Offline ( in-direct ) Protocol development Personnel education Prospective and retrospective patient care review Online (direct ) Real-time interaction between a physician and field providor Medical Direction
Airway & Respiratory Emergencies Comprise majority of EMS calls Basic technicquese.g chin lift , head tilt Studies shown that basic levels EMT’s were able to use blind-insertion airway devices (e.g., Combitube or larygneal mask airway), which enable faster placement and provide improved minute ventilation 49.. Guyette FX, et al: Feasibility of laryngeal mask airway use by prehospital personnel in simulated pediatric respiratory arrest. PrehospEmerg Care 2007; 11:245.
A prospective multicenter evaluation of prehospitalairwaymanagement performance in a large metropolitan region. PrehospEmerg Care 2009; 13: 304‐ Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. The data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation. Airway---
Difficult Airway ?!….. Prehospital management of the difficult airway: A prospective cohort study. JEM 2009; 36(3): 257‐265. Objective to evaluate ETI management in a system of advanced life support (ALS) providers experienced in ETI and other advanced airway techniques, and describe management and outcomes of patients with a“difficult airway.” Results Of 80,501ALS patient contacts, 4091 (5.1%) underwent attempted oral ETI, with a 96.8% success rate in four or fewer attempts 130 were difficult airway & managed by ETI > 4 attempts bag‐valve‐mask ventilation Cricothyroidotomy retrograde ETI
Conclusion Prehospital ETI can be performed with a high success rate by experienced ALS providers, but may still require advanced airway techniques in a small subset of patients. Among the advanced procedures, cricothyroidotomy had the highest success rate and should not be delayed by other interventions
Prehospital intubation failed in 31% of trauma patients in a large urban trauma system. Cobas MA et al., AnesthAnalg 2009 Aug; 109:489 Herff H et al., AnesthAnalg 2009 Aug; 109:303 Researchers in a single urban trauma system (Miami )reviewed the records of all 203 patients who received PHI during a 34-month period. PHI, was successful in 69% of patients Intubation failure, occurred in 31% &included unrecognized esophageal intubation (12%), Combitube use (14%), LMA use (3%), and cricothyrotomy (2%). When things go wrong !!
Overall, 64% of patients who received PHI died Though In-hospital mortality did not differ significantly between patients with failed and successful PHI (71% and 60%), But percentage of patients who were dead on arrival was significantly higher in the failed-intubation group (48% vs. 26%). Conclusion The 12% incidence of esophageal intubation is unacceptably high, consistent with prior study findings, and, therefore, profoundly disturbing. As editorialists remind us, this study, despite its flaws, provides further impetus to reexamine how we manage airways for trauma patients in the prehospital setting.
Early defibrillation challenged Hayakawa M, et al. Shortening of cardiopulmonary resuscitation time before the defibrillation worsens the outcome in out‐of‐hospital VF patients. AJEM 2009; 27(4): 470‐474. In 143 patients who had out of‐hospital–witnessed VF, 43 patients and 100 patients were treated with the CPR‐first strategy and the shock‐first strategy, respectively. The duration of CPR before the first defibrillation was longer in the CPR‐first group than that in the shock‐first group Cardiac emergencies
The CPR‐first group showed ahigher rate of favorable neurologic outcome 30 days after (28% vs 14%; P = .048) and 1 year after cardiac arrest (26% vs 11%; P = .033) than those of the shock‐first group In the patients with witnessed VF, a stepwise multiple logistic regression analysis showed the CPR‐first strategy to improve the neurologic outcome. Conclusions. In patients with out‐of‐hospital–witnessed VF, sufficient CPR before the first defibrillation is considered to improve the neurologic outcome in comparison to the performance of immediate defibrillation
Immediate prehospital hypothermia protocol in comatose survivors of out‐of hospital cardiac arrest. Hammer L, et al. AJEM 2009; 27(5): 570‐573. Objective to evaluate retrospectively the efficacy and safety of an immediate prehospital cooling procedure implemented just after the return of spontaneous circulation with a prehospital setting During 30 months, the case records of comatose survivors of out‐ofhospital CA presumably due to a cardiac disease were studied. A routine protocol of immediate postresuscitation cooling had been tested by an emergency team, which consisted of an infusion of large‐volume, ice‐cold intravenous saline.
total of 99 patients were studied; 22were treated with prehospital TH 77 consecutive patients treated with prehospital standard resuscitation served as controls. For all patients, TH was maintained for 12 to 24 hours After 1 year of follow‐up, 6 (27%) of 22 patients in the cooling group and 30 (39%) of 77 patients in the control group had a good outcome Conclusion In comatose survivors of CA, prehospital TH with infusion of large‐volume, ice‐cold intravenous saline is feasible and can be used safely by mobile emergency and intensive care units.
