Prehospital Emergency Care最新文献

Objectives: While epinephrine is widely used for medical cardiac arrests, there is a knowledge gap regarding its utility for traumatic arrests. Traumatic arrests result from hypovolemia, hypoxia, or anatomic impairment of cardiac function such that the inotropic and vasoconstrictive effects of epinephrine may be ineffective or harmful. We hypothesized that epinephrine does not improve survival among patients with traumatic cardiac arrest.

Methods: This was a multicenter retrospective cohort study of trauma patients sustaining prehospital cardiac arrest who were treated at seven level I and II trauma centers over 6 years (2011-2017), ascertained via trauma registry data and chart abstraction. The primary outcome was survival to hospital discharge; patients treated with or without epinephrine were compared. Multivariable analyses were performed using Poisson regression. Time to event analyses were conducted using Cox proportional hazard models.

Results: We included 1631 adult and pediatric trauma patients with prehospital cardiac arrest. Prehospital epinephrine was administered to 844 (52%). The median age was 35 years, 335 (21%) were female, 712 (44%) sustained blunt trauma, and 58 (4%) had a shockable initial rhythm. Survival to hospital discharge was significantly lower in the prehospital epinephrine cohort compared to the no epinephrine cohort in univariable analysis [43/844 (5%) vs. 125/787 (16%), p < 0.001]. Among patients with blunt mechanism, survival was significantly lower in the prehospital epinephrine cohort [12/382 (3%) vs. 54/330 (16%), p < 0.001]. Among patients with penetrating mechanism, survival was not statistically different [10/276 (4%) with epinephrine vs. 22/374 (6%) without, p = 0.19]. In multivariable analyses adjusting for age, sex, mechanism, and initial rhythm, epinephrine was associated with lower likelihood of survival in the overall and blunt cohorts; there was no significant difference in the penetrating cohort (overall aRR 0.33, 95% CI 0.23-0.46; blunt aRR 0.20, 95% CI 0.11-0.37; penetrating aRR 0.62, 95% CI 0.30-1.28). Adjusted and unadjusted time to event analyses across each of these cohorts showed that epinephrine was associated with either statistically inferior or indistinct hazard ratios.

Conclusions: Epinephrine was not associated with improved survival following traumatic cardiac arrest, and in multiple subanalyses, it was associated with inferior outcomes. These results may inform prehospital traumatic arrest protocols.

Objectives: Detailed job satisfaction evaluations are often used to build strategies for employee retention. Despite recognizing that emergency medical services (EMS) dissatisfaction drives turnover, validated tools rigorously evaluating satisfaction have not been employed. We aim to assess the association between EMS clinician satisfaction and their likelihood of leaving the profession using the validated Spector Job Satisfaction Survey (JSS).

Methods: We conducted a cross-sectional survey of nationally certified EMS clinicians in the United States recertifying between October 2022 and April 2023. Our primary outcome was the self-reported likelihood of leaving EMS within 12 months (likely or not likely to leave). The primary exposure was job satisfaction, assessed using the 36-item JSS, scored from 36 to 216, and analyzed in two models: total satisfaction (dissatisfied [scores 36-108], ambivalent [108-144], satisfied [144-216]), and satisfaction subscales (e.g., pay, promotion, supervision). We applied Least Absolute Shrinkage and Selection Operator (LASSO) regression to identify key predictors of intent to leave EMS, adjusting for demographic and agency characteristics. Post-LASSO Bayesian logistic regression estimated odds ratios (OR) and 95% credible intervals (CrI).

