Prehospital Emergency Care最新文献

Caring for sexual assault survivors requires interdisciplinary collaboration, pre-planning, and education. The purpose of this document is to guide emergency medical service (EMS) agencies and clinicians in the patient-centered management of survivors of sexual assault.

The National Association of EMS Physicians Recommends:Trauma-Informed Care: EMS clinicians should recognize that sexual assault is a traumatic event, and we recommend a trauma-informed care approach. Some recommended actions include, but are not limited to, asking questions that validate a survivor's experience, asking permission before doing an exam to acknowledge a patient's choice, and allowing a support person during the physical exam.Physical Injuries after sexual assault: EMS clinicians should assess for serious traumatic injuries associated with sexual assault including strangulation.Collaboration with Sexual Assault Forensic Examiner Organizations: EMS clinicians should understand general forensic guidelines and state-specific regulations relevant to prehospital care. Indications for forensic exams vary by state, thus partnerships between EMS and sexual assault forensic examiner organizations can facilitate access to forensic examiners who can provide clear guidance on available forensic resources.Transport to Sexual Assault Forensic Examiner-resourced facilities: EMS systems should identify local facilities that are resourced to care for sexual assault survivors or systems designed to provide these resources to the survivor and preferentially transport stable survivors to these destinations for medical and forensic evaluation. If there is concern for a life-threatening injury, patients should be transported to a trauma center for evaluation.Documentation: In addition to awareness of local regulations, EMS clinicians should be complete, accurate, and culturally competent in their documentation. They should minimize bias in their documentation.Evidence Preservation: EMS clinicians should be aware of best practices for evidence preservation and be trained in evidence collection in the prehospital setting, including avoiding showering, eating, changing clothes before the forensic exam, and maintaining chain of custody.Consider other special populations: EMS clinicians should be aware of high-risk special populations for sexual assault with unique medical, cultural and/or regulatory considerations including, but not limited to, the pediatric, elderly, transgender, gender diverse, LGBTQ (lesbian, gay, bisexual, transgender, queer), pregnant, and male survivors.

Objectives: Intimate partner violence (IPV) is increasingly being recognized as a clinical circumstance to which Emergency Medical Services (EMS) clinicians attend. IPV refers to the use of physical, sexual, psychological, and coercive violence by a current or former intimate partner to exert power and control. The intersection of paramedicine and IPV remains largely unclear. Our objective is to provide a comprehensive synthesis of the available evidence at the intersection of paramedicine and IPV.

Methods: This review followed a published protocol (Open Science Framework), and PRISMA-ScR guidelines. Co-developed with two trained librarians, a search strategy was used to locate potential articles in MEDLINE and CINAHL, and conduct a gray literature search. Included articles examined perceptions and/or practice of EMS clinicians and students in the context of IPV. Two reviewers screened titles and abstracts, then full texts. A third reviewer resolved any disagreement. Data were extracted from eligible articles using a purpose-built template and the findings were summarized and synthesized.

Results: Of the 518 articles, 34 met inclusion criteria. The literature was varied and heterogenous, preventing mass, detailed synthesis. Generally, EMS clinicians were motivated to assist IPV survivors but perceived their education as insufficient to provide high-quality care, reporting low rates of training/education with corresponding low self-efficacy. Considerations for the specific and unique environment of paramedicine were lacking. Standardized patients and/or simulations were beneficial for pre-practice students acquiring history gathering and interview skills. Jurisdictional variations in legislation, policy, and standards, as well as overlapping agency/department regulations introduced practice variance. The validity and utility of EMS clinician-collected surveillance data were unclear.

Conclusions: While EMS clinicians were recognized as a poorly understood, under-utilized, and under-equipped resource for IPV survivors, current literature is insufficient to comprehensively guide practice. Heterogeneity and limited quantity contribute to this challenge. Future research should leverage newly developed and validated measures to identify gaps responsive to educational and/or policy interventions and explore novel technologies to improve the quality of EMS clinician-collected IPV data. Equipping EMS clinicians with the tools to provide high-quality IPV care will benefit IPV survivors, EMS clinicians, and health care more broadly.

Objectives: Ensuring occupational safety in high-risk professions requires validated tools to assess and promote safety behavior tailored to specific organizational contexts. Safety compliance, a specific form of safety behavior, refers to workers' adherence to safety policies, procedures, and standards within an organization. Current safety instruments adapted for emergency medical services (EMS) do not specifically measure safety compliance and may not capture the unique challenges and risk faced by fire-based EMS personnel. We developed and validated an EMS Safety Compliance scale for fire-based EMS personnel to address their occupational safety risks.

