Advanced Life Support Providers Research Articles

Emergency medical services level of training is associated with mortality in trauma patients: A combined prehospital and in hospital database analysis.

There is conflicting evidence regarding emergency medical service (EMS) provider level of training and outcomes in trauma. We hypothesized that advanced life support (ALS) provider transport is associated with lower mortality compared with basic life support transport. We performed secondary analysis of a combined prehospital and in-hospital database of trauma patients utilizing ESO electronic medical records from 2018 to 2022. We included encounters with patients aged 15 years to 100 years transported by ground to a Level I or II trauma center with trauma-specific ICD-10-CM codes. Patients dead upon EMS arrival and transfers were excluded. We matched patients using 1:1 nearest neighbor propensity scores based on demographic, injury, and EMS characteristics, prehospital vitals, and trauma center designation. The exposure variable was EMS level of training and outcome was mortality. We conducted subgroup analyses on predefined cohorts (age > 50 years, mechanism of injury, prehospital EMS time > 30 minutes). We identified 30,735 ALS and 1,758 basic life support encounters, representing 1,154 pairs following propensity matching. Mortality was lower among patients transported by ALS providers (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.18-0.88; p = 0.023). Mortality was also lower in the subgroups of patients aged > 50 years (OR, 0.35; 95% CI, 0.13-0.98; p = 0.046), and in patients with mechanisms of injury excluding falls (OR, 0.35; 95% CI, 0.13-0.98; p = 0.047). In those with prolonged prehospital time, the association approached significance (OR, 0.30; 95% CI, 0.08-1.08; p = 0.067). In those with mechanisms of injury of fall, the association was not significant. In this retrospective, propensity matched cohort study using a national sample of trauma patients, attendance by ALS providers was associated with reduced mortality. This was observed in the entire cohort, in those aged > 50 years, and those with a higher-risk mechanism of injury. It approached significance in those with prolonged prehospital time. Therapeutic/Care Management; Level III.

Derivation of a clinical decision rule for termination of resuscitation in non-traumatic pediatric out-of-hospital cardiac arrest

AimPrehospital termination of resuscitation (ToR) rules are used to predict medical futility in adult out-of-hospital cardiac arrest (OHCA), however, the available evidence for pediatric patients is limited. The primary aim of this study is to derive a Pediatric Termination of Resuscitation (PToR) prediction rule for use in pediatric non-traumatic OHCA patients. MethodsWe analyzed a retrospective cohort of pediatric OHCA patients within the CARES database over a 10-year period (2013–2022). We split the dataset into training and test datasets and fit logistic regressions with Least Absolute Shrinkage and Selection Operator (LASSO) to select predictor variables and estimate predictive test characteristics for the primary outcome of death and a secondary composite outcome of death or survival to hospital discharge with unfavorable neurologic status. ResultsWe analyzed a sample of 21,240 children where 2,326 (11.0%) survived to hospital discharge, and 1,894 (8.9%) survived to hospital discharge with favorable neurologic status. We derived a PToR rule for death demonstrating a specificity of 99.1% and a positive predictive value (PPV) of 99.8% and a PToR rule for death or survival with poor neurologic status with a specificity of 99.7% and PPV of 99.9% within the test dataset. ConclusionWe derived a clinical prediction rule with high specificity and positive predictive value in prehospital settings utilizing Advanced Life Support (ALS) providers which may inform termination of resuscitation considerations in pediatric patients. Further prospective and validation studies will be necessary to define the appropriateness and applicability of these PToR criteria for routine use.

Mastering multicasualty trauma care with the Trauma Non-technical Skills Scale.

