Prehospital Emergency Care最新文献

Objectives: Trauma patients are a high volume and morbidity population, showing the importance of their prehospital care. This study aimed to evaluate the current status and consistency of prehospital trauma triage protocols in the United States.

Methods: States with statewide emergency medical services (EMS) protocols and trauma triage criteria were included. For each state, EMS protocols were analyzed to assess trauma centers and categories, trauma triage criteria (including physiologic, anatomic, mechanism, and patient factors), and transport mode and destination guidance.

Results: Of 31 states with statewide EMS protocols, 29 (94%) included prehospital trauma triage criteria. States most commonly had two (15 (52%) states) or four (nine (31%) states) trauma categories identified with colors, numbers, or letters. Systolic blood pressure (29 (100%) states), Glasgow Coma Scale (15 (52%) states), and respiratory rate (29 (100%) states) were the most frequently used physiologic criteria. Anatomic criteria included central penetrating trauma (29 (100%) states), bilateral femur fractures (26 (90%) states), open skull fractures (25 (86%) states), bilateral extremity paralysis (28 (97%) states), amputation above the wrist/ankle (28 (97%) states), unstable pelvic fracture (27 (93%) states), and flail chest (27 (93%) states). Death from the same mechanism (27 (93%) states), ejection (28 (96%) states), or pedestrian/bike versus automobile (29 (100%)) were mechanistic criteria for motor vehicle accidents. Patient factors, including age, anticoagulation, and pregnancy were patient factors used as trauma criteria. Destination differed by trauma category in 22 (76%) states, and helicopter transport was advised for drive times exceeding thresholds ranging from ten to sixty minutes.

Conclusions: In this national study of EMS protocols, we found heterogeneity in the structure and indications used for prehospital trauma triage criteria. This study highlights the need for standardization to ensure trauma patients receive timely and appropriate care.

Objectives: We aimed to identify the abstract-to-manuscript conversion rate of abstracts presented at the National Association of Emergency Medical Services Physicians (NAEMSP) conference by year, abstract number, and status as oral or poster abstract.

Methods: We conducted a cross-sectional evaluation of all abstracts presented at the NAEMSP annual meetings from 2018 to 2022, and withdrawn abstracts were excluded. We used PubMed to identify publication status, year of publication, journal of publication, and first-author continuity from abstract to manuscript. We used a Chi-square test to assess changes in the proportion of abstracts published as manuscripts.

Results: A total of 1,010 abstracts were included and 348 (34%) were published in a PubMed-indexed journal within 2 years of presentation. The conversion rate was higher for oral abstracts (n = 71/150, 47%) than poster abstracts (n = 277/765, 36%). The conversion rates were not different across the five years (lowest: 2018, 29%; highest: 2022, 39%, p = 0.137); however, author continuity varied across years (lowest: 2018, 64%; highest: 2021: 86% p = 0.046).

Conclusions: In this cross-sectional analysis of NAEMSP conference presentations from 2018 to 2022, abstract-to-manuscript conversion rates were low and did not change over time.

Objectives: In 2019, the Centers for Medicare and Medicaid Services (CMS) announced the Emergency Triage, Treat, and Transport (ET3) Model, an innovative care model aimed at increasing the quality and lowering the cost of emergency service care through telehealth services and alternative destination options for low-acuity cases. New York City (NYC) implemented ET3 protocols to enable broad adoption in the 9-1-1 system. The purpose of this study is to identify the characteristics, disposition of patients and challenges of the ET3 program in a single 9-1-1 emergency medical service (EMS) system.

Methods: Retrospective chart review of program data from one urban EMS service in NYC as per the inclusion/exclusion criteria in the local prehospital protocol including 1) rates of patients meeting criteria for an ET3 encounter; 2) rates of acceptance of ET3 telehealth treat-in-place encounters, 3) disposition of cases; 4) rates of return visits within 72 h.

Results: From August 2022-December 2023, 133,646 9-1-1 calls were answered. Of these, 78,911 (59%) were triaged for ET3, of which only 2,130 (3%) met inclusion criteria. Telehealth ET3 encounters were not offered to 1556 (73%). Of the remaining, 524 (92%) refused to participate in ET3 encounters, and 50 (9%) accepted. Of those who accepted, 31 (62%) were treated in place with telehealth, 15 (30%) were transported to the emergency department (ED), and 3 (6%) refused medical attention. Only 4 (13%) of those treated in place subsequently encountered an ED within 72 h.

Conclusions: The NYC EMS launch of the ET3 pilot was met with very low acceptance from eligible participants. The pilot helped to identify implementation challenges including proper personnel training, public outreach and awareness, and technological barriers. There is promise in avoiding transportation to the ED among those willing to participate with an even smaller rate of those requiring further unscheduled acute care. Our findings highlight limited offerings of ET3 encounters, and poor patient participation once offered. Further initiatives may consider workflow improvements and education to the public to improve willingness to participate.