Methods: Items were developed by the research team and three EMS personnel using iterative item development. The items were field-tested as a scale of 15 items on the Fire service Organizational Culture of Safety (FOCUS) survey. The FOCUS survey is a validated safety climate survey specific for the United States (U.S.) fire and rescue service and is administered in U.S. fire departments that opt in. Our analysis included survey respondents that self-reported holding an EMS role (n = 3,117). We conducted exploratory factor analysis (EFA) (n = 1,041) to identify the number of factors for the scale through factor reduction and then we conducted confirmatory factor analysis (CFA) (n = 2,076) to confirm the measurement structure of the scale. We also tested the discriminant validity between this new scale and a previously developed Fire Safety Compliance scale.

Results: The EFA identified a 1-factor 10-item EMS Safety Compliance scale among respondents self-reporting holding an EMS role within U.S. fire departments. The CFA results indicated support for the 1-factor structure and the fit statistics were indicative of a good fit. Further, we found discriminant validity between this new measure and an established measure of safety compliance related to fire suppression contexts measured on FOCUS.

Conclusions: Our results suggest the EMS Safety Compliance scale is a reliable and valid measure. This scale can be used in future research to gauge safety compliance among EMS personnel in U.S. fire departments that participate in FOCUS or as a standalone measure.

Objectives: High-risk pulmonary embolism (PE) manifests as obstructive shock or cardiac arrest and requires immediate treatment. Our aim was to explore survival and bleeding complications of prehospital fibrinolysis in the treatment of suspected high-risk PE.

Methods: We collected patient data from the emergency medical services (EMS) registry of the Helsinki metropolitan area and the hospital database of Helsinki University Hospital between 2007 and 2019. The inclusion criteria were clinically suspected, high-risk PE treated with intravenous fibrinolysis by EMS. Diagnosis of PE was confirmed in all patients with imaging or by autopsy. Patients who did not receive prehospital fibrinolysis served as comparators.

Results: The study included sixty patients. Twenty-three patients, 44% female, with a mean age of 57 years received prehospital fibrinolysis. Seventeen of those patients (74%) had suffered cardiac arrest and six patients (26%) had obstructive shock as the leading manifestation. Prehospital mortality was 35% (n = 8/23) and in-hospital mortality 27% (n = 4/15), for a total (prehospital + in-hospital) mortality rate of 52% (n = 12/23). All deaths were among patients presenting with cardiac arrest. Two patients had major bleeding complications, but none were fatal. All eleven fibrinolysis patients who were discharged alive from the hospital were still alive at a twelve-month follow-up. In comparison, there were 37 high-risk PE patients who did not receive fibrinolysis. They were older (mean, 72 years) and more likely to present with cardiac arrest (51%), and their 12-month mortality tended to be higher (76%) (p = 0.06).

Conclusions: Out-of-hospital high-risk PE is associated with high mortality. In this case-series, fibrinolysis appears to be safe. The possible survival benefit needs to be confirmed in further trials.

Objectives: Out-of-hospital cardiac arrest (OHCA) remains a significant global health challenge. Cardiopulmonary resuscitation (CPR) plays a pivotal role in patient survival; the International Liaison Committee on Resuscitation (ILCOR) recommends compressions on the lower half of the sternum. However, emerging evidence suggests that performing compressions below this point, directly targeting the maximal diameter of the left ventricle, may improve cardiac output and clinical outcomes. This study assessed the safety of the new compression landmark by comparing complications with the standard approach.

Methods: This study was conducted as a randomized controlled trial using cadavers. The cadavers were assigned to two groups: The alternative landmark group received a mechanical chest compression cup that was placed 12.6 cm below the sternal notch, targeting the maximal diameter of the left ventricle. The nonintervention group used the standard landmark (lower half of the sternum). Each cadaver underwent pre- and post-chest compression computed tomography scans, followed by an autopsy to identify and compare complications. The primary outcome was the incidence of serious injuries. Secondary outcomes included the incidence of organ-specific injuries.

Results: Forty-two cadavers were equally assigned into two groups (21 per group). Serious injuries occurred similarly in the alternative and standard landmark groups (61.90% vs. 66.67%, p = 0.747). Rib cage injuries were similar between groups 11 (52.38%) versus 13 (61.90%) (p = 0.533). Flail chest affected 1 (4.76%) versus 3 (14.29%) (p = 0.293), and heart injuries were 2 (9.52%) versus 0 (p = 0.147). Skeletal fractures were universal, with sternal fractures in 16 (76.19%) versus 15 (71.43%) (p = 0.726). Visceral injuries were 7 (33.33%) versus 4 (19.05%) (p = 0.292). Liver and spleen injuries occurred only in the standard group (0% versus 4.76%, p = 0.312). No kidney injuries were reported.

Conclusions: The alternative landmark showed no significant difference in serious injuries compared to the standard landmark. Further studies should focus on chest compression at the new landmark, which has the potential to improve cardiac arrest outcomes.

Objectives: Rapid vascular access is essential in trauma resuscitation, with intraosseous (IO) access providing a reliable alternative when peripheral intravenous access is not feasible. While the proximal humerus, tibia, and sternum are food and drug administration -approved IO sites, the distal femur has been proposed as a potential alternative, particularly in out-of-hospital adult cardiac arrest scenarios. This study aims to assess the feasibility of distal femur IO access in adults by evaluating the required needle length.