Multicasualty events present complex medical challenges. This is the first study to investigate the role of nontechnical skills in prehospital multicasualty trauma care. We assessed the feasibility of using the Trauma Nontechnical Skills Scale (T-NOTECHS) instrument, which has not yet been investigated to evaluate these scenarios. We conducted an observational study involving military medical teams with Israel Defense Forces Military Trauma Life Support training to assess the T-NOTECHS' utility in predicting prehospital medical team performance during multicasualty event simulations. These teams were selected from a pool of qualified military Advanced Life Support providers. Simulations were conducted in a dedicated facility resembling a field setting, with video recordings to ensure data accuracy. Teams faced a single multicasualty scenario, assessed by two instructors, and were evaluated using a 37-item checklist. The T-NOTECHS scores were analyzed using regression models to predict simulation performance. We included 27 teams for analysis, led by 28% physicians and 72% paramedics. Interrater reliability for simulation performance and T-NOTECHS scores showed good agreement. Overall T-NOTECHS scores were positively correlated with simulation performance scores ( R = 0.546, p < 0.001). Each T-NOTECHS domain correlated with simulation performance. The Communication and Interaction domain explained a unique part of the variance ( β = 0.406, p = 0.047). Assessment and Decision Making had the highest correlation ( R = 0.535, p < 0.001). These domains significantly predicted specific items on the simulation performance checklist. Cooperation and Resource Management showed the least correlation with checklist items. This study confirms the T-NOTECHS' reliability in predicting prehospital trauma team performance during multicasualty scenarios. Key nontechnical skills, especially Communication and Interaction, and Assessment and Decision Making, play vital roles. These findings underscore the importance of training in these skills to enhance trauma care in such scenarios, offering valuable insights for medical team preparation. Diagnostic Tests or Criteria; Level III.

The association of prehospital systemic corticosteroids with emergency department and in-hospital outcomes for patients with asthma exacerbations.

Timely administration of systemic corticosteroids is a cornerstone of asthma exacerbation treatment, yet little is known regarding potential benefits of prehospital administration by emergency medical services (EMS) clinicians. We examined factors associated with prehospital corticosteroid administration with hospitalization and hospital length of stay (LOS). We performed a retrospective study of EMS encounters for patients 2-50 years of age with suspected asthma exacerbation from a national data set. We evaluated factors associated with systemic corticosteroid administration using generalized estimating equations. We performed propensity matching based on service level, age, encounter duration, vital signs, and treatments to evaluate the association of prehospital corticosteroid administration with hospitalization and LOS using weighted logistic regression. We evaluated the association of prehospital corticosteroid administration with admission using Bayesian models. Of 15,834 encounters, 4731 (29.9%) received prehospital systemic corticosteroids. Administration of corticosteroids was associated with older age; sex; urbanicity; advanced life support provider; vital sign instability; increasing doses of albuterol; and provision of ipratropium bromide, magnesium, epinephrine, and supplementary oxygen. Within the matched sample, prehospital corticosteroids were not associated with hospitalization (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.73-1.01) or LOS (multiplier 0.76, 95% CI 0.56-1.05). Administration of corticosteroids was associated with lower odds of admission and shorter LOS in longer EMS encounters (>34 min), lower admission odds in patients with documented wheezing, and shorter LOS among patients treated with albuterol. In a Bayesian model with noninformative priors, the OR for admission among encounters given corticosteroids was 0.86 (95% credible interval 0.77-0.96). Prehospital systemic corticosteroid administration was not associated with hospitalization or LOS in the overall cohort of asthma patients treated by EMS, though they had a lower probability of admission within Bayesian models. Improved outcomes were noted among subgroups of longer EMS encounters, documented wheezing, and receipt of albuterol.

138 Instructor and Candidates views of a novel educational approach to recertify as an Advanced Life Support provider in the UK

138 Instructor and Candidates views of a novel educational approach to recertify as an Advanced Life Support provider in the UK

Transitioning from Direct to Video Laryngoscopy during the COVID-19 Pandemic Was Associated with a Higher Endotracheal Intubation Success Rate