Implementation of specialty centers for patients with ST‐segment elevation myocardial infarction: The Los Angeles STEMI Receiving Center Project PrehospEmerg Care PrehospEmerg Care 2009 ,13: 203-200 Known fact : Early (PCI) has been shown to be superior to fibrinolytic therapy and with reduced morbidity and mortality for patients with (STEMI) Objective prospective study to determine the performance of a regional system with prehospital 12‐lead (ECG) identification of STEMI patients and direct paramedic transport to STEMI receiving centers (SRCs) for primary PCI Conclusion Door‐to‐balloon times within the 90‐minute benchmark were achieved for almost 90% of STEMI patients transported by paramedics after implementing our regionalized SRC system.
Co Do IV Meds Matter in Out-of-Hospital Cardiac Arrest? Olasveengen TM et al. Intravenous drug administration during out-of-hospital cardiac arrest: A randomized trial. JAMA 2009 Nov 25; 302:2222. Intravenous access and drug administration have long been central elements of advanced cardiac life support (ACLS) protocols despite the absence of evidence that they improve outcomes methodology In a randomized, controlled, nonblinded trial, 851 consecutive adult patients with out-of-hospital, nontraumatic cardiac arrest in Oslo, Norway from 2003 to 2008 were randomized to receive ACLS with IV access and drug administration (epinephrine, atropine, and amiodarone were used) or ACLS with no IV access. In the group that received ACLS with no IV access, IV access was established within 5 minutes after return of spontaneous circulation (ROSC)
. In both groups, patients with ventricular fibrillation received cardiopulmonary resuscitation for 3 minutes before the first shock and between unsuccessful series of shocks Endo tracheal intubation was standard, and post resuscitation therapeutic hypothermia was instituted regardless of initial rhythm or course of arrest The primary outcome was survival to discharge. The admission rate was higher in the group with IV access than in the group without IV access (32% vs. 21%) however no significant difference in in rates of survival to discharge (10% and 9%), survival with favorable neurological outcome (10% and 8%), and survival at 1 year (10% and 8%)
Conclusion These interventions were not associated with improvement in long-term survival or neurological outcome. The results are r similar to studies in which epinephrine, atropine, and amiodarone improved short-term but not long-term outcomes compared with placebo. In addition, IV access had no negative effect on the quality of CPR. This trial begs for research targeted at novel pharmacologic therapies and should prompt the rethinking of ACLS guidelines.
Improved patient survival using a modified resuscitation protocol for out‐ofhospital cardiac arrest Circulation. 2009; 119: 2597-2605. EMS system at urban center made changes to current CPR protocol Minimizing chest compression interruptions, increasing the ratio of compressions to ventilation, deemphasizing or delaying intubation, and advocating chest compressions before initial countershock Methodoloogy retrospective observational cohort study reviewed all adult primary VF and pulseless VT cardiac arrests 36 months before and 12 months after the protocol change. Primary outcome was survival to discharge; secondary outcomes were return of spontaneous circulation and cerebral performance category CPR & CPR
Results Survival of out‐of‐hospital arrest of presumed primary cardiac origin improved from 7.5% (82 of 1097) in the historical cohort to 13.9% (47 of 339) in the revised protocol cohort (odds ratio, 1.80; 95% confidence interval, 1.19 to 2.70). Similar increases in return of spontaneous circulation were achieved for the subset of witnessed cardiac arrest patients with initial rhythm of ventricular fibrillation from 37.8% (54 of 143) to 59.6% (34 of 57) (odds ratio, 2.44; 95% confidence interval, 1.24 to 4.80) Survival to hospital discharge also improved from an unadjusted survival rate of 22.4% (32 of 143) to 43.9% (25 of 57) (odds ratio, 2.71; 95% confidence interval, 1.34 to 1.59) with the protocol. Of the 25 survivors, 88% (n=22)had favorable cerebral performance categories on discharge.
