Prehospital Emergency Care最新文献

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.

Objectives: Pediatric out-of-hospital cardiac arrest (OHCA) impacts 15,000-25,000 children annually in the U.S. The objective of this study was to determine if specific Emergency Medical Services (EMS) agency factors, such as pediatric volume and preparedness factors, including hours of required pediatric training, pediatric emergency care coordinator (PECC), or pediatric informational resources are associated with improved quality of care or adverse events for pediatric OHCA.

Methods: We conducted a retrospective chart review of EMS clinical records and EMS agency survey among five agencies in the Portland OR, Pittsburgh PA, Milwaukee WI, San Bernardino CA, Atlanta GA, and Dallas TX regions. We reviewed medical records of children who experienced an EMS-treated OHCA between 2013 and 2019 using a validated structured chart review tool to identify adverse safety events (ASEs). Agencies who contributed medical records completed a survey that described elements of pediatric preparedness and organizational structure relevant to pediatric care. We first conducted a descriptive analysis of agency and patient characteristics, followed by an evaluation of the association of agency factors that we hypothesized could improve pediatric care and reduce the occurrence of ASEs.

Results: Twenty-two agencies with a total of 659 OHCA patient encounters completed the survey. The Broselow system was used by 81% of agencies, local protocol guides were used in 86% of agencies. Forty-five percent of agencies had a designated pediatric emergency care coordinator (PECC). Agencies reported a similar number of hours for pediatric and neonatal simulation (1.3 and 1.5 h, respectively) and skills training (2.0 and 2.5 h, respectively) annually. We found that younger patient age significantly increased the risk of an ASE. In both univariate and multivariate analyses, several hypothesized variables were not associated with decreased risk of an ASE, including pediatric and neonatal skills/simulation training hours, conducting pediatric-specific quality reviews, and having an identified PECC.

Conclusions: In this large medical record review of EMS-treated pediatric OHCA cases, pediatric training, pediatric care coordination, and conducting pediatric quality reviews were not associated with reduced ASEs. Additional research is needed to understand how EMS agencies can improve the quality of care for pediatric OHCA, especially for infants.

Objectives: Efficient dispatching of physician-staffed vehicles in emergency medical services requires clear criteria to ensure timely allocation of resources, improve patient outcomes, and minimize response time under high-pressure conditions. The aim of this study was to identify criteria ensuring that emergency physicians are safely managed and efficiently deployed.

Methods: Rescue service deployments in the city of Dresden, Germany (01/01/2021-12/31/2021), were analyzed retrospectively. The rescue mission indications determined by the telecommunicator, along with the presence of vital sign abnormalities at site - such as airway, breathing, circulation, and disability - based on the ABCDE approach from the Advanced Life Support and Advanced Trauma Life Support algorithms, were analyzed. Specific emergency medical procedures carried out in the particular mission were assigned to the respective competence level (CL): CL1: invasive measures reserved for physicians; CL2: invasive measures that paramedics are trained to use independently in emergency situations; CL3: standard measures; CL4: counseling only; and CL5: no measures.

Results: In all, 67,975 missions were analyzed. Missions were most frequently dispatched for internal indications, such as cardiovascular and pulmonary emergencies (28.4%), and traumatological indications (20.4%). Despite the physician being dispatched in 36.5% of cases, invasive measures (CL1/CL2) were only used in 13.9% of missions. Internal indications (11.8%) and resuscitation (19.6%) frequently required CL1 measures. CL2 measures were more frequently applied than CL1 measures for allergic (44.2% vs. 1.9%), neurological (12.5% vs. 3.4%), and psychological (6.1% vs. 0.7%) indications. In most interventions (62.2%), only the standard competencies (CL3) were used as the highest level of competence. For most mission indications, the probability of invasive measures (CL1/CL2) increased significantly in the presence of at least one vital sign abnormality.

Conclusions: The results show opportunities for optimizing emergency physician dispatch. The presence of a vital sign abnormality should be given greater consideration in the future. Query algorithms for detecting cases with a high probability of requiring CL1/CL2 measures could support efficient dispatching. Furthermore, emergencies requiring CL2 but rarely CL1 measures could be handled independently by emergency paramedics, particularly if they have access to the support of a tele-emergency physician for situations where CL1 measures become necessary.

Objectives: Personal attitudes amongst emergency medical services (EMS) clinicians could influence successful implementation of prehospital buprenorphine administration programs (PBAPs), yet few studies have investigated EMS clinician perceptions concerning these innovative programs. This mixed-methods study assessed EMS clinician perceptions and concerns about PBAPs.