Objective The objective of this study was to determine the effect of transitioning from direct laryngoscopy (DL) to video laryngoscopy (VL) on endotracheal intubation success overall and with enhanced precautions implemented during the COVID-19 pandemic. Methods We examined electronic transport records from Mayo Clinic Ambulance Service, a large advanced life support (ALS) provider serving rural, suburban, and urban areas in Minnesota and Wisconsin, USA. We determined the success of intubation attempts when using DL (March 10, 2018 to December 19, 2019), VL (December 20, 2019 to September 29, 2021), and VL with an enhanced COVID-19 guideline that restricted intubation to one attempt, performed by the most experienced clinician, who wore enhanced personal protective equipment (April 1 to December 18, 2020). Success rates at first attempt and after any attempt were assessed for association with type of laryngoscopy (VL vs DL) after adjusting for patient age group, patient weight, use of enhanced COVID-19 guideline, medical vs trauma patient, and ALS vs critical care clinician. A secondary analysis further adjusted for degree of glottic visualization. Results We identified 895 intubation attempts using DL and 893 intubation attempts using VL, which included 382 VL intubation attempts using the enhanced COVID-19 guideline. Success on first intubation attempt was 69.2% for encounters with DL, 82.9% overall with VL, and 83.2% with VL and enhanced COVID-19 protocols (DL vs overall VL: p < 0.001; COVID-19 vs non-COVID VL: p = 0.86). In multivariable analysis, use of VL was associate with higher odds of successful intubation on first attempt (odds ratio, 2.28; 95%CI, 1.73–3.01; p < 0.001) and on any attempt (odds ratio, 2.16; 95%CI, 1.58–2.96; p < 0.001) compared with DL. Inclusion of glottic visualization in the model resulted in a nonsignificant association between laryngoscopy type and successful first intubation (p = 0.41) and a significant association with the degree of glottic visualization (p < 0.001). Conclusions VL is designed to improve glottic visualization. The use of VL by a large, U.S. multistate ALS ambulance service was associated with increased odds of successful first-pass and overall attempted intubation, which was mediated by better visualization of the glottis. COVID-19 protocols were not associated with success rates.

Legal review of state emergency medical services policies and protocols for naloxone administration

BackgroundGiven the continued rise in opioid-related overdoses, many states have expanded access to the opioid antagonist naloxone. We sought to provide comprehensive data on one such strategy: the authority of providers at different emergency medical services (EMS) licensure levels to administer naloxone. MethodsWe conducted a systematic legal review of state laws and protocols governing the authority of different EMS licensure levels to administer naloxone. We used Westlaw, state government websites and scope of practice protocols. We coded relevant policies regarding which, if any, administration routes and dosages of naloxone are permitted for each licensure level: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and paramedic. ResultsAs of July 2020, all states with relevant laws or protocols authorize paramedics, AEMTs, and EMTs to administer naloxone. Thirty-nine states with an EMR licensure level and statewide protocol authorize naloxone administration by EMRs, up from only two in 2013. Permissible routes of administration have increased across all EMS provider levels, providing advanced life support providers (i.e., paramedics and AEMTs) with expanded discretion; however, authorization for intravenous and intramuscular administration remains relatively uncommon for basic life support (BLS) providers. When specified, maximum doses authorized ranged widely, from 2.0 to 12.0 milligrams. ConclusionsNaloxone administration authority is now widely granted to EMS providers. Most states allow all licensed EMS provider levels to administer naloxone, a substantial increase for EMRs and EMTs since 2013. Paramedics and AEMTs have the greatest authority to select the dosage and route of administration.

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion.

Compliant surfaces beneath a casualty diminish the quality of cardiopulmonary resuscitation (CPR) in clinical environments. To examine this issue in a sporting environment, we assessed chest compression quality and rescuer exertion upon compliant sports safety matting. Twenty-seven advanced life support providers volunteered (13 male/14 female; mass = 79.0 ± 12.5 kg; stature = 1.77 ± 0.09 m). Participants performed 5 × 2 min, randomized bouts of continuous chest compressions on a mannequin, upon five surfaces: solid floor; low-compliance matting; low-compliance matting with a backboard; high-compliance matting; high-compliance matting with a backboard. Measures included chest compression depth and rate, percentage of adequate compressions, and rescuer heart rate and perceived exertion. Chest compression depth and rate were significantly lower upon high-compliance matting relative to other surfaces (p<0.05). The percentage of adequate compressions (depth ≥50 mm) was lowest upon high-compliance matting (40 ± 39%) versus low-compliance matting (60 ± 36%) and low-compliance matting with a backboard (59 ± 39%). Perceived exertion was significantly greater upon high-compliance matting versus floor, low-compliance matting, and low-compliance matting with a backboard (p<0.05). Providers of CPR should be alerted to the detrimental effects of compliant safety matting in a sporting environment and prepare to alter the targeted compression depth and rescuer rotation intervals accordingly.

