Prehospital Emergency Care最新文献

Objectives: Cardiopulmonary resuscitation (CPR), which is used in cases of life-threatening cardiopulmonary arrest, is a physically exhausting procedure. Adding to that, sometimes, even before performing CPR, interventions to rescue the injured person from a challenging environment have caused significant fatigue. In this study, taking a novel research approach, we generated a scenario of fatigue during a rescue from earthquake debris and aimed to measure the effect of that fatigue on the quality of CPR performed by paramedics.

Methods: The research followed an experimental design with 2 groups (experimental/control) and 2 measurements (pretest/post-test). The study population was selected using power analysis. The sample, consisting of 84 paramedic students, was randomly divided into 42 control and 42 experimental participants. Current American Heart Association (AHA 2020) and European Resuscitation Council (ERC 2021) guidelines were strictly followed when performing CPR. In order to assess the accuracy of CPR, a General Doctor GD-CPR200S-A (2010 standard) simulator was utilized. The participants were fatigued by practicing the process of extracting and transporting earthquake victims from rubble. A personal information form with 20 questions and a CPR measurement form were used to obtain the data.

Results: In the analysis performed to measure the differences between the CPR indicators for the control and experimental groups in the post-test and pretest, the difference in compression (control: 6.5 ± 50.1 and experimental: -10.3 ± 46.0) was not significant. Meanwhile, we found that the difference in ventilation (control: 0.3 ± 5.4 vs. experiment: 8.1 ± 4.6) and the difference in CPR completion times (control: 0.2 ± 1.2 vs. experiment: -0.7 ± 0.7) between the post-test and pretest were significant.

Conclusions: There was no significant difference in correct compressions between the control and experimental groups, but there was a significant difference in ventilation and CPR completion times. For this reason, it is recommended to focus on the effect of fatigue on CPR quality, especially on the ventilation process. It is also recommended to include fatigue scenarios in CPR trainings.

Objectives: Low titer O⁺ whole blood (LTO+WB) has been shown to improve outcomes in trauma patients and use is increasingly common. Studies on prehospital use and efficacy have been published throughout the literature, but few of these fully address the risks of transfusion reactions and other side effects. The focus of this study is to look at prehospital LTO+WB transfusions in trauma patients and review for transfusion reactions.

Methods: This was a retrospective review of consecutive trauma patients who received prehospital LTO+WB over a 4.5-year period. We used EMS agency transfusion records and institutional blood bank data from two urban level I trauma centers for records on blood transfusion reactions. Excluded from the study were patients declared dead on arrival to the hospital, patients transfused for non-traumatic complaints, patients for whom hospital records were unavailable, and any transfusion reaction that occurred more than 10 days after the prehospital transfusion. Descriptive statistics were used for data analysis.

Results: Of 1126 prehospital transfusions 572 met inclusion criteria. There were 2 (0.35%) suspected transfusion reactions, none of which were determined to be hemolytic reactions. There was 1 febrile non-hemolytic reaction on hospital day 1 and there was 1 allergic reaction with hives and shortness of breath that occurred on hospital day 1.

Conclusions: Prehospital LTO+WB is safe to use and has a similar rate of transfusion reaction as when given in-hospital. Concerns about transfusion reactions caused by LTO+WB should not preclude its use prehospital. Regardless of the low incidence of transfusion reactions, prehospital personnel should be trained in their recognition and management. Limitations include retrospective study design and the inability to distinguish transfusion reactions from prehospital LTO+WB versus reaction to blood products transfused at the trauma center.

Objectives: Emergency medical services (EMS) clinicians often do not achieve sufficient levels of physical activity. We investigate behavioral determinants that influence participation in physical activity among EMS clinicians.

Methods: We enrolled EMS clinicians from a North Carolina third-service EMS agency in 2023. A trained qualitative investigator conducted twenty virtual, 30-minute, individual, semi-structured interviews using an interview guide developed by experts in physical activity behaviors, EMS, and qualitative research. Interviews were guided by the Theoretical Domains Framework and Capability Opportunity Motivation Behavior Change Model. Structured interviews were digitally recorded and transcribed verbatim by a professional transcription service. Transcriptions were verified against audio for accuracy and de-identified. A codebook was established using a hybrid inductive/deductive approach, and thematic analysis was performed.