Methods: Emergency Medical Technicians (EMTs), advanced EMTs and paramedics were recruited for focus groups from Upstate South Carolina. Researchers moderated groups of 12 or fewer and field personnel were interviewed separately from EMS training officers and leadership. Participants took a survey assessing demographic, employment, and contextual information on EMS-led interventions addressing the opioid epidemic. Moderators asked participants to provide confidential responses to four open-ended questions. Thematic analysis was applied to all responses using the framework method. A codebook was modeled using deductive themes from previous literature, while inductive themes and subthemes were added through researcher consensus. Final coding of themes and subthemes was constructed independently by two researchers with disagreements resolved by a third. Descriptive statistics summarized demographic, employment, and contextual information collected from the survey.

Results: The 107 participants were predominantly male (69.2%) and White (96.3%) with an average age of 38.4 years (SD = 11.4). Half were paramedics and 35.5% were EMTs with EMS experience ranging from 3 months to 39 years, median of 10 years. Most (70.2%) heard of buprenorphine and 28.9% received education on medication for opioid use disorder (MOUD). Describing initial reactions to an overdose, themes included overdoses as a routine part of EMS and naloxone distribution changing overdose dynamics. Themes included opioid withdrawal is not a medical emergency, buprenorphine negatively affecting EMS operations, and PBAPs requiring culture shift. Themes surrounding concerns included EMS clinician perceptions of individuals with opioid use disorder (OUD), PBAPs increasing substance misuse, and buprenorphine increasing EMS clinician liability. At the end of the session 45.8% stated they would want their EMS agency to participate in a PBAP, 44.9% would not want their agency to participate, and 8 (7.5%) did not answer.

Conclusions: Emergency medical services clinicians' perceptions towards prehospital buprenorphine administration could influence adoption of PBAP protocols. Findings may inform PBAP educational initiatives which mitigate these concerns and knowledge gaps.

Objectives: During the COVID-19 pandemic, the number of ambulance calls increased sharply, and ambulances could not be dispatched due to unavailability, especially in rural areas. This study assessed the integration of traditional emergency care systems in rural areas with online medical services from urban areas.

Methods: In this retrospective observational cohort study, patients recovering from mild COVID-19 at home who called an ambulance (November 2022 to January 2023) in Asahikawa, Japan were included. When an emergency call was received, the fire department control center initiated an online medical consultation to ascertain the necessity of ambulance transport while conventionally dispatching an ambulance. We compared chief complaints and patient characteristics between those who were transferred to hospitals and those who were not transferred, considering the time from the beginning of the 1-1-9 call to the start of the online service, and the duration of the online consultation for each group. The statistical significance of the differences between groups was analyzed by the Mann-Whitney U-test for continuous variables and the chi-square test or Fisher's exact test for categorical variables with statistical significance set at p < 0.05.

Results: Among the 136 patients, 73 (53.7%) were transferred to a hospital via ambulance. The median age of the transferred patients was significantly higher, at 83 years (interquartile range (IQR): 57-90), compared with 37 years (IQR: 26-60) for those not transferred (p < 0.001). A significantly higher number of transferred patients had hypoxemia (17, 23.3%; vs. non-transferred, 2, 3.2%; p < 0.001). The time from the start to the end of the online consultation was shorter for the transferred patients (13 min (IQR: 8-20) compared to non-transferred patients (15 min (IQR: 13-22); p < 0.001). There were no significant differences between groups in terms of sex, medical history, other chief complaints, or the time from the start of the 1-1-9 call to the start of the online service.

Conclusions: Online medical services have the potential to optimize medical resource allocation and utilization in rural areas.

Objectives: Emergency medical services (EMS) post-overdose outreach programs expand beyond traditional 9-1-1 response to offer overdose survivors linkage to substance use treatment and other related harm-reducing interventions. Although intuitive and increasingly popular, evidence to define expected outcomes is exceedingly limited. We evaluated process and patient outcomes of one large Midwestern post-overdose outreach program to describe outreach characteristics and linkage to substance use treatment.

Methods: This retrospective cohort study used clinical program records of individuals referred to a multidisciplinary post-overdose outreach program following a non-fatal presumed opioid overdose with emergency response. Measures included (i) number of outreach attempts, (ii) modalities of outreach attempts (in-person visit, text message, letter, phone call, or electronic mail), (iii) outcome of outreach (i.e., if the individual was contacted), (iv) interventions provided including linkage to substance use treatment with coordinated admission and transportation. We used descriptive statistics to report patient characteristics, outreach frequency, outreach modality, successful contact, and treatment linkage through the program.

