Prehospital Emergency Care最新文献

Objectives: Neonates, infants 30 days of age or younger are understudied in prehospital emergencies. Our objective was to describe prehospital assessment and care for patients <30 days of age at the San Diego-Tijuana Point of Entry (POE). Additional objectives included describing assessments, care, frequency, and level of care for newborns brought to the border by Mexican ambulances.

Methods: This was a retrospective analysis from January 1, 2014, to January 01, 2020, of all 9-1-1 calls involving patients <30 days of age at the San Diego POEs. The 9-1-1 responses to newly delivered patients were "newborns". Patients who were not immediately post-delivery were "neonates." Patient demographics, response intervals, clinician interventions, and dispositional data were collected from electronic patient records. Descriptive statistics were applied.

Results: A total of 57 patients <30 days of age were included. With 27 newborn patients, 15 were delivered by emergency medical services (EMS) personnel (27, 55.6%). Initial appearance, pulse, grimace, activity, and respiration (APGAR) scores were 8-10 in 44.4% and 5-7 in 29.6%. Procedures included newborn care (88.9%), advanced life support (ALS) assessment (63.0%), and warming (59.3%). There were five patients that had stimulation, 7 received oxygen, and 3 received Bag-Valve-Mask (BVM) ventilation. No serial heart rates were documented. Regarding 30 neonates, the predominant method of transport to the POE was Mexican ambulance (n 16, 53.3%). Medications administered included oxygen (n 16, 53.3%) and albuterol/ipratropium (n 1, 3.3%). Procedures included ALS assessment (n 19, 63.3%), pulse oximetry (n 22, 73.3%), and 3-lead electrocardiogram (n 8, 26.7%). Three patients (10%) received BVM. Mexican Ambulances brought 16 neonates. A physician or nurse was present in 37.5% of transfers, 50% were incubated, 25% intubated, 37.5% on supplemental oxygen, and 71% had preexisting intravenous access. These were not interfacility transfers but were 9-1-1 activations by U.S. border agents; and 14 neonates did not arrive via Mexican ambulance. Their complaints were respiratory distress (n 7, 50%) and Brief Resolved Unexplained Episode (n 4, 28.6%).

Conclusions: We found that 9-1-1 transports at the San Diego-Tijuana POE for patients <30 days were few and involved resuscitation, neonates in Mexican ambulances with specialized equipment, physicians, and unfamiliar medications. Neonates arriving via private transport had respiratory distress and BRUE.

Objectives: The impact of emergency medical services (EMS) response times when integrating bystanders' automated external defibrillator (AED) use into established response systems remains unclear. This study aims to investigate 30-day survival probabilities for different EMS response times for bystander and non-bystander defibrillated patients and identify for which EMS response times bystander defibrillation improves 30-day survival probability.

Methods: Data on patients with bystander witnessed out-of-hospital-cardiac arrest (OHCAs) with initial shockable rhythm who received bystander cardiopulmonary resuscitation were retrieved from Danish Cardiac Arrest Registry for years 2016-2022. Proportions of 30-day survival were calculated for five intervals of EMS response time for patients who received bystander defibrillation and those who did not. The causal inference framework utilizing targeted maximum likelihood estimation was used to estimate 30-day survival probability for each interval of EMS response time and when comparing cases where bystander defibrillation was performed with those where it was not. This analysis was adjusted for relevant confounding factors and conducted separately for residential and public OHCAs.

Results: The study included 3,924 patients with OHCA. Bystander defibrillation was more frequent in public than in residential OHCAs (64.1% vs. 35.9%). Short EMS response times had higher 30-day survival probability. Bystander defibrillation resulted in higher probability of 30-day survival for EMS response times of 7-9 min (survival ratio 1.24 [95% CI: 1.03; 1.49]) in public OHCAs in the adjusted model, when compared to non-bystander defibrillated patients.

Conclusions: With EMS response times of 7-9 min, we detected a clear 30-day survival benefit for bystander defibrillated patients in public locations. No 30-day survival benefits were seen for other EMS response time intervals or in residential locations.

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: Out-of-hospital births are associated with a 2- to 11-fold increased risk of death compared to in-hospital births and are growing. Emergency Medical Services (EMS) clinicians have limited exposure to hospital birth emergencies, and there is no standardized prehospital neonatal resuscitation curriculum. Neonatal Resuscitation Program (NRP) guidelines are the standard of care for infants born in the United States but focuses on in-hospital births and is not easily applied to EMS. There is a need for tailored NRP training to meet EMS clinicians' specific needs, context, and systems.

Methods: This was a prospective observational study of a virtual EMS-tailored, newborn resuscitation curriculum focused on initial steps of newborn resuscitation in the out-of-hospital setting. The initial content (90-minute) was pilot tested virtually among 350 urban EMS clinicians, with favorable feedback (89% survey response rate). Based on feedback, we created a 60-minute interactive, virtual curriculum that includes NRP-based didactic and memory aids to reinforce how NRP differs from pediatric resuscitation designed specifically for EMS. The course also includes video demonstrations with pauses for hands-on self-directed skills practice. We delivered the curriculum to clinicians from 17 EMS agencies in rural Oregon. To assess neonatal resuscitation knowledge acquisition and retention, participants completed the same 10-question test before, after, and 3 months following the training. Questions were adapted from the 8^th Edition NRP Textbook and NRP test questions.

Results: Eighty-four EMS clinicians completed the pretest, curriculum, and post-test and demonstrated improvement in immediate post-curriculum NRP knowledge (pretest mean score 5.32 ± 1.99; post-test mean score 8.61 ± 1.26; p < 0.001). Forty participants completed the 3-month follow up test and scores remained improved from baseline (3 month-follow up mean score 6.88 ± 1.83, p < 0.001). Prehospital clinicians (N = 84) thought that this EMS-tailored NRP curriculum was easy to complete (100%), valuable to their clinical practice (99%), and filled a gap in their education (98%). They felt that implementing/requiring this training is possible/doable (99%) and recommend the curriculum to other EMS agencies (99%).

Conclusions: A virtual EMS-tailored, NRP-based educational curriculum improved neonatal resuscitation knowledge immediately and was sustained at 3 months compared to baseline. The curriculum is feasible and acceptable to 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: 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: 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.