Prehospital Research Articles

Prehospital seizure management protocols need standardized guidelines. A descriptive study from Norway.

BackgroundPatients with convulsive seizures constitute a significant group in acute neurology. No common European clinical practice guidelines on prehospital seizure management exists, and today most patients are brought to hospital for seizure treatment, with great variation in which prehospital treatment is provided. Only 33% of status epilepticus patients receive a benzodiazepine as first anti-seizure medication (ASM). The aim of this study is to assess the prehospital seizure control protocols in the Emergency Medical Services (EMS) in Norway, and compare these with current evidence for acute management. MethodWe performed a descriptive analysis of the 18 regional EMS protocols in Norway and compared the findings with recent evidence on prehospital treatment. We analysed recommended drug and dosage, route of medication administration, number of additional rescue doses permitted, requirements for registration of type of seizures and seizure duration. ResultsThe protocols vary in terms of preferred medication, administration method, dosage and recommendations regarding first- and second-line therapies. 33 % of protocols explicitly define status epilepticus according to contemporary guidelines, and 16.7 % have an operational definition of when to administer benzodiazepines. All protocols showed variations in dosing and administration instructions and only 28% had a clearly stated first line treatment. ConclusionThere are disparities in the prehospital seizure management protocols within the Norwegian healthcare system, a system comparable to other European countries. To improve seizure management there is a need for standardised guidelines for prehospital treatment.

A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting

ObjectiveAcute behavioral disturbance is characterized by altered mental status and psychomotor agitation. Pharmacological sedation may be required, risking potential respiratory compromise. We compared the need for emergent airway support following administration of midazolam or ketamine to treat acute behavioral disturbance in the prehospital setting. MethodsIn this retrospective cohort study of patients with acute behavioral disturbance in an urban Emergency Medical Service (EMS) system between 2017-2021, we compared the likelihood of prehospital advanced airway management following administration of midazolam or ketamine. Advanced airway management was defined as prehospital endotracheal intubation or supraglottic airway insertion. ResultsAmong 376 eligible patients, the median age was 35; and 78% were male. The most common etiologies of acute behavioral disturbance were substance use (51%), trauma (18%), and presumed postictal agitation (11%). In all, 162 patients (43%) initially received midazolam and 214 (57%) ketamine. The frequency of advanced airway management was similar between these respective groups (12% [n=19] vs 11% [n=24], difference 0.5%, 95% CI -6.0% to 7.0%). Adjusted for potential confounders, the odds of receiving advanced airway management did not differ between midazolam and ketamine (aOR 1.02, 95% CI 0.44 to 2.38), nor were differences observed in emergency department intubation rates (14% in midazolam recipients, 11% for ketamine) or overall mortality (2% in midazolam recipients, 1% for ketamine). ConclusionIn this cohort study of patients with acute behavioral disturbance, emergent airway support nor other outcomes differed following prehospital treatment with midazolam or ketamine.

Pre-Hospital Care and Effect of Cardiopulmonary Resuscitation (CPR) On Survival Rate of Out-Of-Hospital Cardiac Arrest (OHCA) Victims, Telangana (India)

Introduction: OHCA is among the leading causes of mortality worldwide. India lacks a comprehensive database of cardiac arrests and an efficient emergency medical system. The treatment of cardiac disease has improved, yet the outcomes of OHCA remain poor. Methods: This is an observational 1-year prospective, single center, cohort study conducted on cohorts of OHCA victims. “Utstein Resuscitation Template” was followed for gathering the information starting location of arrest till the final resuscitation outcome. The information on OHCA patient treatment and current knowledge gaps is the aim of this study. Results: The study was conducted in the Warangal region of Telangana, India. The research comprised 1167 OHCA patients with a suspected cardiac etiology who were taken to the Mahatma Gandhi Memorial Hospital between June 1, 2022, and June 30, 2023. CPR attempts were recorded. Findings suggested if an individual was aware of the risk factors for CVD, they were more likely to report symptoms before OHCA. Conclusion: OHCA survival rate can be increased if the chain of survival is maintained by offering awareness and CPR training programs to the general public or bystanders, as well as efficient emergency ambulance services with qualified emergency medical staff.

Pcv-aCO2/Ca-cvO2 Combined with Optic Nerve Sheath Diameter in Predicting Elevated Intracranial Pressure of Patients with Traumatic Brain Injury in Prehospital Setting.