Results: The 20 participants had a median age of 31 years (IQR 27-34), of which 65% (13/20) were female. Several key themes emerged that represent opportunities for behavioral intervention. First, physical activity is often viewed as a process requiring high inhibitory self-regulation and is often paired with highly restrictive behaviors, which likely leads to existing poor behavioral habits. Existing confidence in being physically active was often tied to goal setting and mastery experiences, suggesting an opportunity to leverage specific and achievable goal setting, self-monitoring, and feedback. Further, EMS clinicians often struggle with incorporating physical activity amid work and life demands in a practical, sustainable way. They also identified a lack of available time, resources, and organizational support. High-quality social networks are foundational behavior change components and were often lacking among participants.

Conclusions: Behavioral determinants of physical inactivity included a theme of negative implicit associations around physical activity among some participants and need for achievable goal setting, self-monitoring, and building positive social support networks. Further investigation is needed to develop and test toolsets to improve physical activity behaviors among EMS clinicians.

Objectives: Use of supraglottic airways by emergency medical services (EMS) clinicians has increased for patients of all ages. However, data are limited on real-world use in the prehospital setting, including success rates, complications, and paramedic experience. The objective of this study was to determine frequency of successful i-gel^® insertion and associated complications, and to describe paramedic perception of i-gel^® use.

Methods: This was a prospective study of i-gel^® use in adult patients at four fire-based EMS Provider Agencies in Los Angeles (LA) County from June to September 2021. All paramedics received asynchronous and hands-on training prior to implementation. The i-gel^® was indicated for adult patients in respiratory and/or cardiac arrest of any etiology, as directed by LA County protocols. Patients were included if a paramedic attempted i-gel^® placement at any point. After transition of care, paramedics completed a web-based questionnaire and contacted an on-call EMS physician investigator to discuss the case. Further data were abstracted from the EMS electronic patient care record. The primary outcome was successful placement of i-gel^® based on adequate ventilation post insertion confirmed with capnography. Secondary outcomes were frequency of complications and paramedic perceived ease of placement and of ventilation with i-gel^® measured on a 5-point Likert scale. Descriptive statistics were reported.

Results: Of the 102 adult patients, 55 (54%) were female and the median age was 69 years (IQR 53-79). The majority 91 (89%) of the patients had a paramedic impression of non-traumatic cardiac arrest. Placement was successful in 90 (88%) patients overall with 85 (83%) i-gel^® insertions successful on the first attempt. Complications included: 28 (28%) cases with regurgitation/emesis, bleeding (8, 8%), hypoxia (7, 7%), and dislodgement (5, 5%). Among cases of successful i-gel^® placement, the majority of paramedics rated both ease of placement and ease of ventilation as "very easy" (69% and 78%, respectively) or "somewhat easy" (23% and 9%).

Conclusions: Paramedics were successful in 88% of i-gel^® insertion attempts with the most common complication being regurgitation/emesis. Paramedics rated the ease of placement and ease of ventilation of the i-gel^® device as "very easy" or "somewhat easy" in the vast majority of cases.

Objectives: Hydrazine (HZ) and Hydrazine Derivative (HZ-D) exposures pose health risks to people in industrial and aerospace settings. Several recent systematic reviews and case series have highlighted common clinical presentations and management strategies. Given the low frequency at which HZ and HZ-D exposures occur, a strong evidence base on which to develop an evidence-based guideline does not exist at this time. Therefore, the aim of this project is to establish a consensus guideline for prehospital care of patients with exposures to HZ and HZ-Ds.

Methods: A modified Delphi technique was used to develop clinical questions, obtain expert panel opinions, develop initial patient care recommendations, and revise the draft into a final consensus guideline. First, individuals (Emergency Medical Services (EMS) physicians and hazardous materials technicians) with experience in management of HZ and HZ-Ds identified relevant clinical questions. An expert panel was then convened to make clinical recommendations. In the first round, the panel voted on clinical care recommendations. These recommendations were drafted into a guideline that expert panel members reviewed. After review, additional unanswered questions were discussed electronically by expert panel members, and electronic votes were cast. Ultimately, patient care recommendations were condensed into a concise, consensus guideline.

