Prehospital Emergency Care最新文献

Emergency services leaders have long recognized the importance of timely, high-quality care for critically ill and injured children. The establishment of the federal Emergency Medical Services for Children Program in 1985 has helped disseminate and promote the adoption of pediatric emergency care standards nationwide for the past four decades. Additional efforts were further driven by an impactful report by the Institute of Medicine in 2006: Emergency Care for Children: Growing Pains, which outlined key recommendations to improve pediatric emergency care. In response, the National Pediatric Readiness Project (NPRP) launched in 2011, providing a roadmap for emergency departments to improve pediatric care. Following the success of the NPRP, national organizations collaborated to address pediatric emergency care in the prehospital setting and published a set of recommendations in a 2020 joint policy statement, accompanied by a technical report that summarized the evidence behind the recommendations. Subsequently, the National Prehospital Pediatric Readiness Project (PPRP) was initiated to implement these recommendations. The work of this project has resulted in the development and dissemination of a comprehensive checklist, a corresponding toolkit, and a first-of-its-kind nationwide assessment of prehospital Pediatric Readiness. We describe here the scope of the PPRP, along with a description of future directions, including disseminating assessment results, supporting emergency medical services agency quality improvement efforts, research opportunities, and building a sustainable infrastructure to ensure all emergency medical service agencies are equipped to deliver high-quality emergency care to children.

Objectives: Prehospital pediatric medication administration (PMA) carries a persistent dosing error rate of approximately 31%, despite efforts to mitigate these events. While the characteristics of these errors are well documented, underlying latent conditions in the emergency medical services (EMS) system contributing to these errors are not well understood. The purpose of this study is to identify the root causes within the EMS system that contribute to these errors.

Methods: This study builds upon our previous mixed-methods simulation-based study that identified the frequency and characteristics of active errors associated with PMA. Eleven two-person EMS crews from two agencies in Michigan each completed three simulated pediatric emergencies requiring two doses of epinephrine, midazolam, or fentanyl. Simulations were recorded, and a physician and paramedic measured the accuracy of dosage administration. Post-simulation interviews were conducted to investigate actions associated with error and potential contributing factors. A multidisciplinary team analyzed equipment, protocols, interviews, observer notes, and participant comments through a modified Delphi method, identifying latent conditions using a Root Cause Analysis and Action framework and categorized them using a human factors framework.

Results: Latent conditions were identified and categorized after two rounds of the modified Delphi method. These conditions were found in all five tiers of the human factors framework. They included: 1) Individual Characteristics: limited clinician experience, knowledge, stress, and anxiety; 2) Nature of Work: high task complexity and limited teamwork; 3) Human-System Interface: cognitive aid and medical device usability issues; 4) Management: limited employee training and development; and 5) External Environment: protocol issues and a lack of assistive technology.

Conclusions: These results highlight the critical systemic vulnerabilities underlying PMA dosing errors in EMS, supporting that errors result from systemic issues rather than solely from individual actions. By addressing these systemic weaknesses with comprehensive strategies, progress can be made in effectively resolving the ongoing issue of PMA dosing errors in EMS.

Objectives: The objective of this study was to measure the physiological demands of reserve medics performing tactical combat casualty care (TCCC) within evacuation scenarios.

Methods: Seven active reservist medics (three female) in the Canadian Armed Forces (CAF) completed three self-paced TCCC scenarios developed by a casualty evacuation subject matter expert, based on one- and multi-person evacuations determined to be the most relevant to current CAF operations. Patrol and stretcher carry, trench evacuation, and vehicle extrication were performed on three consecutive days. The casualty was an 86.1 kg manikin dressed in military attire. Participants performed a 1-kilometer pre-fatigue approach march prior to the "patrol" and "trench evacuation" scenario. Oxygen consumption (VO₂) and heart rate (HR) were measured continuously, and rating of perceived exertion (RPE) were recorded at the end.