Results: Among 33,414 EMS clinicians (response rate: 26.3%), the median age was 36 years (IQR: 29,46), 74.2% were male, and 83.0% were White, non-Hispanic. Most respondents worked full-time (77.6%), primarily as EMTs (48.5%), in urban settings (89.9%). Mean satisfaction scores were higher among those not likely to leave EMS (146.7 [standard deviation: 29.0]) than those likely to leave (121.2 [28.4]). Odds of leaving decreased for more satisfied clinicians: ambivalent clinicians [0.35 (0.32-0.38)]; satisfied clinicians [0.11 (0.10-0.13)]; referent dissatisfied. Additionally, specific satisfaction subscales were associated with lower odds of leaving for those satisfied compared to those dissatisfied, including nature of work [0.32 (0.28-0.37)], pay [0.46 (0.40-0.52)], promotion opportunities [0.53 (0.47-0.61)], supervision [0.65 (0.57-0.73)] and contingent rewards [0.77 (0.67-0.88)].

Conclusions: The EMS clinicians with higher satisfaction with their nature of work, pay, and promotion opportunities were less likely to report intent to leave. These findings highlight key factors that may inform workforce retention efforts.

Objectives: Emergency medical services (EMS) clinicians express dissatisfaction with the quality and quantity of clinical feedback received from hospitals, which is exacerbated by the absence of standardized feedback processes. A reported lack of regular feedback impedes their ability to learn and improve care. We evaluated a newly implemented feedback tool's utilization and perceived impact on EMS clinicians and our health system.

Methods: We employed a mixed-methods study design in a single academic medical center emergency department. Quantitative data collected focused on patients' clinical characteristics and characteristics of utilizers of the feedback tool during implementation (September 2023-July 2024). Qualitative data involved semi-structured interviews with EMS clinicians who had diverse experiences with the feedback tool and years of EMS service Semi-structured interviews applied a phenomenological framework, and were videorecorded, transcribed, and independently coded to identify key themes surrounding the utilization and impact of the implemented tool.

Results: Among the 381 feedback requests, 139 (36.5%) pertained to patients aged ≥65 years, while 44 (11.5 %) included patients <18 years; 343 (90%) had an Emergency Severity Index score of ≥2. Major complaints included traumatic (n = 165; 43.3%), neurologic (n = 90; 23.6%), and cardiac (n = 82; 21.5%). Emergency responder agencies included ground ambulance 227 (59.6%), air medical 90 (23.6%), public safety answering points 37 (9.7%), and fire service 27 (7.1%). The primary response method was e-mail 353 (93.7%). There was an average of 35 feedback requests per month (interquartile range: 27-59). EMS clinicians from multiple agencies with varying levels of knowledge of the feedback mechanism provided qualitative insights regarding the feedback tool, which covered several key areas: application and technological design, utilization, utility of feedback provided, barriers, comparisons to other systems, and areas for improvement.

Conclusions:  The standardized feedback mechanism implemented for EMS clinicians showed engagement, especially among ground responders caring for high-acuity patients, highlighting its importance in patient care. The preference for email emphasizes the need for efficient communication channels. Clinicians found the system accessible and user-friendly. The feedback tool was perceived as crucial for professional development and personal growth, allowing clinicians to gain closure on patient cases and potentially improve future patient care practices.

Objectives: The objective of this study was to assess the prevalence and characteristics of hospice and palliative care (HPC) protocols in emergency medical services (EMS) systems across the United States (U.S.), including both statewide and city-level protocols.

Methods: We conducted a cross-sectional review of publicly available EMS protocols from all 50 U.S. states and the District of Columbia, as well as the 50 most populous U.S. cities. Protocols were obtained between July and November 2024 using the centralized platform EMSProtocols.org and supplemental public sources. Protocols were included if they referenced hospice or palliative care-related terms ("hospice," "palliative," "comfort care," "end-of-life," "terminal illness"). Hospice protocols were included only if the term "hospice" appeared explicitly. Data were abstracted using a standardized form developed around several best-practice protocol features informed by the 2023 National Association of EMS Physicians and the American Academy of Hospice and Palliative Medicine joint position statement. Descriptive statistics were used to analyze the prevalence and content of identified protocols.