Results: Eight clinical questions regarding treatment of patients with HZ and HZ-D exposures were identified. These questions were reviewed by the expert panel which included 2 representatives from: aerospace medicine, military medicine, EMS medicine, paramedicine, pharmacy, and toxicology. Draft patient care recommendations generated three additional questions which were discussed electronically and voted on. These recommendations were then formatted into a guideline outlining recommendations for care prior to decontamination, during decontamination, and after decontamination.

Conclusions: The consensus guideline for clinical care of patients with exposure to HZ/HZ-Ds is as follows: Prior to decontamination, use appropriate personal protective equipment, and when necessary, support ventilation using a bag-valve-mask and administer midazolam intramuscularly for seizures. After decontamination, provide supplemental oxygen; consider selective advanced airway management when indicated; administer inhaled beta-agonists for wheezing; and, for seizures unresponsive to multiple doses of benzodiazepines that occur during pre-planned, high-hazard activities, such as spacecraft recovery, consider intravenous or intraosseous pyridoxine.

Objectives: Pulseless electrical activity (PEA) arrest, which includes pseudo-PEA, is increasingly common and survival remains dismal. We hypothesized that mechanical chest compressions synchronized to native cardiac contractions improve coronary perfusion pressure (CPP) during pseudo-PEA resuscitation.

Methods: We developed a model of pseudo-PEA by infusing high dose esmolol intravenously into anesthetized, intubated, and central arterial and venous catheterized swine to a goal of 45 mm Hg mean arterial blood pressure (MAP). We performed a randomized unblinded repeated crossover trial by administering alternating synchronized and unsynchronized chest compressions for 52 s preceded by 8 s breaks consecutively 4 times. We repeated the protocol approximately 4 times with 1 min breaks. Synchronized compressions were provided 1:1 with native contractions during systole and unsynchronized compressions were provided at 100 beats per minute (BPM). We measured average CPP, MAP, and heartrate (HR) for 5 beats immediately preceding the chest compression onset and for 30 s 10 s after compression onset. We computed the difference in continuous CPP during compressions compared to the immediately preceding baseline for each interval. We developed a mixed linear model with outcome average CPP during compressions minus baseline, fixed variable compression type, and random variable animal.

Results: We included 6 animals. Mean baseline HR was 76.0 BPM, MAP 49.9, and CPP 36.2. Chest compressions increased CPP from baseline an average 1.7 mm Hg when unsynchronized and 5.6 mm Hg synchronized. The adjusted difference was 4.0 mm Hg (95% CI 2.4-5.5).

Conclusions: Synchronized chest compressions increased CPP 4.0 mm Hg (135%) more than unsynchronized compressions despite a lower compression rate in medication-induced pseudo-PEA. Further refinement and eventual application to patients suffering pseudo-PEA arrest appear warranted.

Objectives: Benzodiazepines are the treatment for seizures in prehospital settings, but fail in up to 40% of cases, leading to benzodiazepine refractory status epilepticus (BRSE). Early treatment of BRSE is essential to prevent neurological damage and death. Ketamine, an N-methyl-D-aspartate receptor antagonist used by emergency medical services (EMS) for a variety of indications, has potential as a safe, effective prehospital treatment for BRSE. However, safety and efficacy data for early treatment of patients with seizures are limited.

Methods: We retrospectively analyzed patients treated by EMS clinicians with ketamine for BRSE at a single urban ground-based EMS system between September 1, 2021, and December 1, 2023. Ketamine dose and route, patient characteristics, and airway interventions are described. Data were gathered from EMS records.

Results: Forty-two patients aged 8 months to 79 years, were included. Ketamine was administered intramuscularly in 22 with an average dose of 3.3 mg/kg, and intravenously or intraosseous in 20, with an average dose of 2.2 mg/kg. Ketamine stopped seizures in 38 patients (90.5%). Transient hypoxia occurred in 9 patients (22%). Respirations were supported with bag-valve-mask ventilation in 13 patients (31%), a supraglottic airway in three (7%), and one patient was endotracheally intubated (2.4%).