Methods: A prospective observational case series study was conducted involving 100 healthy adult volunteers. Ultrasound was used to measure soft tissue depth 2 cm proximal to the superior border of the patella. Measurements were taken with the transducer placed lightly on the skin and with gentle downward pressure. Participants with a skin-to-bone depth greater than 40 mm were considered at high risk for insertion failure, as the longest standard IO needle measures 45 mm.

Results: One hundred participants were enrolled, with a median age of 27.3 years (IQR 25.0-29.0); 64 (64.0%) were male. Body mass index ranged from 17.42 to 35.26 kg/m², with a median of 22.86 kg/m² (IQR 20.81-25.03). The mean soft tissue depth at the distal femur site was 25.0 mm (IQR 21.9-29.6) without pressure and 14.0 mm (IQR 12.0-16.0) with gentle pressure. No participant had a soft tissue depth exceeding 40 mm.

Conclusions: Distal femur IO access appears to be a feasible alternative for vascular access in young, non-obese adult patients. Our findings suggest that standard IO needle lengths are adequate for this site in this population, supporting its potential incorporation into emergency protocols. Further research is recommended to validate these results and inform standardized guidelines for distal femur IO placement.

Objectives: The use of sodium bicarbonate (SB) in the treatment of cardiac arrest without known etiology is still controversial and is not routinely recommended by the American Heart Association guidelines. This study summarizes current evidence on the use of SB in out-of-hospital cardiac arrest (OHCA).

Methods: We systematically searched PubMed, Scopus, and Cochrane databases for randomized controlled trials (RCTs) and observational studies evaluating SB in OHCA. Return of spontaneous circulation (ROSC) was the primary outcome, explicitly defined as the return of a palpable pulse and measurable blood pressure; sustained ROSC (≥20 min) was noted separately. Survival to discharge was a secondary outcome. Using a random-effects model, we pooled Odds Ratios (OR) for binary outcomes with 95% confidence intervals (CI).

Results: Eleven studies (2 RCTs, 9 observational; N = 126,013) were included. No significant differences were observed in ROSC (OR 0.85, 95% CI 0.59-1.23; p = 0.38) or survival to discharge (OR 0.63, 95% CI 0.17-2.28; p = 0.48).

Conclusions: Administration of sodium bicarbonate in patients with OHCA was not associated with improved ROSC or survival to discharge. Therefore, its routine use cannot be recommended. However, our review does not exclude the possibility of benefit in selected, guideline-specified contexts such as hyperkalemia or tricyclic antidepressant overdose, or when administered early during resuscitation. Further high-quality studies with standardized reporting of etiology, timing, dose, and airway management are needed to clarify these potential indications.

Objectives: National guidelines highlight the benefit of prehospital ultrasound (PHUS) in patient care and identify it as a priority for research. Few studies presently exist that identify the current uses of PHUS. We aimed to evaluate the frequency and current utilization of PHUS within the United States (U.S.).

Methods: A structured review was conducted of emergency medical services (EMS) protocols from the United States listed in the Acid Remap website, the largest publicly accessible online database for EMS protocols for individual agencies and defined regions in the country. All listed protocols were eligible for inclusion. The EMS protocols were reviewed and those containing PHUS were included. Protocols were excluded if they were not related to prehospital care, duplicates, password protected, or if the protocol document could not be located. Additionally, if PHUS was listed solely as within EMS clinician scope of practice, but no specific use case was defined, the protocol was excluded. Included EMS Protocols were then reviewed to collect PHUS indication for use, type of scan, and minimum approved level of performing clinician. Descriptive statistics were reported.

Results: Of 657 EMS protocols, 514 protocols (78.2%) were reviewed. We excluded 143 (21.7%) protocols; the majority of these could not be accessed or located (n = 128/143, 89.5%). Ninety (17.5%) of the 514 protocols contained PHUS and it was most frequently intended for use by paramedics (n = 52, 57.8%). Prehospital ultrasound was most often contained in cardiac arrest treatment protocols (n = 68, 75.6%) and used to evaluate cardiac activity (n = 59/68, 86.8%). The next three most common protocols which contained PHUS included trauma (n = 51, 56.7%) with the extended focused assessment with sonography in trauma (EFAST) exam (n = 39/51, 76.5%), procedural guidance (n = 33, 36.7%) with peripheral access (n = 23/33, 69.7%), and dyspnea (n = 33, 36.7%) with B-Line assessment (n = 24/33, 72.7%).

Conclusions: In the largest EMS protocol repository within the U.S., 17.5% of EMS protocols contained PHUS and use indications. The most frequently described indication for use was in cardiac arrest, followed by trauma, procedural guidance, and dyspnea. The most common scanning types of scans include evaluation of cardiac activity, EFAST, peripheral access, and B-Line assessment.