Results: Participants' mean age was 26 ± 5 years, mean height 179.7 ± 9.6 cm, and mean unloaded mass 83.4 ± 12.2 kg. They wore minimal tactical equipment weighing 27.0 ± 2.1 kg. The patrol scenario total time was 12 ± 2 min, mean relative VO₂ was 26.4 ± 5.8 mL/kg/min (load adjusted 19.6 ± 4.1 mL/kg/min), which was 54% of estimated VO₂max, and mean HR was 166.0 ± 11.3 bpm (88% of HRmax). Final RPE was 16.0 ± 0.8. The trench scenario total time was 12 ± 2 min, mean relative VO₂ was 30.2 ± 4.0 mL/kg/min (load adjusted 22.8 ± 2.5 mL/kg/min), which was 64% of estimated VO₂max, and mean HR was 159.0 ± 13.7 bpm (84% of HRmax). Final RPE was 16.4 ± 1.1. The vehicle extrication scenario total time was 102 ± 25 s, mean relative VO₂ was 22.2 ± 5.5 mL/kg/min (load adjusted 18.2 ± 4.4 mL/kg/min), which was 46% of estimated VO₂max, and mean HR was 153.0 ± 15.8 bpm (81% of HRmax). Final RPE was 13.4 ± 1.1.

Conclusions: Reserve medic TCCC training scenarios demonstrate high relative physiological demand as determined through directly measured VO₂ and HR. The VO₂ demands of these tasks exceed those required to successfully perform the CAF physical employment standard. Due to these physiological requirements, occupational training courses should prioritize combining fitness training at a relatively high intensity with medical tasks to best simulate the occupational environment.

Objectives: Mechanical CPR (mCPR) device use during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients is increasing in the United States. Multiple device types are commercially available, but limited data exist investigating the association between device type and patient outcomes. We aimed to compare the outcomes of patients treated with band-type and plunger-type mCPR devices.

Methods: We used the ESO Data Collaborative 2022-2024 annual datasets for this retrospective cohort study. We included all adult (18-80 years), non-traumatic OHCA patients treated with mCPR following a 9-1-1 call. We excluded patients if they had a resuscitation-limiting advanced directive, experienced OHCA in a nursing home or health care facility, or achieved ROSC prior to mCPR device use. We classified patients into treatment groups based on the mCPR device type used during resuscitation, and used patients treated with plunger-type devices as the reference group for all analyses. Our primary outcome was prehospital return of spontaneous circulation (ROSC). To compare these devices, we used a multi-level mixed effects logistic regression model with emergency medical services agency as a random intercept and adjusted for age, sex, race, witnessed status, bystander CPR, etiology, response interval, initial ECG, interval from scene arrival to mCPR device initiation, OHCA location, year, attempted airway management prior to mCPR, initial airway management strategy, initial vascular access strategy, medication administration prior to mCPR, and agency characteristics.

Results: After application of exclusion criteria, 38,561 patients were eligible for analysis (4,010 (10.4%) treated with band-type devices). Our cohort was a median 62 (50-71) years of age, 33.9% female, 45.5% had witnessed OHCA, 34.5% received bystander CPR, 20.9% presented with a shockable rhythm, and the median time from scene arrival to mCPR initiation was 4.8 (3.0-7.7) minutes. The use of a band-type device was associated with lower odds of achieving prehospital ROSC (band-type: 894/4,010 (22.3%) vs. plunger-type: 8,446/34,551 (24.5%); aOR: 0.87 (0.78, 0.96)).

Conclusions: Our study suggested that the use of a band-type mCPR device was associated with a small decrease in odds of achieving prehospital ROSC in comparison to the use of a plunger-type device. Limitations include the potential for residual confounding, unmeasured confounders, and selection bias.

Objectives: Errors occur in 31% of prehospital pediatric medication administrations (PMA) in Michigan despite the implementation of the MI-MEDIC pediatric dosing reference aid. Reference aids may not effectively target the causes of dosing errors and could introduce new types of error. Our study examines the frequency, magnitude, and immediate causes of PMA dosing errors in emergency medical services (EMS) after implementation of the MI-MEDIC dosing reference aid.

