Prehospital Emergency Care最新文献

Objectives: Recently, the rising frequency and severity of mass casualty incidents further complicate the inherently challenging process of mass casualty triage, revealing the need for remote triage. Accordingly, drone-based triage systems are emerging as an innovative solution, supported by advances in image processing technology and remote photoplethysmography for hemodynamic monitoring. Despite these advances, there is limited scientific research regarding algorithms specifically designed for drone-assisted triage. The aim of this study is to develop the Drone Integrated Mass Casualty Triage Algorithm (DIMaCTA).

Methods: The study was conducted in two stages. In the first stage, a draft algorithm was developed using a comprehensive literature review and disaster field experiences. In the second stage, a two-round modified Delphi study was conducted with the participation of emergency medicine specialists to ensure the validity of the algorithm decision points and evaluation criteria. Content validity ratio (CVR) and content validity index (CVI) were calculated to determine the level of expert consensus and content validity. In addition, participants' opinions on the drone-assisted triage application were collected through a researcher-made questionnaire.

Results: The majority of participants (86.7%) found the drone-based application of the algorithm effective for continuous triage and time-saving in hard-to-reach incidents. In the first Delphi round, more than 80% consensus was reached on the parameters and decision points of the algorithm. Suggestions for pulse and body temperature thresholds were also made in this round. In the second round, the experts agreed on a pulse threshold of 30/min to discriminate between the 'emergency' and 'dead' categories, and a temperature threshold of 28 °C for the same classification. In addition, a pulse threshold of 100/minute was agreed to distinguish between 'immediate' and 'delayed' cases. Content validity ratio and CVI values were found to be in the range of 0.73-1.00 and 0.87-1.00, respectively.

Conclusions: The DIMaCTA is a drone-assisted triage algorithm based on image processing technology and can also be used as a primary triage tool in the field. Its drone-based application is expected to accelerate the prioritization of the most critical cases. Further research is needed to validate the algorithm and assess its potential impact on mass casualty management.

Objectives: Injury mechanisms play a critical role in determining the need for advanced airway management during prehospital trauma care. While prior studies have examined airway interventions in the context of physiological compromise or specific clinical conditions, few have evaluated how airway device use varies across trauma mechanisms (e.g., falls, motor vehicle collisions). Understanding which injury types are most associated with airway placement, and which airway devices are most commonly used, can help emergency medical service (EMS) clinicians anticipate airway needs and inform trauma system preparedness.

Methods: We analyzed 2023 data from the National Emergency Medical Services Information System (NEMSIS) to evaluate 9-1-1 trauma activations with documented advanced airway device placement (endotracheal intubation [ETI], supraglottic airway [SGA], and cricothyrotomy [Cric]). Injury causes were categorized based on clinically relevant categories derived from the 20 most common ICD-10 trauma codes. Airway use was described by patient age, sex, urbanicity, incident location, EMS system response, scene, and transport times. Age-stratified airway use rates (per/1,000 trauma activations) were calculated for pediatric (≤15), adult (16-64), and geriatric (≥65) patients.

Results: Among 5,716,650 trauma activations in 2023, 18,628 (3.6 per/1,000) involved advanced airway placement: ETI-only (13,452; 72.2%), SGA-only (3,544; 19.0%), Cric-only (110; 0.6%), and multiple airways (1,522; 8.2%). Patients were primarily male (75.0%) with a median age of 48 years (IQR: 30-66), found in urban areas (81.2%), on street/highway (40.0%) locations, with over half experiencing out-of-hospital cardiac arrest (55.8%). Falls (29.0%) and motor vehicle collisions (MVCs) (21.0%) accounted for the largest frequency of airway placements, while firearm-related injuries (51.9/1,000) and motorcycle accidents (16.1/1,000) had the highest airway use rates across all age groups. Cricothyrotomy was most commonly performed in firearm-related trauma (39.1%). Among patients with scene and transport times <60 min, median scene and transport times differed across airway types.