Conclusions: Ketamine appears safe and effective for prehospital treatment of BRSE. Monitoring and intervention for respiratory complications appears necessary, but rates of these complications are consistent with expected rates from seizures and appropriate benzodiazepine dosing. These findings support ketamine's use in EMS for BRSE. Larger prospective studies are needed to confirm safety and efficacy.

Objectives: Although earlier antibiotics are known to be beneficial in sepsis, very few emergency medical services (EMS) agencies have protocols for prehospital antibiotics for sepsis. Therefore, we sought to assess how well a large EMS agency that uses prehospital antibiotics for sepsis adheres to its sepsis protocol (when initiated), and to determine how soon antibiotics are typically given.

Methods: We conducted a retrospective chart review of patients identified as "sepsis alerts" by EMS clinicians from a single EMS system in Florida, USA. The prehospital sepsis protocol dictated that EMS clinicians initiate a "sepsis alert" if the patient had a suspected infection and at least 2 of the following 3 criteria based on the sequential (sepsis-related) organ failure assessment (qSOFA) score: altered mental status, respiratory rate > 22 breaths per minute or end-tidal CO2 < 25 mmHg, or systolic blood pressure < 100 mmHg. Per protocol, patients meeting sepsis criteria were supposed to receive intravenous ceftriaxone and intramuscular gentamicin. We reviewed the charts of sepsis alert patients to determine demographic information, clinical characteristics, sepsis protocol compliance, and when patients received antibiotics.

Results: Between June 1, 2023, and June 30, 2024, there were 1308 patients for whom a prehospital sepsis alert was initiated. Median age was 80.0 years (IQR: 72-87.5), and 48.5% had hypotension (systolic blood pressure < 100 mmHg). Of the 1308 sepsis alert patients, review of documentation confirmed that 1301 (99.5%) had a suspected infection with at least 2 sepsis alert criteria. In total, 1264 (96.6%) received at least 1 antibiotic (either ceftriaxone or gentamicin) prior to hospital arrival. The median time from 9-1-1 call to first antibiotic administration was 26 min (IQR: 21-31 min). The first antibiotic was given a median of 11 min (IQR: 7-16 min) prior to hospital arrival.

Conclusions: For patients in whom a sepsis alert was initiated, EMS clinicians adhered to the sepsis protocol and administered antibiotics prior to hospital arrival in 97% of cases. Patients received their first antibiotic a median of approximately 26 min after 9-1-1 call and 11 min prior to hospital arrival.

Objectives: Automatic External Defibrillators (AEDs) are a tremendous advance in the care of victims of out-of-hospital cardiac arrest. We sought to define and assess the legal landscape regarding Automatic External Defibrillators (AEDs) in the United States (U.S.).

Methods: We performed a retrospective study of all state and federal laws relevant to the use of AEDs outside the hospital in the U.S. In the first of three phases, we searched a database of U.S. laws and regulations ("rules") using broad relevant search terms. Teams of two investigators reviewed all rules identified for relevance to ten realms: location, acquisition, deployment, liability, training, accessibility, maintenance, registration, interface, and reporting. We termed the application of each rule to a single realm an "action," so each rule could have one or more actions. In Phase 2, a third reviewer resolved any differences or discrepancies. A separate team of investigators confirmed or identified a "URL" online address for each rule. In Phase 3, we performed quantitative assessments of all included rules using summary statistics and Cohen's kappa to assess reviewer reliability. We made qualitative assessments for each realm across all jurisdictions using SWOT (Strengths, Weaknesses, Opportunities, and Threats) analyses.

Results: Nine hundred twenty-one rules, which included 1,987 actions, were deemed relevant to defibrillator access and use in the community, with a mean of 17.4 (SD 14.0) rules and 37.5 (SD 35.0) actions per jurisdiction, suggesting large heterogeneity in actions across states. There were 21 federal rules, including 42 actions. Qualitative analyses revealed that some states have successfully implemented AED training programs and public awareness campaigns, but uneven public awareness, cost, liability, and overly complex or stringent rules have posed barriers to successful AED deployment and use.

Conclusions: We have provided a focused overview of U.S. rules governing community AEDs. We found high heterogeneity across states and a limited federal floor of rules. It is hoped this report can be used to improve legislation and resulting future successful AED use.

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.