Methods: We used a mixed method, mobile simulation-based approach to examine PMA dosing errors. Emergency medical services crews were recruited from a private EMS service and a fire-based EMS service in Michigan. Each crew completed three high-fidelity simulations (infant seizure, infant cardiac arrest and child burn) requiring two doses of midazolam, epinephrine, or fentanyl. Post-simulation interviews were conducted. Error rates and magnitudes were analyzed using descriptive statistics. A multidisciplinary team used a modified Delphi method, incorporating simulation observations, interview recordings, pictures of equipment that were used during the simulations, and protocols to categorize observed errors and reach consensus on their immediate causes.

Results: Eleven crews were recruited between both agencies, completing 33 simulations and 66 medication administrations, using the MI-MEDIC dosing reference aid. Dosing errors occurred in 19 of the 66 doses (28.8%), with 13 underdoses (68.4%) and six overdoses (31.6%). The median underdose was 0.50 (95% IQR: 0.20-0.56). The median overdose was 2.00 (95% IQR: 1.40-12.50). After two rounds, Delphi consensus categorized 13 slips (68.4%), six mistakes (31.6%), and no lapses. Immediate causes included crews obtaining the wrong weight (4/19, 21.0%), a large volume of air present in the syringe (6/19, 31.6%) and improper dilution of medications when following instructions on the MI-MEDIC reference aid (6/19, 31.6%). The remaining three involved epinephrine administration directly from the prefilled syringe system (2/19, 10.5%) and an intentional underdose (1/19, 5.3%).

Conclusions: PMA dosing errors persist at a high rate with the use of the MI-MEDIC dosing reference aid. Immediate causes of error involve incorrect weight, administering air, and improper dilution, which tools like the MI-MEDIC dosing reference aid do not address. Further research is needed to develop comprehensive strategies addressing the active errors identified in our study.

Objectives: Medical students rarely get the opportunity to witness the impact of social determinants of health (SDOH) on patients within their community. Mobile integrated healthcare (MIH) programs utilize community paramedics (CPs) to tackle patient-specific SDOH to promote continuity of care and linkage to treatment for patients lacking access to health care resources. This study discusses the creation of an MIH ride-along program for medical students and assesses whether ride-along participation would influence medical students' knowledge and perceptions of SDOH and the role SDOH play in accessing health care resources.

Methods: First- or second-year medical students in the Southeastern U.S. completed at least one 8-hour ride-along with the MIH program. Pre-shift surveys assessed baseline SDOH knowledge and post-shift surveys reassessed SDOH knowledge and documented students' perceptions on the educational value of the ride-along. Five key categories of SDOH assessed included: 1) education quality and access, 2) health care quality and access, 3) economic stability, 4) neighborhood and built environment and 5) social and community context. Paired T-tests assessed differences in the mean scores pre-test and post-test.

Results: The 33 participants were predominantly White (72.0%) and female (64.0%), with an average age of 26 (±3.84). Students conducted home visits (93.0%), medication reconciliations (67.0%), chronic disease education (48.0%), lab draws (48%), and social and resource referrals (35.0%) during ride-alongs. Nearly all (94.0%) reported the MIH program improved their understanding of all five SDOH categories and health care challenges within their community. All but one recommended permanent integration of MIH ride-alongs into the medical school curriculum.

Conclusions: Working alongside CPs to care for underserved patients increased medical student knowledge of SDOH and heightened awareness how SDOH impacts patients' health care within their local community. Most recommended integrating the MIH program into the medical school curriculum. Medical educators should consider incorporation of MIH interactions to enhance real-world experience with SDOH.

Objectives:  To explore and describe the incidence of psychological impact, including post-traumatic stress-type symptoms, in volunteer lay responders following involvement with out-of-hospital cardiac arrest, and to identify factors influencing these outcomes.