Results: Of 101 jurisdictions reviewed, 62 EMS protocols were available for analysis (31 statewide and 31 city-level). Among these, 24.2% (15/62) included a hospice protocol and 25.8% (16/62) included a palliative care protocol. Among hospice protocols, 80.0% included orders for pain medication, 80.0% addressed general symptom management, 73.3% recommended contacting hospice agencies, and 86.7% included guidance on transport decisions. Among hospice protocols, 33.3% permitted EMS clinicians to administer medications from hospice emergency kits. Only one palliative care protocol addressed naloxone use, advising against its routine administration in end-of-life symptom management.

Conclusions: Across the U.S., HPC protocols remain inconsistently integrated into EMS systems. Fewer than one in four reviewed protocols included any HPC-specific guidance, and most lacked comprehensive components recommended by national guidelines. Broader adoption of HPC protocols and alignment with expert recommendations may improve the delivery of compassionate, goal-concordant care to a growing population of seriously ill patients in the out-of-hospital setting.

Objectives: Los Angeles County initiated an extracorporeal cardiopulmonary resuscitation (eCPR) program to transport patients with refractory shockable out-of-hospital cardiac arrest (OHCA) to dedicated eCPR-capable centers (ECCs). The impact of an eCPR program on patients with OHCA who do not receive eCPR has not been described.

Methods: We measured the association between EMS unit participation in the program and survival-to-hospital discharge for patients with OHCA who did not receive eCPR, treated between July 2019 and September 2023. Six of the 29 EMS agencies participated in the program, which included eCPR protocol development, hands-on scenario-based training on the eCPR protocol and application of the mechanical compression device (MCD) on a manikin, and provision of MCDs. Because the deployment model for one agency differed from others (MCDs on supervisor units, no paramedic hands-on training), we prespecified a subgroup analysis excluding that agency.

Results: We analyzed 30,855 patients with EMS-treated OHCA: 7% had a shockable rhythm, 32% were treated by a pilot unit pre-implementation, 24% by a pilot unit post-implementation, and 44% were treated by a unit that never participated in the eCPR pilot. Treatment by a pilot unit post-implementation was not associated with a significant difference in the odds of survival-to-discharge compared to pre-implementation (1.14 95%CI 0.99-1.34) in the primary analysis but was associated with it in the subgroup analysis (1.61 95%CI 1.37-1.95). Similar results were found for neurologic outcome at discharge.

Conclusions: Implementation of an eCPR program is not associated with worse outcomes for patients with OHCA who did not receive eCPR and may be associated with benefit depending on implementation.

Objectives: Delays in hospital management resulting from the failure of emergency medical services (EMS) to activate the stroke code (SC) diminish the probability of receiving acute stroke treatment, adversely affecting patient outcomes. This study aims to analyze the proportion and characteristics of patients eligible for SC not activated by EMS, within a contemporary cohort.

Methods: A retrospective cohort analysis was conducted on prehospital stroke patients from the Catalan SC registry from 2016 to June 2022, who were transported by ambulance. Patients were classified according to whether EMS activated SC or not. Baseline demographic characteristics, comorbidities, clinical episode details, and treatment timelines were analyzed.

Results: Among 34,331 subjects, 28,221 (82%) were transported by EMS, with SC activation occurring in 22,968 (81%) cases. Patients for whom SC was not activated presented with lower National Institutes of Health Stroke Scale scores and longer intervals from symptom onset. Large vessel occlusions were more frequent in EMS-activated patients (24% vs. 18%). The non-EMS-activated cohort exhibited a higher prevalence of posterior circulation occlusions. Despite the absence of initial SC activation, 28% of these patients ultimately received reperfusion therapy, albeit with significant delays compared to the EMS-activated group.

Conclusions: Most acute neurological patients who qualify for SC activation are accurately identified by EMS. However, a substantial proportion of patients are missed, leading to treatment delays. Enhancing the capacity of EMS to recognize the clinical heterogeneity of stroke presentations is essential for prompt SC activation and optimizing patient outcomes.

