Prehospital Emergency Care最新文献

Objectives: Our study details Online medical consultation (OLMC) usage for Pediatric out-of-hospital cardiac arrest (P-OHCA), including proportion of P-OHCA utilizing OLMC, the characteristics of cases using OLMC, the types of information exchanged during OLMC calls, and the outcomes in patients where Emergency Medical Services (EMS) contacted OLMC.

Methods: The study included P-OHCA patients treated by EMS agencies participating in the regional cardiac registry with total catchment population of approximately 1.5 million residents. We reviewed linked calls and EMS charts for P-OHCA cases treated from January 1st, 2018 through December 31st, 2022.

Results: In total, 112 cases from January 2018 to December 2022 were included in the final analysis. Twenty-two out of 112 utilized OLMC with a mean time from 9-1-1 call to OLMC of 28.8 min. The no OLMC group had a significantly higher transport rate than OLMC group as well as higher percentages of ROSC at any time and ROSC upon arrival at the ED. Both survival to admission and survival to discharge were more prevalent in the no OLMC group, while there were no instances of survival to discharge in the OLMC group. During the calls, the discussion of crucial prognostic factors, including witness status, initial rhythm, ETCO2, and arrest duration, appears inconsistent.

Conclusions: Pediatric-OHCA cases with OLMC tend to contact OLMC late in the resuscitation, have poor prognostic factors, and have poor survival outcomes. The information exchanged during OLMC calls was highly variable, representing a clear opportunity for improvement. Future studies should explore the potential effect of early OLMC contact on patient outcomes and if a standardized template for OLMC data exchange improves consistency in recommendations for P-OHCA.

Objectives: Out of Hospital Cardiac Arrest (OHCA) is a frequently encountered pathology with resultant poor outcomes in the majority of patients. Echocardiography has been utilized to help guide clinical decision making and monitor effectiveness of resuscitative efforts. Transthoracic echocardiography (TTE) the mainstay of point-of-care ultrasound (POCUS) real time resuscitative imaging has limitations, most notably is the disruption of closed chest compressions. Trans-esophageal echocardiography (TEE) is an emerging technology in emergency care and can potentially overcome these limitations but image quality and accuracy of use in the prehospital environment remains unknown. Our primary objective is to identify the accuracy of Emergency Medical Services (EMS) fellow physicians in performing TEE via the identification of key cardiac structures. Secondarily we assess image quality as well as accuracy on cardiac activity interpretation as compared to TEE-experienced cardiologists.

Methods: A pilot study using descriptive analysis of a retrospective case-series with specific focus on inter-rater reliability as well as pragmatic management alterations based on real-time image interpretation by EMS physicians. After focused education, 13 patients were eligible for prehospital TEE who suffering OHCA from July 2022 to June 2023. Ultrasound (US) images were interpreted by EMS fellow physicians and over-read by cardiologists with specific focus on inter-rater reliability. After collection of patients presenting data and US images, analysis was performed.

Results: Of 13 patients initially screened, 10 patients were included in a study with a median age of 50 years old (41-70). Three patients were excluded due to equipment malfunction or insufficient image capture. An interrater reliability identified a kappa of 0.96 with respect to identification of cardiac structures and a kappa of 0.65 for identification of cardiac activity.

Conclusions: In this small study of prehospital TEE, EMS fellow physicians had high inter-rater reliability in image interpretation pertaining to anatomy and cardiac activity when compared with cardiologists. Further research is needed to determine its efficacy, safety, and widespread application in the prehospital setting.

Objectives: To investigate the benefits of virtual reality (VR) first-aid training in acquiring cardiopulmonary resuscitation (CPR) skills.

Methods: A total of 100 non-medical professional volunteers from Nanchang were selected in March 2021 using the convenience sampling method. They were randomly divided into two groups: the VR training group (VR group) and the traditional simulation scenario training group (traditional group). The VR Group underwent immersive virtual reality CPR training with interactive feedback, while the Traditional Group received standard simulation-based CPR training using mannequins and instructor guidance. After training, relevant data were collected for comparative analysis.

Results: The study revealed that the VR group consistently outperforming the traditional group in theoretical knowledge test (cardiac arrest recognition, chest compressions, airway management, and artificial respiration) scores at 1, 3, 6, and 12 months post-training (p < 0.05). Similarly, the VR group showed superior performance in overall skills test scores and individual CPR quality metrics at all post-training assessments. The VR group scored higher in total skills, assessment, post-resuscitation assessment, chest compressions (at 1, 3, and 6 months), airway opening, and artificial respiration compared to the traditional group (p < 0.05). Despite these findings, both groups exhibited a gradual decrease in skills test scores over time.