To investigate a correlation between the central venous minus arterial CO2 pressure to arterial minus central venous O2 content ratio (Pcv-aCO2/Ca-cvO2) combined with optic nerve sheath diameter (ONSD) in predicting prehospital elevated intracranial pressure (ICP) in traumatic brain injury (TBI) patients. This was a prospective observational study of all adult TBI patients from the surgical intensive care unit who underwent invasive ICP monitoring between January 2023 and December 2023. Using a Delica MVU-6300 machine with 14-5 MHz linear probe to measure ONSD. We drew blood samples for arterial and central venous blood gases to measure and calculate the following indicators such as Pcv-aCO2, Ca-cvO2, and Pcv-aCO2/Ca-cvO2 ratio. ONSD and Pcv-aCO2/Ca-cvO2 were recorded during the first 3 days after admission. Simultaneous ICP values were gained from the invasive monitoring. Associations between ONSD, Pcv-aCO2/Ca-cvO2 and simultaneous ICP were explored by Spearman correlation analysis. We constructed an ROC curve to identify the ONSD and Pcv-aCO2/Ca-cvO2 cutoff for the evaluation of elevated ICP. We included 54 patients aged mean 57.13 (standard deviation 4.02) years and 24 (44%) were male. A significant correlation was observed between ONSD and ICP (r = 0.74, P < 0.01). The AUC was 0.861 (95% CI: 0.727-0.951), with a best cutoff value of 5.62 mm. Using a cutoff of 5.62mm, ONSD had a sensitivity of 92.8%, specificity of 80.4%. The Pcv-aCO2/Ca-cvO2 ratio also significantly correlated with ICP (r = 0.70, P < 0.01). The AUC was 0.791 (95% CI: 0.673-0.889). The optimal Pcv-aCO2/Ca-cvO2 value for predicting elevated ICP was 1.98mmHg/mL. Using a cutoff of 1.98mmHg/mL, Pcv-aCO2/Ca-cvO2 had a sensitivity of 87.3%, specificity of 77.2%. The AUC for ONSD combined with Pcv-aCO2/Ca-cvO2 was 0.952 (95% CI: 0.869-0.971), which had a sensitivity of 95.1%, specificity of 93.9%. Pcv-aCO2/Ca-cvO2 combined with ONSD performed best in predicting elevated intracranial pressure of patients with TBI in a prehospital setting. Our findings provide a crucial tool to improve earlier management of these patients in prehospital care, where the availability and utilization of invasive monitoring is limited. It could lead to significant changes in how TBI patients are monitored and treated before reaching a hospital.

39 Assessing the Impact of Language Barriers in Prehospital Care: Interpretation Use and Pain Management in PLOE Patients

39 Assessing the Impact of Language Barriers in Prehospital Care: Interpretation Use and Pain Management in PLOE Patients

When to choose intraosseous access in prehospital trauma care: A registry-based study from the Israel Defense Forces

PurposePrompt vascular access is crucial for resuscitating bleeding trauma casualties in prehospital settings but achieving peripheral intravenous (PIV) access can be challenging during hemorrhagic shock due to peripheral vessel collapse. Early intraosseous (IO) device use is suggested as an alternative. This study examines injury characteristics and factors linked to IO access requirements. MethodsA registry-based cohort study from the Israel Defense Forces Trauma Registry (2010 – 2023) included trauma casualties receiving PIV or IO access prehospital. Casualties who had at least one documented PIV or IO access attempt were included, while those without vascular access were excluded. Casualties requiring both PIV and IO were classified in the IO group. Univariable logistic regression assessed the factors associated with IO access. Results were reported as odds ratios (OR) with 95% confidence intervals (CI), and significant difference was set at p < 0.05. ResultsOf 3462 casualties (86.3% male, the median age: 22 years), 3287 (94.9%) received PIV access and 175 (5.1%) had IO access attempts. In the IO group, 30.3% received freeze-dried plasma and 23.4% received low titer group O whole blood, significantly higher than that in the PIV group. Prehospital mortality was 35.0% in the IO group. Univariable analysis showed significant associations with IO access for increased PIV attempts (OR = 1.69; 95% CI: 1.34 – 2.13) and signs of profound shock (OR = 11.0; 95% CI: 5.5 – 23.3). ConclusionProfound shock signs are strongly linked to the need for IO access in prehospital settings with each successive PIV attempt increasing the likelihood of requiring IO conversion. IO access often accompanies low titer group O whole blood or freeze-dried plasma administration and higher prehospital mortality, indicating its use in emergent resuscitation situations. Early IO consideration is advised for trauma casualties with profound shock.