Conclusions: Advanced airway placement occurred in approximately 4 of every 1,000 EMS trauma activations. While falls and MVCs were the most frequent injury types, firearm-related injuries and motorcycle accidents had the highest incidence of airway use. These findings highlight high-risk scenarios for airway intervention and may inform EMS training, triage, and airway preparedness strategies.

Objectives: Patients receiving extracorporeal membranous oxygenation (ECMO) support often have fragile conditions that make them susceptible to physiological deterioration during interhospital transport (IHT). This study aimed to assess the safety of IHT for ECMO-supported patients, utilizing a dedicated critical care transport team.

Methods: A retrospective analysis was conducted on patients who underwent IHT while receiving ECMO support in a metropolitan city between January 2016 and April 2024. The primary outcome was the occurrence of abnormal physiologic parameters during IHT, including hypotension (mean arterial pressure <65 mmHg), desaturation (pulse oximetry <90%), tachycardia (heart rate >120/min), and bradycardia (heart rate <50/min).

Results: A total of 151 patients were included in the study, with 96 (59.6%) on veno-arterial (VA)-ECMO and 55 (40.4%) on veno-venous (VV)-ECMO. Of these, 37.1% had experienced cardiac arrest prior to ECMO initiation. The median transport time from departure at the referring hospital to arrival at the receiving hospital was 25 min (interquartile range, 19-37 min). Several adverse events occurred during transport, including ECMO console shutdown in 8.9% of cases (n = 10 spontaneous shutdowns, n = 3 due to human error), all of which were appropriately managed by the trained transport team. Physiological parameters remained stable between the start and end of IHT, with a significant reduction in the prevalence of tachycardia (p < 0.01).

Conclusions: Interhospital transport for ECMO-supported patients by a dedicated critical care transport team is safe. These findings support the implementation of specialized transport systems to facilitate the safe transfer of critically ill patients receiving ECMO support.

Laryngeal tube suction (LTS) is widely used by emergency medical technicians for airway management in patients with out-of-hospital cardiac arrest, but reports of serious complications are limited. Here, we report a rare case of out-of-hospital cardiac arrest in which an LTS was inserted during resuscitation, and perforation of the posterior pharyngeal wall was confirmed by forensic autopsy. The present case is notable because the perforation site was directly visualized during an autopsy while the device remained in place. The case highlights important findings from both the emergency education and forensic perspectives. While the LTS offers the advantage of rapid blind insertion, it carries the risk of fatal complications, such as perforations or deviations from the insertion path. To prevent such perforations from occurring, some essential measures are required, including appropriate device size selection, recognition of resistance during insertion, and confirmation via capnography. Emergency medical personnel should be mindful of these risks during their clinical practice.

Objectives: Emergency medical services (EMS) clinicians rarely perform pediatric critical procedures, necessitating continued education for skill maintenance, which presents unique challenges. This study transitioned a previously reported, traditional, simulation-based training (SBT) curriculum delivered by on-site pediatric simulation experts (On-Site Phase 1), into a program delivered by agency Pediatric Emergency Care Coordinators (PECCs) supported by remote pediatric experts (Remote Phase 2). Primary outcome was non-inferiority of Remote Phase 2 compared to On-Site Phase 1 as analyzed using bag-valve-mask (BVM) ventilation, supraglottic device (SGD) placement, and intraosseous (IO) catheterization assessment tool scores.

Methods: This was a non-randomized, prospective study of simulated procedural outcomes by emergency medical technicians and paramedics recruited from the same three EMS agencies that participated in On-Site Phase 1, along with their PECCs. Without additional on-site simulation staff, PECCs incorporated the program into their regular training schedule over the one-year study period and submitted participants' first-person-view videos for remote expert assessment across two sessions. Assessment data were analyzed longitudinally across both phases for non-inferiority testing, and between agencies. Qualitative comments from participants and PECCs were solicited via e-mail.