Methods:  A convergent integrated mixed-methods systematic review was conducted (PROSPERO registration: CRD42023467307). APA PsycInfo, CINAHL (EBSCO), PubMed (Medline), and Web of Science were searched for studies published between January 2003 and October 2025. The Joanna Briggs Institute methodological approach guided study selection, quality appraisal, data extraction, and synthesis.

Results:  Twelve studies involving 80,742 participants from seven countries were included. Five key areas were identified: risk and prevalence of psychological impact; lay responder characteristics; situational dynamics; social connectedness and a sense of community; and emotions experienced while awaiting activation. Most studies reported low levels of severe psychological impact and individual characteristics, situational factors, and community support influenced psychological outcomes.

Conclusions: Severe psychological effects following out-of-hospital cardiac arrest were uncommon, but lay responders may experience mild-to-moderate distress influenced by demographics, situational exposure, and social support. This review highlights modifiable factors - targeted training, clear role expectations, and structured post-event support - that can mitigate psychological burden. Strengthening these areas is critical for protecting lay responders, enhancing the resilience of volunteer programs, and sustaining the Chain of Survival.

Objectives: Cardiac arrest leads to an array of metabolic disturbances, including glucose metabolism. Intra-arrest blood glucose level (BGL) is rarely reported in out-of-hospital cardiac arrest (OHCA) literature, and the influence of BGL on patient outcomes has yet to be conclusively established. To describe the interrelationship between intra-arrest BGL, dextrose administration, and short-term outcomes.

Methods: A retrospective analysis of the 2020 ESO Data Collaborative Annual Research dataset was conducted that included adults who experienced non-traumatic arrests prior to emergency medical services (EMS) arrival and for whom at least one intra-arrest BGL was measured. Logistic regression was used to determine the association between BGL and return of spontaneous circulation (ROSC) while controlling for confounding variables. In this analysis, BGL was modeled with seven categories representing visually distinct bins of the unadjusted probability distribution of ROSC stratified by first intra-arrest glucose measurement.

Results: Data were available for 16,847 patients, of which presumed cardiac etiology was present in 81.6%, followed by respiratory/asphyxia (9.6%), drug overdose (5.0%), and other (3.7%). Most (62.0%) were males with a mean age of 63.5 (±16.7) years and a mean BGL of 184.4 (±104.8) mg/dL. Present in 20.0% was an initial shockable rhythm, while 25.8% received bystander cardiopulmonary resuscitation, and 35.9% attained ROSC. Compared to patients with BGLs of 161-300 mg/dL, patients with ≤50 mg/dL, 51-110 mg/dL, 111-160 mg/dL, 351-430 mg/dL, and ≥431mg/dL were less likely to attain ROSC (OR = 0.407, 0.543, 0.864, 0.718, 0.574, respectively, all p < 0.001). There was no association between ROSC and BGLs of 301-350 mg/dL compared to the reference category (OR = 0.862, p = 0.059). For cumulative BGL ≤ 90 mg/dL, no statistically significant difference in the odds of ROSC between those who received dextrose and those who did not was observed. For cumulative BGL values above 90 mg/dL, intra-arrest dextrose administration was associated with a lower odds of ROSC.

Conclusions: Within the limitations of our observational study design, these data suggest that an association exists between the likelihood of ROSC and intra-arrest BGL. However, this relationship does not appear to be improved with exogenous dextrose administration at any threshold of intra-arrest BGL. Additional study using more robust designs is warranted to further elucidate the interrelationship between BGL, dextrose administration, and longer-term patient outcomes.

Objectives: Community-dwelling populations in Japan are increasingly experiencing complex health and social challenges. Fire-based emergency medical service (EMS) agencies are encountering a growing number of socially vulnerable individuals and are emerging as key partners. However, evidence regarding the implementation and sustainability of such collaborations within Japanese communities remains limited. We aimed to explore the positive experiences and challenges of inter-organizational collaboration between fire-based EMS agencies and long-term care, welfare, and health organizations in Japan as well as strategies for its sustainability.