The impact of patient sex on paramedic pain management in the prehospital setting. AJEM 2009; 27 (5): 525‐529. Objective to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting Results Sex is not associated with the rate of paramedic‐initiated analgesia, but is associated with differences in the type of analgesia administered as Males were mor likely to receive Morphine than Females
Does Emergency Medical Services transport for pediatric ingestion decrease time to activated charcoal? PrehospEmerg Care 2009; 13: 295‐303 Objective. Activated charcoal when administered within one hour, it can reduce absorption of toxins by up to 75%. This study evaluated whether pediatric emergency department (ED) patients arriving by ambulance receive AC more quickly than patients arriving by alternative modes of transport. Tox
Methodology retrospective review of AC administration in children in a large, urban pediatric ED from January 2000 until January 2006. Patients aged 0‐18 years were identified from pharmacy billing codes and the National Capital Poison Center's database. Charts were reviewed for age, gender, triage acuity, disposition, transportation mode, triage time, and time of AC administration; analysis of variance (ANOVA) controlling for these covariates tested the equality of mean time intervals
The sickest patients arriving by EMS had a faster time from triage to AC administration. when comparing patients of all triage categories, EMS arrival alone did not influence time to AC administration. Furthermore, the interval from triage to charcoal administration was often insufficiently long. There is a need for reevaluation of triage and prehospital practices Conclusion
The accuracy of portable ultrasonography to diagnose fractures in an austere environment PrehospEmerg Care 2009; 13: 50‐52. Methods longitudinal, prospective, observational study on patients presenting with suspected closed fractures using a digital handheld ultrasound device. All patients presenting with suspected fracture underwent an ultrasound examination by a board‐certified emergency medicine physician credentialed in emergency ultrasonography Patients were then categorized into ultrasound‐positive and ultrasound negative groups Trauma
Results A total of 44 subjects underwent ultrasound examination for suspected fractures. There were initially 12 (27%) positive and 32 (73%) negative scans. Of the initial 12 positive scans, ten had a true fracture verified by plain radiography. Ultrasonography yielded an overall sensitivity of 100% and a specificity of 94%. Only four patients with an initial negative ultrasound scan continued to have clinical symptoms for more than three days and were found to have no evidence of fracture by radiograph.
Conclusion use of ultrasound by an experienced clinician in the austere environment can be performed accurately and can possibly prevent unnecessary evacuations for suspected fractures requiring radiographic verification.
Information loss in Emergency Medical Services handover of trauma patients PrehospEmerg Care 2009; 13: 280‐285 Objective To determine the degree to which information presented in the EMS trauma patient handover is degraded Conclusion Even in the controlled setting of a single‐patient handover with direct verbal contact between EMS providers and in‐hospital clinicians, only 72.9% of the key prehospital data points that were transmitted by the EMS personnel were documented by the receiving hospital staff. Elements such as prehospital hypotension, GCS score, and other prehospital vital signs were often not recorded. Methods of “transmitting” and “receiving” data in trauma as well as all other patients need further scrutiny. Do we really listen to EMS handover?
Spine Immobilization for Penetrating Trauma Can Be Harmful Haut ER et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma 2010 Jan; Despite a lack of supportive evidence, prehospital providers often apply spine immobilization to patients who have penetrating trauma to the head, neck, or torso without neurological symptoms or deficit This study retrospectively assessed the effect of prehospital spine immobilization on mortality in patients with penetrating trauma using data from the American College of Surgeons National Trauma Data Bank between 2001 and 2004
Of 45,284 patients (median age, 29), 4.3% received cervical collars, spinal backboards, or both. The overall mortality rate was 8.1% Multiple logistic regression analysis that controlled for confounders, including Injury Severity Score and Revised Trauma Score, showed that immobilized patients had significantly increased mortality(odds ratio, 2.06); . Only 30 patients (0.1%) underwent operative spine stabilizing procedures for incomplete spinal-cord injury. The number needed to treat with spine immobilization to potentially benefit 1 patient was 1032. The number needed to harm with spine immobilization to potentially contribute to 1 death was 66.
Conlcusion Increasing evidence indicates that limited intervention at the scene allows trauma patients to receive definitive care at a trauma center more rapidly. This study indicates that prehospital spine immobilization is associated with increased mortality in patients with penetrating trauma. Trying to assign cause and effect in a retrospective study is risky, but possibly increased scene time or interference with later care (e.g., intubation, radiography, examination of the patient's back) contribute to worse outcomes. Spine immobilization might be applied more wisely to patients with altered mental status, spine tenderness, or sensorimotor dysfunction.
Use of the pediatric EZIO needle by Emergency Medical Services providers PediatrEmer Care 2009; 25: 329‐332. This prospective pilot study was conducted between May 2006 and October 2007. After completing an initial training session, the EZ‐IO PD was deployed for use on patients. Emergency medical services (EMS) providers completed a telephone data collection process after each insertion attempt. Succees rate was very high with 95 % rate in less than 60 seconds New intraosseous needle !