Conclusions: Virtual reality training can significantly improve non-medical professional volunteers' CPR knowledge and skill levels, helping them master and maintain these competencies. However, a decrease in CPR knowledge and skills among the participants over time was observed after VR training, suggesting the need for further retraining sessions.

Objectives: Transport destination decisions by prehospital personnel depend on a combination of protocols, judgment, patient acuity, and patient preference. Non-protocolized transport outside the service area may result in unnecessary time out of service and inappropriate resource utilization. Scant research exists regarding clinician rationale for destination decisions.

Methods: We retrospectively reviewed one year of scene transports by a single rural, hospital-based emergency medical services (EMS) system. We collected dispatch, patient demographic, primary impression, and transport data from prehospital records and matched them to emergency department (ED) data. We characterized rationale for transport decisions and compared rates of hospital admission and specialist consultation in the ED as surrogates for decision appropriateness.

Results: We reviewed 2,223 patient transports, 281 of which were transported out of the service area. The most common reasons for out-of-area transport were patient preference NOT related to prior medical care (40%) and clinician judgment (24%). Admit rates were highest for per protocol (85%) and patient preference related to prior medical care (67%) groups and lowest for no explanation (41%) and clinician judgment (47%) groups. Rates of in person specialist consultation in the ED were highest in per protocol (69%) and clinician judgment (47%) groups and lowest in no explanation (23%) and patient preference NOT related to prior medical care (30%) groups. Clinician judgment was less predictive of admission and specialist consultation for non-trauma and pediatric patients than for all patients. Median time out of service was more than twice as long for out-of-area transports (140 min) compared to patients transported to the nearest facility (62 min). For out-of-area transports discharged from the ED without specialty consultation (n = 104), ambulances traveled an additional 52 miles/patient compared to theoretical transport to nearest facility.

Conclusions: Unit out of service time more than doubled for non-protocolized transports outside of the service area and rationale for destination decisions variably predicted admission and specialist consultation rates. Patient preference NOT related to prior medical care and, in pediatric and non-trauma populations, clinician judgment, were less predictive of admission and specialist consultation. Transport guidelines should balance rationale for transport destination and patient characteristics with resource preservation, especially in low-resource systems.

Objectives: Physician staffed Helicopter Emergency Medical Services (P-HEMS) care in the Netherlands has transitioned from predominantly trauma management to handling a variety of medical conditions. Relevant outcome parameters for Dutch P-HEMS research have not been previously defined. National consensus was sought to identify relevant long term patient outcome parameters, process outcome parameters and performance outcome parameters for Dutch P-HEMS care.

Methods: This was a mixed methods Delphi consensus study. A list of potentially relevant outcome parameters was identified using a systematic literature review. These parameters were subsequently surveyed in a Delphi consensus study. Helicopter Emergency Medical Services physicians and relevant stakeholders were invited to participate in this Delphi survey, where they were allowed to suggest additional outcome parameters. Descriptive analysis was performed on all data sets.

Results: Forty-nine potential outcome parameters for Dutch P-HEMS care were surveyed. Of 71 invited participants, 53 (75%), 40 (56%), and 20 (28%) participated in the first, second, and third round of the Delphi study, respectively. Consensus was reached on 25 (51%) of 49 outcome parameters as being important. These consisted of seven long term patient related outcome parameters, four short term patient related outcome parameters, five process outcome parameters and nine performance outcome parameters.

Conclusions: In conclusion, this study identified 25 outcome parameters relevant for Dutch physician staffed HEMS care. These parameters should be considered when designing future studies and should be routinely collected for each dispatch if possible.

Objectives: Current guidelines for parameters of the delivery of chest compressions (CC) for infants and children are largely consensus based. Of the two recommended depth targets - 1.5 inches and 1/3 anterior-posterior chest diameter (APD) - it is unclear whether these have equal potential for injury. In previous experiments, our group showed in an animal model of pediatric asphyxial out-of-hospital cardiac arrest (OHCA; modeling ∼ 7 year-old children) that 1/3 APD resulted in significantly deeper CC and a higher likelihood of life-threatening injury. We sought to examine and compare injury characteristics of CC delivered at 1.5 inches or 1/3 APD in an infant model of asphyxial OHCA.