Inexperienced but Confident: A Survey of Advanced Life Support Providers and Life-saving Interventions in the Israel Defense Forces.

The objective of this study was to assess the current experience of Israel Defense Forces' (IDF) advanced life support (ALS) providers in performing life-saving interventions (LSIs), the rate of doctors and paramedics achieving the Trauma and Combat Medicine Branch benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks. This study was based on an online survey delivered to IDF ALS providers. The survey investigated demographics; experience in performing endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access on human patients; and confidence in performing these LSIs. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation, 3 for cricothyroidotomy, 4 for tube thoracostomy, and 3 for intraosseous access. During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it, 93 (67%) of them were paramedics. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the benchmark for cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics. IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test.

The accuracy of Bloemfontein-based Emergency Medical Services providers in recognising sepsis

Background: Sepsis is considered a severe life-threatening medical emergency and globally carries a high mortality. Research suggests early recognition of sepsis can lead to early initiation of treatment and effective communication of this condition to the receiving facility by pre-hospital emergency care (PEC) providers. Depending on system operations, this has been shown to improve patient outcomes. However, sepsis often presents non-specifically, and in the absence of validated pre-hospital sepsis screening tools, less than half of sepsis patients seen by PEC providers are recognised. This study aimed to determine the accuracy with which Bloemfontein-based PEC providers recognise sepsis in a series of patient vignettes. Methods: A series of seven case vignettes were presented to a convenient sample of advanced life support (ALS) and intermediate life support (ILS) PEC providers. The PEC providers were asked to review each vignette and indicate whether the patient described had sepsis or not. The vignettes consisted of a clinical case description with signs and symptoms of patients presenting with or without sepsis, and images were shown where relevant. Elements of the Robson Prehospital Severe Sepsis Screening (RPSS) tool were used to populate the sepsis vignettes. Results: A total of 27 ILS and ALS PEC providers in the Bloemfontein area partook in the research study. Thus, a total of 189 vignettes were evaluated for sepsis. PEC providers, both ILS and ALS, recognised sepsis with a sensitivity of 69.63% and a specificity of 37.04% (PPV 73.44%, NPV 32.79%), indicating an accuracy of 60.32%. Although all participants mentioned some motivations for their answers, none of the participants gave specific cut-off value ranges at which point they would suspect sepsis. Conclusion: This vignette-based study found that PEC providers can recognise sepsis with modest accuracy, echoing previous work on this topic. In addition, the study provides a platform for similar studies, which, in turn, could aid in the development of a validated, pre-hospital sepsis screening tool.

South African paramedic perspectives on prehospital palliative care

BackgroundPalliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice.MethodsA qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings.ResultsFour categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist.ConclusionChallenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Implementing ERC ALS courses to strengthen emergency care in developing countries

Purpose: In many countries, the European Resuscitation Council (ERC) courses are an important tool for qualifying healthcare professionals to develop guideline-oriented skills in the care of cardiac arrest patients. 1 Fischer H. et al. The effectiveness of ERC advanced life support (ALS) provider courses for the retention of ALS knowledge. Resuscitation. 2012; 83: 227-231 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In many low and middle income (LMIC‘s) countries, high quality training for health professionals with a focus on resuscitation does not exist.