Results: From 2020-2022, the program attempted outreach to 3,437 individuals. The median age was 37 years (interquartile range, IQR, 30-47). Most individuals were white/non-Hispanic (n = 2,077, 63.1%) and male (n = 2,084, 61.2%). Few were unhoused at the time of outreach (n = 246, 7.2%). The program made a total of 7,935 outreach attempts with a median of 2 outreach attempts (IQR 1-3) per individual. The most common outreach modalities were in-person visit (n = 3,300, 41.6%) and text message (n = 2,776, 35.0%), though phone calls and in-person visits most often resulted in successful contact (52.6% and 23.7%, respectively). Outreach attempts resulted in 743 (21.6%) successful contacts and the program linked 304 individuals (40.9% of all contacted individuals, 8.8% of all attempted outreach) to treatment. Notably, 160 (52.6%) of the 304 individuals linked to treatment required 3 or more outreach attempts before treatment linkage occurred.

Conclusions: Post-overdose outreach initiated by EMS can successfully find and link individuals to substance use treatment following a non-fatal opioid overdose. However, this intervention may be resource intensive, often requiring multiple attempts at outreach and several modalities of interaction to facilitate treatment linkage.

Objectives: To conduct a literature review and provide a summary of the evidence surrounding prehospital administration of antibiotics for open fractures and other major open wounds.

Methods: We performed a literature search and summarized the evidence following the methodology established for the NAEMSP Prehospital Trauma Compendium. We searched PubMed from inception to 23 December 2022 for articles relevant to Emergency Medical Services, trauma, and antibiotics. Due to resource limitations, the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was not used during review of the evidence, and no formal assessment of bias or strength of evidence was performed.

Results: Of 105 articles identified in the initial search, 13 articles were included in the final evidence review and synthesis. Prehospital administration of antibiotics in combat and civilian trauma patients consists of mostly observational, retrospective studies that describe use as likely safe, but with uncertainty as to its effect on important clinical outcomes. Both combat and civilian analyses of protocol adherence and inter-rater reliability for recognition and treatment of injuries have also produced variable and inconsistent results. These results pose a challenge for implementation and highlight the inherent limitations and external validity of efficacy outcomes published to date.

Conclusions: Prehospital administration of prophylactic antibiotics for trauma appears safe and may be considered in some specific patient populations. Universal and widespread adoption of this intervention needs further study to identify the true impact on patient-centered outcomes and identification of patients who might confer greatest benefit. Local practice characteristics may support adoption of multidisciplinary-developed prudent and practicable protocols incorporating the use of prophylactic antibiotics for some trauma patients such as those with open fractures or those with significant delays in transport to definitive care. Future research should attempt to address the appropriate identification of wounds and injury patterns that have the highest likelihood of benefit from prehospital administration of antibiotics, the ideal timing of administering the antibiotic(s) following initial injury, impact on infection rates, and other important patient outcomes.

Objectives: Opioids kill tens of thousands of patients each year. While only a fraction of people with opioid use disorder (OUD) have accessed treatment in the last year, 30% of people who died from an overdose had an Emergency Medical Services (EMS) encounter within a year of their death. Prehospital buprenorphine represents an important emerging OUD treatment, yet limited data describe barriers to this treatment. Our objectives were to quantify the number of patients encountered by EMS who were eligible for prehospital buprenorphine, and to examine characteristics of patients who did or did not receive treatment.

Methods: In this retrospective observational study, we analyzed EMS patient records from Contra Costa County, CA, where paramedics were trained to identify patients experiencing opioid withdrawal and administer buprenorphine. Patient records were selected for review based on "buprenorphine patient triggers," which were keywords within the charts that identified patients with potential overdose or symptoms that could indicate withdrawal or naloxone administration. We describe proportion of eligible patients and the characteristics of those who did and did not receive prehospital buprenorphine.

Results: We reviewed 1,159 records from September 2020 to July 2022. Of included patients, 984 (85%) were not eligible for buprenorphine. Nearly half (482, 49%,) of patients ineligible for buprenorphine fell into 2 primary categories: 331 (33%) had altered mental status (326 of 331 received naloxone), and 151 (15%) had no active withdrawal symptoms documented. Additional exclusions included other intoxicants, severe medical illness, or the patient denied having an OUD. Of those eligible for buprenorphine, 67 (38%) received buprenorphine. Of the 108 patients who did not receive buprenorphine, 69 (64%) had protocol deviation, 24 (22%) declined treatment, and 15 (14%) were in a non-enabled zone. Of all buprenorphine administrations, 19 (28%) were post-opioid overdose and 48 (72%) were for abstinence withdrawal.