Methods: Swine were sedated, anesthetized, paralyzed, intubated through direct laryngoscopy, and then mechanically ventilated (10 ml/kg, FiO2:21%). APD was measured and confirmed by two investigators via a sliding T-square at the xiphoid. After instrumentation for vital signs monitoring, and while still anesthetized, the endotracheal tube was manually occluded to induce asphyxia, and occlusion was maintained for 9 min. Animals were then randomized to receive CC with a depth of 1.5 inches (Group 1) or 1/3 APD (Group 2), both with a rate of 100 per minute. Advanced life support drugs were administered at 13 min, and defibrillation at 14 min. Resuscitation continued until return of spontaneous circulation (ROSC) or 20 min of failed resuscitation. Survivors were sacrificed with KCl after 20 min of observation. Veterinary staff conducted necropsy to assay lung injury, rib fracture, hemothorax, airway bleeding, great vessel dissection, and heart/liver/spleen contusion. Injury characteristics were summarized and compared via Chi-Squared test or Mann-Whitney U-test using an alpha = 0.05.

Results: A total of 36 animals were included for analysis (Group 1: 18; Group 2: 18). Mean (SD) APD overall was 5.58 (0.23) inches, yielding a mean 1/3 APD depth of 1.86 inches. APD did not differ between groups. ROSC rates did not differ between groups. No injury characteristics differed significantly between groups.

Conclusions: In an swine model of infant asphyxial OHCA and resuscitation considering 1/3 APD or 1.5 inches, neither CC depth strategy was associated with increased injury.

Entrapped patients may be simply entombed or experiencing crush injury or entanglement. Patients with trauma who are entrapped are at higher risk of significant injury than patients not entrapped. Limited access and prolonged scene times further complicate patient management. Although patient entrapment is a significant focus of specialty teams, such as urban search & rescue (US&R) teams that operate as local, regional, and/or national resources in response to complex scenes and disaster scenarios, entrapment is a regular occurrence in routine EMS response. Therefore, all EMS clinicians must have the training and skills to manage entrapped patients and to support medically-directed rescue throughout the extrication process. NAEMSP RECOMMENDSEMS clinicians must perform a timely and thorough primary and secondary assessment and reassessments in parallel with dynamic extrication planning; the environment may require adaption of standard assessment techniques and devices.EMS clinicians should establish early, clear, and ongoing communications with rescue personnel to ensure a coordinated patient-centered medically directed approach to extrication. Communication with the patient should be frequent, clear, and reassuring.EMS clinicians should immediately take measures to effectively prevent and manage hypothermia.EMS clinicians should recognize airway management in the entrapped patient is always challenging. When required, advanced airway placement should be performed by the most experienced operator with proficiency in multiple modalities and alternative techniques in limited access situations.In entrapped patients who are experiencing or are at risk for crush syndrome, EMS clinicians should initiate large-volume (i.e., 1-1.5 L/h for adults and 20 mL/kg/h for pediatric patients for the initial 3-4 h) fluid resuscitation with crystalloid, preferably normal saline, as early as possible and prior to extrication.In entrapped patients who are experiencing or are at risk for crush syndrome, EMS clinicians should administer medications to mitigate risks of hyperkalemia, infection, and renal failure, early and prior to extrication.Tourniquet application should be considered in the setting of the crushed extremity as a potential adjunct to medical optimization before extrication of some patients.Patients with prolonged entrapment with the potential for severe injuries require complex resuscitation and may benefit from EMS physician management on scene. EMS systems should consider an early EMS physician response to entrapped patients.

Objectives: Exposure to prehospital rearrest has previously been associated with mortality following out-of-hospital cardiac arrest (OHCA). Our objective was to conduct a systematic review and meta-analysis examining the association between prehospital rearrest and survival in adults following OHCA resuscitation.

Methods: We searched the PubMed, Scopus, and Web of Science bibliographic databases for observational studies that included adult OHCA patients who achieved return of spontaneous circulation in the prehospital setting following OHCA and reported survival to hospital discharge data stratified by rearrest status. The primary exposure was prehospital rearrest. The primary outcome for this study was survival to hospital discharge. Secondary outcomes included survival with a favorable neurological outcome and rearrest prevalence. We pooled data using inverse heterogeneity modeling and presented effect sizes for the survival outcomes as odds ratios with 95% confidence intervals. We quantified heterogeneity using Cochran's Q and the I² statistic and examined small study effects using Doi plots and the LFK index.

Results: Of the 84 publications screened, we included 7 observational studies containing 27,045 patients with survival to hospital discharge data. Rearrest was common (30% [18-43%]; n = 7 studies; Q = 1086.1, p < 0.001; I² = 99%; LFK index = 1.21) and associated with both decreased odds of survival to discharge (pooled aOR: 0.27 [0.22, 0.33]; n = 7 studies; Q = 32.2, p < 0.01, I² = 81%, LFK index = -0.08) and decreased odds of survival to discharge with a favorable neurological outcome (pooled aOR: 0.25, [0.22, 0.28]; n = 4 studies; Q = 3.5, p = 0.3; I² = 13%, LFK index = 1.30).