Evaluating the current breadth of randomized control trials on cardiac arrest: A scoping review.

Despite the significant disease burden due to cardiac arrest, there is a relative paucity of randomized controlled trials (RCTs) to inform definitive management. We aimed to evaluate the current scope of cardiac arrest RCTs published between 2015 and 2022. We conducted a search in October 2023 of MEDLINE, Embase, and Web of Science for cardiac arrest RCTs. We included trials published between 2015 and 2022 enrolling human subjects suffering from non-traumatic cardiac arrest. Descriptive statistics were reported and the Mann Kendall test was used to evaluate for temporal trends in the number of trials published annually. We identified 1764 unique publications, 87 RCTs were included after title/abstract and full-text review. We found no significant increase in trials published annually (eight in 2015 and 16 in 2022, p=1.0). Geographic analysis of study centers found 31 countries represented; Denmark (n=13, 15%) and the United States (n=9, 10%) conducted the majority of trials. Nearly all trials included adults (n=84, 97%) and few included children (n=9, 10%). The majority of trials focused on out-of-hospital cardiac arrest (n=62, 71%). Thirty-eight (44%) trials used an intervention characterized as a process improvement; 28 (32%) interventions were characterized as a drug and 20 (23%) as a device. Interventions were implemented with similar frequency in the prehospital (33%) and intensive care unit (38%) setting, as well as similarly between the intra-arrest (53%) and post-arrest (46%) periods. Twenty (27%) trials selected a primary outcome of survival at ≥ 28 days. Publication of cardiac arrest RCTs remained constant between 2015 and 2022. We identified significant gaps including a lack of trials examining in-hospital cardiac arrest and pediatric patients.

Elevating Prehospital Traumatic Brain Injury Care: A Comparative Analysis of Civilian and Military Air Transport Guidelines

ObjectiveTraumatic brain injuries (TBIs) are a leading cause of death and disability worldwide. Establishing TBI guidelines is crucial for prehospital management. Civilian medical practices are often influenced by military trauma guidelines. This study provides a comparative analysis of prehospital TBI management by a civilian air medical evacuation service using civilian guidelines and military clinical practice guidelines from the Joint Trauma System of the Department of Defense. MethodsA retrospective review of 100 deidentified patient transport logs from a prominent civilian air medical service was conducted. The logs were compared with the service's patient care guidelines and the 2023 Joint Trauma System Clinical Practice Guidelines. Data were analyzed for adherence to 14 metrics. ResultsPatients showed improvement in preflight and postflight Glasgow Coma Scale scores and were managed according to recommendations on head elevation, oxygenation, blood pressure, and temperature by both organizations. Discrepancies between guidelines included differences in the management of ventilator settings, blood pressure, oxygenation, temperature, serum glucose, intracranial hypertension, suspected brain herniation, serum sodium levels, and seizure prophylaxis. ConclusionComparing civilian and military guidelines highlights areas for potential improvements in TBI management, such as integrating advanced monitoring and the implementation of (i-STAT, Abbott Laboratories, Chicago, IL) testing in air transport to enhance patient care and outcomes.

Expert-Guided Large Language Models for Clinical Decision Support in Precision Oncology.

Rapidly expanding medical literature challenges oncologists seeking targeted cancer therapies. General-purpose large language models (LLMs) lack domain-specific knowledge, limiting their clinical utility. This study introduces the LLM system Medical Evidence Retrieval and Data Integration for Tailored Healthcare (MEREDITH), designed to support treatment recommendations in precision oncology. Built on Google's Gemini Pro LLM, MEREDITH uses retrieval-augmented generation and chain of thought. We evaluated MEREDITH on 10 publicly available fictional oncology cases with iterative feedback from a molecular tumor board (MTB) at a major German cancer center. Initially limited to PubMed-indexed literature (draft system), MEREDITH was enhanced to incorporate clinical studies on drug response within the specific tumor type, trial databases, drug approval status, and oncologic guidelines. The MTB provided a benchmark with manually curated treatment recommendations and assessed the clinical relevance of LLM-generated options (qualitative assessment). We measured semantic cosine similarity between LLM suggestions and clinician responses (quantitative assessment). MEREDITH identified a broader range of treatment options (median 4) compared with MTB experts (median 2). These options included therapies on the basis of preclinical data and combination treatments, expanding the treatment possibilities for consideration by the MTB. This broader approach was achieved by incorporating a curated medical data set that contextualized molecular targetability. Mirroring the approach MTB experts use to evaluate MTB cases improved the LLM's ability to generate relevant suggestions. This is supported by high concordance between LLM suggestions and expert recommendations (94.7% for the enhanced system) and a significant increase in semantic similarity from the draft to the enhanced system (from 0.71 to 0.76, P = .01). Expert feedback and domain-specific data augment LLM performance. Future research should investigate responsible LLM integration into real-world clinical workflows.