Methods: Semi-structured and joint interviews were conducted with 26 paramedics in administrative roles from 20 fire-based EMS agencies across Japan. These participants were licensed professionals with prior frontline experience who were currently assigned to divisions responsible for planning and coordinating EMS. They were purposively selected from fire-based EMS agencies that had responded to a nationwide survey. The interviews focused on experiences, challenges, and approaches related to collaboration with long-term care, welfare, and health organizations. Interviews were conducted via Zoom, transcribed verbatim, and analyzed using a qualitative descriptive approach. Codes were developed inductively, grouped into subcategories and overarching categories, and validated through member checking.

Results: Collaboration with community organizations was perceived to enhance EMS efficiency and responsiveness, strengthen interprofessional collaboration and mutual understanding, and promote the appropriate use of EMS by facilitating patient referral to relevant support services. Key challenges included ambiguity in coordination roles, limited operational capacity within partner organizations, insufficient interprofessional understanding, and inadequate information sharing. To sustain inter-organizational collaboration, participants emphasized the importance of promoting relationship building and mutual understanding, establishing sustainable inter-organizational collaboration framework, improving infrastructure for information sharing and triage support, clarifying the roles and response policies of fire-based EMS agencies, enhancing interprofessional education, and securing adequate human resources within community organizations.

Conclusions: Inter-organizational collaboration between fire-based EMS agencies and community organizations appears to be a promising approach for advancing integrated emergency care within the community. The six identified practical measures may contribute to the long-term sustainability of collaborative models that bridge medical and social care needs in Japanese communities.

Objectives: High sensitivity cardiac troponin (hs-cTn) measures are used in the emergency department (ED) to evaluate patients with acute chest pain. Prehospital hs-cTn measurement could facilitate earlier rule-out of myocardial infarction (MI). The objective of this study is to assess the performance of prehospital blood draw for hs-cTnI measure alone, in combination with hs-cTnI measured at ED arrival, and incorporating the Myocardial Ischemic Injury Index (MI³) machine learning algorithm to rule-out index MI.

Methods: We conducted a pilot prospective observational cohort study among adult emergency medical services (EMS) patients with acute, non-traumatic chest pain. Two third-service EMS agencies and two tertiary care EDs in North Carolina participated. Demographics and initial ECG findings were collected. Blood was obtained prehospital and on ED arrival for hs-cTnI measurement. The clinical outcome was adjudicated index visit MI. Efficacy (percentage of patients with index MI ruled-out) and negative predictive value (NPV) for index MI were determined for the following strategies: (1) a very-low single prehospital hs-cTnI, (2) serial hs-cTnI change (delta) at the prehospital and arrival timepoints, (3) MI³ incorporating prehospital hs-cTnI alone, and (4) MI³ incorporating prehospital and arrival hs-cTnI.

Results: Of the 75 patients enrolled, 53.3% (40/75) were women, 32.0% (24/75) were Black patients, and the mean age was 62.2 ± 15.7 years. Index MI occurred in 8.0% (6/75). Prehospital hs-cTnI below the limit of quantification (≤2.7 ng/L) had an efficacy of 46.7% (35/75) with an NPV of 100% (95%CI 90.0%-100%) for index MI. A prehospital and arrival hs-cTnI delta ≤3 had an efficacy of 84.3% (43/51) with an NPV of 97.7% (95%CI 87.7-99.9%) for index MI. The standard low-risk MI³ threshold <1.6 with a single prehospital hs-cTnI had an efficacy and NPV for index MI of 76.0% (57/75) and 96.5% (95%CI 87.9-99.6), respectively. Finally, the standard low-risk MI³ threshold incorporating both prehospital and arrival hs-cTnI had an efficacy of 70.6% (36/51) and NPV of 100% (95%CI 90.3-100%) for index MI.

Conclusions: Strategies using prehospital blood for hs-cTnI measurement alone and MI³ with prehospital and arrival hs-cTnI safely identified a large percentage of patients for rule-out, warranting further investigation in a larger trial.