions: Early antibiotic administration, fluid resuscitation, and hemodynamic stabilization reduce mortality rates and improve clinical outcomes. Validated sepsis screening tools exhibit predictive utility and may support EMS protocols for earlier recognition, though evidence linking their use to improved outcomes remains limited.