49 Exploring Current Emergency Medical Services Approaches to Manage Agitated Older Adult Patients: A Comprehensive Analysis of Statewide Protocols

49 Exploring Current Emergency Medical Services Approaches to Manage Agitated Older Adult Patients: A Comprehensive Analysis of Statewide Protocols

Is There an Association Between Emergency Department Overcrowding and Emergency Medical Services Redirection?

BackgroundEmergency Medical Systems (EMS) has developed policies to manage patient flow. In New York City, these practices include both Diversion and Redirection. Currently, gaps in the literature exist regarding the correlation between emergency department (ED) operational metrics and EMS redirection triggers. ObjectivesThis study analyzes the relationship between ED operational metrics and EMS redirection practices. MethodsThis single-center retrospective cohort analysis analyzed EMS patient transports from April 2021 to May 2022. Data on EMS redirection was obtained from FDNY notifications, and ED operational metrics were collected from the hospital's data repository. Metrics included ED length of stay, admission rates, and times from door-to-triage and door-to-room. ResultsDuring the study, 93,783 patient visits were recorded, with 22,734 (24%) transported by EMS. Redirection was activated on 250 days, predominantly on Mondays. A slight association was found between overall ED volume and redirection occurrences (OR 1.02), but no significant correlations were identified with other specific ED operational metrics. ConclusionsOur findings indicate no substantial correlation between these practices and ED operational metrics. These results suggest a need for a paradigm shift toward more objective, data-driven measures to inform EMS redirection, ensuring decisions are grounded in the ED's actual operational capacity.

505 Disparity in Guideline Adherence for Prehospital Care According to Patient Age in Emergency Medical Service Transport for Severe Trauma

505 Disparity in Guideline Adherence for Prehospital Care According to Patient Age in Emergency Medical Service Transport for Severe Trauma

93EMF The Association of Emergency Medical Services Agency- and Clinician-Level Factors With Adherence to Evidence-Based Guidelines for the Prehospital Management of Traumatic Brain Injury

93EMF The Association of Emergency Medical Services Agency- and Clinician-Level Factors With Adherence to Evidence-Based Guidelines for the Prehospital Management of Traumatic Brain Injury

185 An Emergency Medical Services to Emergency Department Checklist for Handoff of Cardiac Arrest: A Modified Delphi Approach

185 An Emergency Medical Services to Emergency Department Checklist for Handoff of Cardiac Arrest: A Modified Delphi Approach

Impact of an emergency department closure on out-of-hospital cardiac arrest survival and emergency medical service system in Ulsan, South Korea

IntroductionThis study evaluated the impact of an emergency department (ED) closure on out-of-hospital cardiac arrest survival outcomes and the emergency medical service system in Ulsan, South Korea. MethodsWe conducted a retrospective observational cohort study from March 2017 to February 2021 and compared survival to hospital discharge and favorable neurological outcomes. We investigated transport time intervals (TTIs) in the total study population and subgroup covered by the closed ED. The analysis methods included propensity score matching (PSM), inverse propensity weighting (IPW), and logistic regression analysis. ResultsThe study included 692 and 920 patients before and after ED closure groups, respectively. After adjusting for covariates, the adjusted odds ratios and 95 % confidence interval for survival discharge and favorable neurological outcomes were 1.040 (0.749–1.444, p = 0.814) and 2.845 (1.563–5.177, p = 0.001), respectively. PSM showed values of 1.015 (0.727–1.416, p = 0.932) for discharge survival and 1.777 (1.074–2.941, p = 0.025) for neurological outcomes. IPW showed values of 0.980 (0.762–1.261, p = 0.875) for discharge survival and 1.782 (1.196–2.656, p = 0.005) for neurological outcomes. The TTI increased from 5.8 ± 5.0 to 6.7 ± 5.5 min (p < 0.001) in the total population and from 9.2 ± 7.9 to 16.2 ± 6.5 min (p < 0.001) in the subgroup. ConclusionsThe findings suggest that while the overall system may remain stable, subgroups could be disproportionately affected by an ED closure, underscoring the importance of the ongoing monitoring of survival outcomes and transport times.