Conclusions: One-in-three EMS patients with suspected opioid use disorder were ineligible for treatment with buprenorphine due to altered mental status. The second largest group consisted of patients who were eligible but not offered buprenorphine, highlighting potential gaps in paramedic training, logistical challenges in field administrations, and other factors that warrant further exploration.

Objectives: Motorcycle helmets save lives and reduce serious injury after motorcycle collisions (MCC). In 2022, 18 states had laws requiring helmet use by motorcyclists aged ≥21 years. Our objective was to compare helmet use and head trauma in emergency medical services (EMS) patients involved in MCC in states with and without helmet use laws.

Methods: We conducted an analysis of the 2022 ImageTrend Collaborate national EMS dataset. We included 9-1-1 responses where the patient was a motorcyclist in a transport accident (ICD-10 V20-V29) and aged ≥21 years. Patient demographics, incident urbanicity, helmet use, presence of state helmet use law, patient disposition, Glasgow Coma Scale (GCS) score, and trauma team activations were examined. Our primary outcome of interest was EMS documentation of helmet use (yes/no). Our secondary outcome was the presence of a head injury. We examined EMS-documented head injury, defined using clinician impressions and chief complaint anatomical location. Chi-square tests were used to assess differences in proportions, and a multivariable logistic regression model was used to estimate odds of moderate/severe head injury adjusted for covariates of interest.

Results: A total of 15,891 patient encounters were included, 10,738 (67.6%) occurred in states without helmet use laws. States without helmet use laws had higher proportions of unhelmeted patients (56.8% vs 24.2%, p < 0.001), encounters in non-metro/rural areas (19.7% vs 13.3%, p < 0.001), and GCS-defined moderate/severe head injuries (4.6% vs 2.3%, p < 0.001). In a multivariable model that included 10-yr age groups, sex, race, urbanicity, and documented helmet use, the adjusted odds of moderate/severe head injury were lower for females (0.47, 95%CI, 0.35-0.65) and Black patients (0.47, 95%CI 0.32-0.70), and were higher for incidents in nonmetro/rural areas (1.58, 95%CI 1.28-1.95) and when EMS had not documented helmet use (3.17, 95%CI 2.56-3.92).

Conclusions: In this retrospective cross-sectional study, a higher proportion of patients involved in MCCs in states without helmet laws were not wearing helmets at the time of injury, and unhelemted patients had increased likelihood of sustaining a head injury. EMS agencies in states without helmet laws should prepare their systems and clinicians for an increased incidence of head injuries after MCCs.

Objectives: Medication for opioid use disorder (MOUD) reduces morbidity and mortality for patients with opioid use disorder (OUD). Recent administrative and legislative changes have made MOUD possible in the prehospital setting. We use an implementation science framework to outline the Reach of a fire department EMS-based Mobile Integrated Health (MIH) prehospital MOUD program.

Methods: The West Allis Fire Department (WAFD) within the Milwaukee County EMS system operates an MIH program that allows for internal and external referrals for patients with OUD. Internal referrals originated from 9-1-1 dispatch via emergency medical dispatch code selection, self-dispatch, or a weekly summary of electronic patient care reports involving opioid-related encounters. External referrals came from emergency departments (ED) or community partners. Among all referral patients with OUD, the primary measures included Overall Reach (those who agreed to MIH services), Clinical Opiate Withdrawal Scale (COWS) Reach (those with a COWS score performed), Buprenorphine Reach (those who based on COWS were offered buprenorphine induction) and Induction Reach (those who accepted buprenorphine induction).

Results: Between 5/24/2023 and 5/25/2024, the WAFD MIH program received 265 total potential OUD patient referrals, 135 internally and 130 externally. Internal referrals consisted of 48 MIH responses received from 9-1-1 dispatch, 5 self-dispatches, and 82 patients captured on a weekly report. In the external referral process, 8 originated from community partners and 122 from EDs. Among the combined 265 patient referrals, 128 (48.3%) patient contacts were made. The Overall Reach was 99/128 patients (77.3%), COWS Reach was 99/99 (100%), Buprenorphine Reach was 8/99 (8.1%) patients, and Induction Reach was 4/8 (50%).

Conlusions: A fire department EMS-based MIH buprenorphine MOUD program is able to reach patients experiencing OUD. External partners make up a sizable proportion of patient referrals to increase a program's reach. Challenges included obtaining real time assessment from designated MIH clinicians utilizing dispatch protocols, a high proportion of ineligible patients based on buprenorphine guidelines, and a relatively high proportion of patients declining induction. Results may assist other fire departments in assessing potential estimates of patient encounters and avenues for patient contact for similar programing.