Objectives: Emergency medical services (EMS) clinicians report lack of training and experience with children, leading to discomfort and uncertainty regarding assessment and treatment. The Pediatric Assessment Triangle (PAT) was designed to provide a rapid and standardized approach. Despite widespread adoption, literature examining EMS implementation of PAT remains limited. We examined EMS use of PAT and assessment of clinical stability and the association between EMS use of PAT and prehospital interventions, EMS transport decisions (advanced life support [ALS] vs basic life support [BLS]), emergency department (ED) interventions, and ED disposition.

Methods: This was a retrospective cohort study of pediatric patients 0 to <15 years transported to a quaternary care pediatric ED via EMS between October 2022 and November 2023. Data were abstracted from EMS and ED electronic health records (EHRs) including PAT evaluation, demographics, EMS and ED interventions, and ED disposition. Data were analyzed using counts and percentages, logistic regression, chi-square, and McNemar's test.

Results: A total of 2929 patients were included. Most patients, 65.9%, had a PAT score of 0; for those with non-zero PATs, abnormalities in the appearance domain were most prevalent, 50.7%. A PAT score of 1 or higher was associated with transport via ALS (OR 67.9; 95% CI 32.0, 144.1) compared to a PAT of 0. Most patients, 62.2%, received an EMS intervention; the most common was diagnostics (blood glucose or electrocardiogram [EKG]). The EMS administered medications to 22% of patients. PAT scores of ≥2 were associated with double the odds of admission to the floor (OR 2.09; 95% CI 1.4, 3.0) and quadruple the odds of admission to ICU level of care/direct to surgery/expired (OR 4.9; 95% CI 2.9, 8.3); PATs abnormal for work of breathing only were associated with increased odds of admission to the floor (OR 2.5; 95% CI 1.8, 3.6).

Conclusions: This study suggests that EMS PAT assessment in the field appropriately reflects patient stability and may be associated with EMS intervention en-route. The EMS PAT scores demonstrate promise as an adjunct to ED assessment, alerting clinicians to increased likelihood of admission. The PAT has potential to serve as a practical mechanism for EMS feedback and quality improvement studies.

Flecainide is an antiarrhythmic with several adverse effects, including dysrhythmias and hemodynamic collapse with an overdose fatality rate of 22.5% (1-3). Here we present a case of intentional flecainide ingestion leading to critical illness. Emergency medical services (EMS) was dispatched to a 17-year-old female after a witnessed flecainide ingestion. Arrival vitals were pulse 120, blood pressure 96/60, and Glasgow Coma Score 15. No initial electrocardiogram was performed. On arrival at the hospital, the patient quickly developed a seizure followed by cardiac arrest. Cardiopulmonary resuscitation was performed with return of spontaneous circulation (ROSC); ECG demonstrated a wide-complex tachycardia. Intubation was performed and norepinephrine started. The patient was also given sodium bicarbonate, lorazepam, levetiracetam, lidocaine, amiodarone, and lipid emulsion. The patient transferred to a pediatric center, where she developed pulseless ventricular tachycardia. After defibrillation and administration of calcium chloride and lipid emulsion, ROSC was achieved. Worsening hypotension and recurrent ventricular tachydysrhythmias led to the pursuit of extracorporeal membrane oxygenation (ECMO). Extracorporeal membrane oxygenation continued through day 5, and the patient was discharged on day 13. This case of an intentional flecainide overdose resulting in critical illness highlights several aspects of prehospital care. Clinician knowledge of the nature of illness, agent ingested, and magnitude of ingestion is critical to timely care. When patients decompensate, lack of access to this information can delay administration of decontamination agents, specific antidotes, and toxicology expert consultation. In this case, a prehospital electrocardiogram was not obtained. Given the rapid development of unstable tachydysrhythmias, having this information en route and on arrival at the emergency department may have expedited management. In all toxic ingestions, early electrocardiograms are paramount. Lastly, the patient may have benefited from direct transport to a pediatric center given it would have added only a few minutes' delay and the EMS crew was advanced life support-capable. In general, one cannot know whether a longer transfer time will result in critical decompensation. Nonetheless, one might consider certain presentations with capacity for critical illness requiring highly specialized care as an indication for direct transport.