Conclusions: Rearrest is common and associated with decreased survival following OHCA. The pooled result of this meta-analysis suggests that preventing rearrest in five patients would be necessary to save one life.

Objectives: Previous investigations comparing intraosseous (IO) and intravenous (IV) epinephrine delivery in out-of-hospital cardiac arrest (OHCA) suggest that epinephrine is oftentimes more expeditiously administered via the IO route, but this temporal benefit doesn't always translate to clinical benefit. However, very few studies adequately controlled for indication and resuscitation time biases, making the influence of first epinephrine route on OHCA outcomes unclear. To determine the association between first epinephrine route and return of spontaneous circulation (ROSC) while controlling for resuscitation time bias and other potential confounders.

Methods: We conducted a retrospective analysis using the 2020 ESO Data Collaborative dataset. Adult patients with a witnessed, non-traumatic OHCA prior to EMS arrival were included. Logistic regression was used to determine the association between medication route and ROSC. Linear regression was then used to calculate the probability of ROSC for each route across all call receipt-to-drug delivery intervals. Using these linear equations, the call receipt-to-drug delivery intervals were calculated that would yield equivalent probabilities of ROSC between the IV and IO routes.

Results: Data were available for 10,350 patients, of which 27.4% presented with a shockable rhythm, 29.7% received bystander CPR, and 39.6% experienced ROSC. After controlling for confounders, IO epinephrine was associated with decreased likelihood of ROSC (OR = 0.77, p < 0.001). The linear regression models provided differing slope coefficients for ROSC between each route, with the IV route associated with a higher likelihood of ROSC for any given call receipt-to-drug-delivery interval. From these equations, the additional time allowed to establish an IV and administer epinephrine intravenously beyond the time required for IO delivery, yet with an equivalent predicted probability of ROSC via the IO route, was calculated. This additional time interval for intravenous administration declined linearly from 9 min at a call receipt-to-intraosseous epinephrine interval of 4 min to no additional time at a call receipt-to-intraosseous epinephrine interval of 29 min.

Conclusions: This retrospective analysis of a national EMS database revealed that IO epinephrine was negatively associated with ROSC. Additionally, there appears to be a finite time window during which intravenous epinephrine remains superior to the intraosseous route even if there are brief initial delays in IV drug delivery.

Objectives: To determine the prevalence and associated risk factors of workplace violence (WPV) experienced by emergency medical services (EMS) clinicians across a large, multistate ground/air EMS agency.

Methods: We used a prospective cohort study design from 1 December 2022 to 30 November 2023. A checkbox was added within the electronic medical record (EMR) asking staff to indicate whether WPV occurred. Patient characteristics, encounter (run), and crew factors were abstracted. Potential risk factors for WPV were assessed using logistic regression, with the occurrence of any form of violence as the primary outcome of interest. Models were both univariable, assessing each risk factor individually, and multivariable, assessing all risk factors together to identify independent factors associated with higher risk of WPV. Multivariable model results were reported using adjusted odds ratios (aORs) and 95% confidence intervals.

Results: A total of 102,632 runs were included, 95.7% (n = 98,234) included checkbox documentation. There were 843 runs (0.86 per 100 runs, 95% CI 0.80-0.92) identified by EMS clinicians as WPV having occurred, including verbal abuse (n = 482), physical assault (n = 142), and both abuse and assault (n = 219). Risk factors for violence included male patient gender (aOR 1.45, 95% CI 1.24-1.70, p < 0.001), Richmond Agitation-Sedation Scale (RASS) >1 (aOR 16.97, 95% CI 13.71-21.01, p < 0.001), and 9-1-1 runs to include emergent (P1; aOR 1.75, 95% CI: 1.17-2.63, p = 0.007) and urgent (P2; aOR 1.64, 95% CI 1.08-2.50, p = 0.021) priority, compared to P3/scheduled transfer or P4/trip requests. Factors associated with lower risk for violence included older patients (aOR per 10 years = 0.95, 95% CI 0.91-0.98, p = 0.007) and run time of day between 0601-1200 h compared to 0000-0600 h (aOR 0.67, 95% CI 0.51-0.88, p = 0.004). Only 2.7% of violent runs captured through the EMR were reported through official processes.

Conclusions: Verbal and/or physical violence is recognized in nearly 1% of EMS runs. We recommend prioritizing WPV prevention and mitigation strategies around identified risk factors and simplifying the WPV reporting process in order to reduce staff administrative burden and encourage optimal capturing of violent events.