Cardiac arrest response and management is a critical piece of prehospital clinical practice yet the majority of these patients do not survive to be transported. Termination of resuscitation and resulting death notification is stressful and emotional for both loved ones and EMS clinicians. We describe a fundamental shift from traditional termination of resuscitation to a patient and family-centered model. This new approach focuses on identifying appropriate situations to have family present at the time resuscitative efforts cease, and possibly throughout the entire resuscitation, thereby reframing termination of resuscitation as withdrawal of life support. This approach draws on best practices from hospital-based end-of-life care and holds the potential to reduce psychological trauma for both families and EMS clinicians.

There are limited methods of differentiating between pulseless electrical activity (PEA) and pseudo-PEA in both prehospital and early hospital settings. According to the European Resuscitation Council (ERC) guidelines, point-of-care ultrasound (POCUS) is a rapid and effective method for differentiating between PEA and pseudo PEA. In addition, ERC guidelines recommend the use of POCUS in cases of non-shockable rhythms for the diagnosis of potentially reversible causes of sudden cardiac arrest (SCA). Here, we present the case of a 73-year-old patient who experienced sudden cardiac death due to an unshockable rhythm. Since the carotid pulse was not palpable, the patient was initially diagnosed with PEA and treated accordingly. Using POCUS during cardiopulmonary resuscitation (CPR) enabled the paramedics to diagnose pseudo-PEA in the prehospital setting. Based on ultrasound findings, successful transcutaneous pacing was applied, and POCUS monitored the treatment's effectiveness by showing color Doppler flow in the femoral artery and systolic left ventricular function. Using POCUS for post-resuscitation assessment allowed for the suspicion of myocardial infarction. This, in turn, led to the early implementation of anticoagulant and antiplatelet therapy in the ambulance. The use of POCUS during and post-CPR in the prehospital setting was crucial for altering the patient's treatment and potentially improving the outcome.

Objectives: Emergency departments (EDs) face growing strain from increased health-seeking behavior. To preserve finite ED resources, a non-medical stabilization center (SC) was implemented in Toronto, Canada as an alternative destination to receive paramedic-transported patients with suspected acute alcohol or opioid intoxication who would otherwise have been taken to an ED. These patients typically require observation and recovery rather than emergency medical intervention. We described the diversion care model, clinical guideline, patient cohort, and its safety.

Methods: We conducted a retrospective study of paramedic-transported patients to a SC in Toronto, Canada between December 8, 2022, and December 31, 2024. Eligible patients originated from 9-1-1 calls and were transported either directly (from the community to SC) or indirectly (from the community to an ED, then to SC). Descriptive statistics summarized the patient cohort stratified by transport method, and those later transferred from the SC to an ED.

Results: A total of 3,744 patients were transported to the SC, of which 3,066 (80.3%) were transported directly, and 738 (19.7%) indirectly. Most patients were male and between the ages of 16 and 49 years. Paramedics performed no medical interventions for 3,557 patients (95.0%), with naloxone administered to only 60 cases (1.6%). A small subgroup of patients were frequent users of the SC, with 3.7% of all patients accounting for 24.6% of all visits. A total of 322 (8.6%) initially transported to the SC were subsequently transferred to an ED, primarily for medical concerns unrelated to intoxication.

Conclusions: The SC model demonstrated that select intoxicated patients who were unlikely to require paramedic or ED medical care could be safely managed in a non-medical setting, thereby reducing pressure on EDs. These preliminary findings support the integration of paramedic diversion models as part of a broader strategy to optimize emergency care delivery and reduce ED utilization.

Objectives: This study aimed to examine the association between the timing of defibrillation by emergency medical service (EMS) and out-of-hospital cardiac arrest (OHCA) patient prognosis using a nationwide database.

Methods: We included patients with non-traumatic OHCA aged ≥15 years from 2010 to 2019, with an initial shockable rhythm, who received EMS defibrillation. Patients were divided into 2 groups: defibrillation within 2 min of cardiopulmonary resuscitation (CPR; immediate defibrillation) or after 2 min (delayed defibrillation). The primary outcome was 1-month survival. We set the primary exposure to immediate defibrillation and employed a 1:1 propensity score matching. Multiple logistic regression analysis estimated the adjusted odds ratio (AOR) and 95% confidence interval (CI) for exposure and outcomes.

Results: After propensity score matching, 16,970 patients were included in each group. The 1-month survival were 32.5% and 29.1% for immediate defibrillation and delayed defibrillation, respectively. Immediate defibrillation was significantly associated with 1-month survival compared to delayed defibrillation (AOR [95% CI], 1.18 [1.12, 1.24]).

Conclusions: Defibrillation within 2 min of starting CPR was associated with 1-month survival, emphasizing the importance of immediate defibrillation.