Determining What Proportion of Helicopter Emergency Medical Services–Transported Patients Are Urban Versus Rurally Based: A Retrospective 36-Year Geospatial Analysis of a Critical Care Helicopter Emergency Medical Services Organization's Patient Transports

ObjectiveThere is an increased mortality rate of patients residing in rural compared with urban communities. Helicopter emergency medical services (HEMS) decrease both the time to hospital arrival and trauma mortality in patients originating from rural areas. An unreported number of urban residents are served by HEMS. Our objective was to quantify the fraction of urban residents who live in the adjoining city of a HEMS base and are transferred by helicopter while they are in rural areas. MethodsThis was a retrospective analysis of HEMS charts between 1985 and 2022. Records were assessed for patients’ city and postal code. A secondary database was searched to assess mission location. ResultsThirty-five thousand nine hundred seventy-one cases were analyzed; 3,871 (10.76%) cases involved patients residing within the urban area of an open HEMS base, and 32,100 (89.24%) did not. This contrasts with 2.04% of all missions conducted in urban areas. Cases flown with patients from outside of the 3 provinces were as follows: British Columbia (1,233/21,941; 5.3% of Alberta cases), international (988/35,971; 2.7% of total cases), Ontario (177/4,691; 3.6% of Manitoba cases), and other provinces combined (158/3,5971; 0.4% of total cases). ConclusionWe highlight the impact of HEMS, where it serves both rural residents and all people who work in, travel through, visit, or recreate across the areas that our HEMS supports.

162 Is There an Association Between Emergency Department Crowding and Emergency Medical Services Redirection?

162 Is There an Association Between Emergency Department Crowding and Emergency Medical Services Redirection?

A Model for Developing Emergency Medical Services Instructor Knowledge

A Model for Developing Emergency Medical Services Instructor Knowledge

Air Rescue Missions for Suicide: A Retrospective Analysis of a 12-Year Period From a German Rescue Helicopter Base

ObjectiveTypical reasons for calling the rescue helicopter are medical emergencies, such as heart disease, trauma, and neurologic emergencies. However, there are also a small number of patients with attempted or completed suicide. The aim of this article was a general analysis and evaluation of the specific circumstances of emergencies related to suicide or attempted suicide in the prehospital environment involving the rescue helicopter (helicopter emergency medical services) Christoph 38 of the DRF Stiftung Luftrettung gAG based in Dresden, Germany. MethodsThe data of all emergency interventions performed by the helicopter emergency medical services in Dresden, Germany, between January 1, 2008, and December 31, 2020, were analyzed by examining the DIVI rescue protocols and electronic data (MEDAT and HEMSDER (Convexis, Germany)) with regard to suicide-related variables. The time, methods and information about the reason, sociodemographic data, and results of medical treatment were recorded and retrospectively analyzed. ResultsThere were a total of 17,754 emergencies during the study period. Of these, 277 cases (1.56%) were due to suicide. The average time for the emergency services to arrive at the scene of the emergency was 11.14 minutes. There were 52 patients with a completed suicide, 183 with a suicide attempt, and 42 patients with a suicide threat. Eleven were pronounced dead before or at the time of arrival of the emergency doctor. Of the 241 patients who were still alive when the emergency physician arrived, 101 were endotracheally intubated and mechanically ventilated, and 25 patients received cardiopulmonary resuscitation. In 19.57% of the patients, health problems were noted as the primary reason for attempted/completed suicide. In a further 12.68%, partnership problems or the loss of a partner were cited. The most common method used was an overdose (49.39%) followed by leaping from a great height (20%) and hanging (15.51%). Stab wounds and gunshot wounds were observed in 24% of the cases. The overall mortality rate was 18.77%. The method used, sex, and a suicide note were identified as possible influencing factors for the fatal outcome of a suicide. ConclusionThe number of suicide victims is low compared with the total number of 17,754 deployments. However, the mortality rate for these missions is quite high at 18%. Although some factors and circumstances could be identified in this study, many backgrounds and explanations are still missing. Therefore, this study shows a general need for more research in regard to better prevention as well as improved education and training of emergency response teams.

388EMF Emergency Medical Services Risk Factors for Stroke in Type A Aortic Dissection

388EMF Emergency Medical Services Risk Factors for Stroke in Type A Aortic Dissection