Neck injuries – israel defense forces 20 years' experience

BackgroundNeck injuries are an important cause of combat mortality and morbidity. This study's objective was to examine the characteristics and causes of neck injuries among Israel Defense Forces (IDF) and emphasize the best treatment protocols for the advanced life support providers in the prehospital combat environment. MethodsThe IDF Trauma Registry (IDF-TR) includes prehospital data regarding casualties treated by the IDF's medical forces. This study was a retrospective, observational study that included all casualties who were injured between January 2006 and December 2018. ResultsBetween January 2016 and December 2018, 3294 casualties were recorded. During the study period, 1% (41/3,394) of all injury casualties in the registry were isolated neck injuries compared to 94% (3185/3,394) without neck injury. 42% (14/41) percent of the neck casualties were classified as urgent compared to 26% (830/3185, P = 0.09) in the no neck group. The most frequent type of injury mechanism in the neck casualties was penetrating injury (54% 22/41), mostly due to shrapnel (68% 15/22). 60% of neck injured personnel were injured during the 2nd Lebanon War and Operation Protective Edge in high-intensity conflicts. As for life-saving interventions, advanced airway interventions were performed in 12% of neck injured group (5/41) compared to 3% (104/3185, P = 0.02) in the no neck group. We revealed that cricothyroidotomy was performed in almost 10% (4/41) of neck injured casualties compared to only 1% (19/3185, P<0.0001) in no neck casualties. As for damage control resuscitation, neck injury casualties received higher amounts of Fresh Dried Plasma 7% (3/41) Vs. 1% (32/3185, P = 0.02) and Tranexamic acid 15% (6/41) Vs. 4% (124/3185, P = 0.01) compared to non-neck casualties. ConclusionsMilitary neck injuries are a significant cause of substantial disability and result in incompatibility with combat duties in previously healthy soldiers. Prompt medical care, especially urgent hemodynamic and airway management, is paramount in these injuries. Routine use of designated neck protection might lower the number of neck injuries, mitigate their severity, and even decrease mortality. Level of EvidenceLevel III (Retrospective study with up to two negative criteria)

OXYGEN CONCENTRATION DURING PATIENT TRANSPORTATION IN THE AMBULANCE OF THE EMS

European Resuscitation Council Guidelines for Resuscitation 2010 and Advanced Life Support Provider Course teaches that the open oxygen supply must be removed from the patient during defibrillation to the distance of minimum of 1 meter. Scientific articles describe few incidents of fire during defibrillation in oxygen – enriched atmospheres. It was performed a series of measurement of the oxygen concentration in the ambulance vehicle of 10 cubic meters. The measurements were made in parked vehicle. Patient was seated on the stretchers and oxygen was applied with oxygen mask on high flow (15 l per minute). The oxygen concentration was measured on different places in the ambulance car – the patient’s face, on the chest, on the wall in front of the car, on the wall in the rear and on the celling. We measured temperature, atmospheric pressure and humidity together with oxygen concentration. The result of our study showed that the oxygen concentration has risen from 20.9 % at all locations of the ambulance. In certain locations the concentration has increased at least to 30 %. It has prepared recommendations for defibrillation during oxygen administration according to the literature and our study.

Preparedness of Western Cape Advanced Life Support Providers to Provide Clinical Stabilisation and Intensive Care for Neonatal Interfacility Transfers

Introduction The Western Cape is a province in South Africa – known for the port city of Cape Town – surrounded by the Indian and Atlantic oceans. The transport of high-risk neonates between neonatal intensive care units in the Western Cape of South Africa is performed by advanced life support (ALS) providers. The implications of this practice have not been documented. This study will evaluate the preparedness of ALS providers to undertake intensive care of critically ill neonates during interfacility transfers. Methods Data collection was performed using a questionnaire with a response rate of 81% (n=145). The data analysis encompassed descriptive statistics using tables and figures. Inferential statistics was done using the chi-square test with a significance reported for p&lt;0.05. Reliability was determined using Cronbach's alpha. Results The respondents highlighted that their initial ALS training was not adequate to prepare them for managing critically ill neonates. This view was expressed by the greater majority (n=63, 43.4%) when asked about their combined neonatal theory and practical training notional hours of their curriculum which focussed on managing critically ill neonates. Conclusion There is an urgent need to improve the training programs of ALS providers with regards to neonatology. Numerous factors affecting the preparedness of ALS providers to manage critically ill neonates have been highlighted.