Results: Remote Phase 2 was found to be non-inferior to On-Site Phase 1 for each procedure (p = 1.0). Procedural performance during Remote Phase 2 Session 1 was similar to the end of On-Site Phase 1 (BVM p = 0.62; SGD p = 0.87; IO p = 0.60); by Remote Phase 2 Session 2, BVM (p = 0.01) and SGD (p = 0.01) performance improved, but IO (p = 0.19) performance remained the same. Performance across sites was similar at all time points, except for higher BVM scores at the rural site during Session 2 (p = 0.00). Qualitatively, PECCs reported scheduling difficulties due to competing educational and administrative tasks.

Conclusions: In this prospective study of EMS clinicians, we found non-inferiority between a traditional on-site approach and a remotely-supported approach in simulation-based pediatric procedural training. Skill overall was high and BVM and SGD performance improved. This demonstrates a viable method for PECCs to deliver recurring evidence-based education while receiving curricular and assessment support from remote pediatric experts. While still effort-intensive, this methodology may help to address several barriers of time, cost, and accessibility for pediatric prehospital education.

Objectives: Prehospital blood transfusion by emergency medical services (EMS) is associated with improved outcomes in trauma patients, but little is known about the statewide protocols that influence the availability and use of prehospital blood. This study aimed to describe statewide EMS protocols regarding field-initiated prehospital blood and blood product transfusion across the U.S.

Methods: This was a cross-sectional analysis of publicly available statewide EMS protocols pertaining to field-initiated blood or blood product use during ground transport by advanced life support (ALS) clinicians. We excluded protocols specific to critical care or interfacility transport. We used a standardized data collection tool to compare clinical indications, blood product type, and considerations for pediatrics and biologically female patients who may bear children in the future. Descriptive statistics were used to describe the protocols.

Results: We identified 31 states and the District of Columbia with publicly available statewide EMS protocols. Thirteen (42%) of these protocols allowed for field-initiated prehospital blood transfusion. There was variability regarding recommendations for transfusion indications and the details of administration in the protocols. All protocols allowed for transfusion in traumatic emergencies, and nine (69%) allowed for transfusion in medical emergencies. Three (23%) protocols specifically recommended low titer group O whole blood, and three (23%) protocols allowed transfusion during cardiac arrest. Nine (69%) protocols allowed for transfusion in pediatric patients. Only four (31%) protocols included special considerations for transfusing blood to biologically female patients.

Conclusions: While most statewide EMS protocols in the US did not include field-initiated blood transfusion, the protocols that do exist vary widely. With the increasing implementation of prehospital blood programs, these findings suggest an opportunity to provide more robust evidence-based guidelines for prehospital blood transfusion to improve patient care and outcomes.

Objectives: To evaluate factors associated with automated external defibrillator (AED) application to out-of-hospital cardiac arrest (OHCA) patients.

Methods: This retrospective cohort study used data from the All-Japan Utstein and Emergency Transport Registries for 2021. The application of AED was classified according to the bystander defibrillation field in the Utstein data. Cases where an AED was applied and the AED pads were attached were defined as "AED applied" and those with unknown AED application as "AED not applied." Multivariable logistic regression was used to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors related to AED applied.

Results: A total of 117,790 patients were analyzed (AED applied, n = 12,354 (0.5%); AED not applied, n = 105,436 (89.5%)). Factors associated with AED applied included daytime occurrence (AOR (95% CI), 1.14 (1.08-1.20) vs. nighttime), conventional cardiopulmonary resuscitation (CPR) (2.29 (2.09-2.50) vs. hands-only CPR), dispatcher assistance (2.02 (1.92-2.12)), and occurrence in a school (3.53 (2.58-4.82) vs. public place). Factors associated with AED not applied included age ≥65 years (0.92 (0.84-0.99) vs. 19-64 years), witnessed by family members (0.55 (0.48-0.64) vs. unwitnessed), no bystander CPR (0.28 (0.26-0.30) vs. hands-only CPR), and occurrences in a home (0.01 (0.01-0.01) vs. public place).

Conclusions: The application of AED was associated with patient age, witness status, bystander CPR, and incident location. These findings should inform the placement of AEDs and educational strategies.