Objectives: Needle thoracostomy (NT) is a time-sensitive procedure infrequently performed by EMS clinicians with variable success rates. Our primary objective was to evaluate the accuracy of NT site selection by paramedics using ThoraSite^® compared to traditional anatomic landmarks (ALs). Secondarily, we assessed paramedic-rated confidence and ease of ThoraSite^® use.

Methods: We conducted a randomized, two-arm crossover study including fire-based paramedics. Emergency physician investigators determined a NT placement zone for live human models in three size groups, confirming with ultrasound and demarcating the zone with "invisible" ultraviolet ink. Following training, paramedics performed NT site selection on the models using ThoraSite^® and ALs by placing a sticker at the selected insertion site. Accuracy of placement was confirmed with ultraviolet flashlight. If placement was outside the demarcated zone (DZ), we identified underlying structures with ultrasound. We evaluated the effect of approach on placement accuracy and time-to-NT placement using linear models with covariates of paramedic, approach, and model size. For the outcome of accuracy, we used a log link function. For time-to-NT, we log-transformed the values for the parametric analysis allowing interpretation of the coefficients as percent differences. We compared paramedic confidence in performing the NT procedure and perceived ease of procedure using a 5-point Likert scale.

Results: There were 112 paramedics that performed 223 ThoraSite^® and 223 landmark attempts with 383 correct placements within the DZ: 198 attempts using ThoraSite^® compared to 185 with ALs, odds ratio (OR) 1.91 (95%CI 1.01-3.62), p = 0.04. Placement accuracy by model size followed similar trends. Incorrect placement over critical structures occurred in 1 ThoraSite^® and 3 AL attempts. The mean time for NT site selection was 14.3s (SD = 7.11) using ThoraSite^® and 18.7s (SD = 7.40) using ALs (p < 0.01). Overall procedural confidence improved with training. However, there was no statistically significant difference in the change in confidence with ThoraSite^® as compared to ALs (OR = 1.55 95%CI = 0.89-2.72). Paramedics rated ease of NT placement significantly higher using ThoraSite^® (median = 5, IQR = 4-5) compared to ALs (median = 4, IQR = 4-5; p < 0.01).

Conclusions: ThoraSite^® was associated with increased odds of NT site selection in the DZ, reduced time-to-NT site selection, and increased self-rated ease reported by paramedics.

Objectives: To examine the association of community-level social drivers of health with variability in the documentation of prehospital 12-lead electrocardiogram (ECG) for patients with suspected acute coronary syndrome (ACS).

Methods: This retrospective observational cohort study was conducted using the 2021 ESO Data Collaborative with de-identified records from more than 1,300 emergency medical services (EMS) agencies in the United States. We included 9-1-1 ground responses for adults ≥35 years with a prehospital clinical impression of ACS who were transported to the hospital. Social vulnerability index (SVI) was linked at the Census tract of the scene encounter and grouped in quartiles with the highest quartile representing communities of greatest vulnerability. The primary outcome was documentation of prehospital 12-lead ECG performance. Multivariable logistic regression models were used to examine the association of SVI with prehospital 12-lead ECG documentation of performance.

Results: Among 34,388 EMS encounters for patients with suspected ACS, 73% were between the ages of 45-79 years old, 49% were female, and 18% were Black. Most calls occurred in the South (64%), with a paramedic crew (90%), and 29% were in rural settings. Compared to communities in the least vulnerable quartile, Q2 (OR 0.86, 95%CI 0.78-0.95, p = 0.004), Q3 (OR 0.64, 95%CI 0.58-0.71, p < 0.001), and Q4 (OR 0.63, 95%CI 0.57-0.70, p < 0.001) quartiles were associated with reduced odds of ECG documentation. The relationship persisted after adjusting for factors associated with 12-lead ECG documentation.

Conclusions: Higher community social vulnerability was significantly associated with lower odds of prehospital ECG for patients with suspected ACS, suggesting that additional resources focused on these communities may be needed to address these inequities.