Pre-hospital emergency care providers’ knowledge and use of peak flow meters in the management of acute asthma in Johannesburg, South Africa

Background: Peak flow meters (PFMs) measure the speed of airflow from the lungs during a forced exhalation. Current clinical practice guidelines advocate the use of PFMs in the management of acute asthma. No literature could be found describing local prehospital emergency care providers’ use of PFMs. We aimed to investigate and describe a sample of prehospital emergency care providers’ knowledge and use of PFMs in the management of acute asthma in Johannesburg, South Africa. Method: Fifty respondents (22 basic, 16 intermediate and 12 advanced life support providers) completed a pre-piloted questionnaire consisting of closed questions with pre-set response options focusing on exploring respondents’ knowledge, understanding and use of PFMs. Results: Responses highlighted a general lack of knowledge and understanding of PFMs. None of the basic life support providers, and only 19% of intermediate life support providers, indicated they had received training on the device. PFMs do not appear to be readily available in ambulances, with only 8% of the respondents indicating they had ever used a PFM on a real patient. Conclusion: A lack of training on the device and its apparent unavailability are concerning since the peak expiratory flow rate (PEFR) measurement for asthma cases is considered best practice, and literature shows that emergency medical service (EMS) providers are commonly dispatched to asthmatic cases. Additional training and further research on the value and use of PFMs in local prehospital emergency care contexts is therefore recommended.

Use of social media by Emergency Medical Care students and qualified Advanced Life Support providers in South Africa

Background: Social media has emerged as a powerful tool for the dissemination of information across a wide range of health professions, including emergency medical care. While social media platforms can be very effectively used in support of educational and operational information sharing, the ubiquitous presence of smart devices and social media access in the clinical environment has led to concerns about professionals’ ethical behaviour; in particular, infringements of patients’ privacy rights. Aim: To explore the use of social media by pre-hospital emergency medical care students and qualified Advanced Life Support (ALS) emergency care personnel. Methods: A cross-sectional survey was used, with a custom-developed questionnaire consisting mostly of closed-ended questions, with some confirmatory open-ended questions. The questionnaire was directly administered to emergency medical care students across all four academic years of study at a large urban university in [Redacted]. ALS providers who were members of an email list were also invited to participate in the survey, by completing the same questionnaire online. Data analysis was descriptive in nature. Results: Response rates were 66% for students and 10% for ALS providers. Social media use was reported by almost all participants, with between 78% and 71% indicating that they used social media for professional or learning purposes. The majority of ALS providers (79%) indicated they were aware of organisational policies on social media use, while only 44% of students indicated awareness of this, and most (53%) were unsure. Between 92% and 73% of participants stated that they had seen unethical or unprofessional postings on social media. Most participants (84%) indicated that they were concerned or very concerned about such postings. Conclusion: Social media is a powerful tool with both positive and negative outcomes. While its use can facilitate educational interactions and support clinical operations, there are concerns for patients’ rights in terms of social media use in the clinical environment – particularly the right to privacy. The development of and compliance with organisational or institutional social media policies may help to enhance the positive aspects of social media use, together with appropriate ethical and professional behaviour.

The Israel Defense Forces experience with freeze-dried plasma for the resuscitation of traumatized pediatric patients.

With the growing recognition of the disadvantages of crystalloid- and colloid-based resuscitation and the advantages of using blood products as the preferred resuscitation fluid, the Israel Defense Forces Medical Corps (IDF-MC) adopted plasma as the primary volume resuscitation regimen in 2013. While data are accumulating for prehospital plasma transfusion, little to no data exist regarding using plasma as a prehospital resuscitation fluid for traumatized pediatric patients. All patients treated by the IDF-MC personnel are recorded in the IDF Trauma Registry, a unique prehospital trauma registry. All patients treated by the IDF advanced life support providers with FDP at the point of injury between April 2013 and June 2018 who were younger than 18 years at the time of injury were included. Six hundred seventy-nine children were treated by IDF medical providers, of whom 33 (5%) were identified in the IDF Trauma Registry as having received FDP at the point of injury. Most patients (80%) were treated for penetrating injuries. Most patients received one plasma unit. Fifty-four percent of the patients were also treated by Tranexamic Acid (TXA) and 48% were transfused with crystalloids. In 33% of patients, additional life-saving interventions were performed. While the ideal resuscitation fluid for the pediatric population remains to be determined, it seems reasonable to pursue a similar approach to that of applied that for adults. In the IDF-MC, the resuscitation fluid of choice for trauma patients in hemorrhagic shock is freeze-dried plasma transfused at the point of injury. The current study demonstrates the feasibility of FDP administration in the prehospital scenario for injured children and further supports the growing confidence in the use of FDP for the treatment of pediatric trauma patients. Retrospective descriptive study, level IV.

Critical Medication Shortages: Effective Strategies to Maintain Continuous Medication Availability for Emergency Medical Services

Objective: Critical shortages of generic injectable medications are an ongoing challenge for Emergency Medical Services (EMS) systems. Mitigation strategies have been proposed to address the issue, but a limited amount of data exists quantifying the scope of the problem or describing strategies being used to ensure access to essential medications for prehospital care. In this study, we sought to quantify specific medication shortages and to determine the most frequently employed mitigation strategies to maintain medication availability in a large, regional EMS system. Methods: A survey was distributed to the 30 public advanced life support (ALS) provider agencies in Los Angeles County (LAC) to assess the prevalence of specific medication shortages and types of shortage mitigation strategies implemented. Survey responses were reviewed and presented using descriptive statistics. Results: Survey responses were received from 29 of 30 (97%) provider agencies. All but one of the responding agencies reported being impacted by medication shortages. Strategies to maintain the supply of medications included use of alternative vendors 20/28 (71%), rotating medications from low to high volume units (54%), utilizing expired medication FDA-approved extensions (50%), substituting medications (43%), borrowing medications from the LAC EMS Agency (39%) or other EMS provider agencies (32%), utilizing expired medications with medical director approval (29%), diluting medications to obtain desired concentration (18%), reducing minimum periodic automatic replacement (PAR) levels (14%), and using alternate medication concentrations/formulations (14%). The medications most frequently reported to have shortages included epinephrine (0.1 mg/mL), morphine, dextrose 10%, and normal saline. None of the provider agencies self-reported adverse events due to the shortages. Conclusions: Critical medication shortages remain a problem for many EMS systems. EMS medical directors need to implement multiple mitigation strategies to maintain supply of critical medications for prehospital patient care.

Use of Capnography and Cardiopulmonary Resuscitation Feedback Devices Among Prehospital Advanced Life Support Providers.

Capnography and cardiopulmonary resuscitation (CPR) feedback devices have been shown to improve resuscitation outcomes, with the American Heart Association recommending their use during advanced life support (ALS). Little is known about the availability of these devices, their protocoled use, and the attitudes toward them in the prehospital setting. The objectives of this study were to assess the availability of capnography and CPR feedback devices among prehospital ALS agencies in New York State (NYS), to describe the protocoled use of these devices, and to evaluate the attitudes of providers toward the use of these devices. Prehospital agencies that provide ALS services in NYS were identified using an online registry. Managers in these agencies were contacted by electronic mail and asked to complete a questionnaire regarding their agency's experience with capnography and CPR feedback devices. The questionnaire included questions on the availability of capnography and CPR feedback devices, the existence of clinical protocols for using capnography, and provider opinion on the utility of capnography and CPR feedback devices for improving pediatric resuscitation. Of 710 ALS agencies, 238 (33.5%) completed the survey. Ninety-five percent and 24% of agencies reported having capnography and CPR feedback devices available aboard ambulances, respectively. Ninety-seven percent of agencies reported having capnography clinical protocols for endotracheal intubation, 63% for return of spontaneous circulation, and 54% for guiding CPR. Forty-seven percent agreed that capnography improves outcomes in the resuscitation of pediatric patients, whereas 51% of providers were neutral and 2% disagreed. Capnography is available in most NYS ALS agencies surveyed. Cardiopulmonary resuscitation feedback devices are less common. Protocols for the use of capnography mainly focused on endotracheal intubation and less for the recognition of return of spontaneous circulation and for guiding CPR. Half of the providers surveyed were neutral on whether capnography improves outcomes in the resuscitation of pediatric patients.