Emergency Medical System Personnel Research Articles

Factors associated with prolonged on-scene time in ambulance transportation among patients with minor diseases or injuries in Japan: a population-based observational study

BackgroundProlonged prehospital time is a major global problem in the emergency medical system (EMS). Although factors related to prolonged on-scene times (OSTs) have been reported in patients with trauma and critical medical conditions, those in patients with minor diseases or injuries remain unclear. We examined factors associated with prolonged OSTs in patients with minor diseases or injuries.MethodsThis population-based observational study used the ambulance transportation and request call record databases of the Higashihiroshima Fire Department, Japan, between January 1, 2016, and December 31, 2022. The participants were patients with minor diseases or injuries during the study period. We performed a multivariable logistic regression analysis with robust error variance to examine the association between patient age, sex, severity, accident type, date and time of ambulance call, and the coronavirus disease 2019 (COVID-19) pandemic with prolonged OSTs. Prolonged OST was defined as ≥ 30 min from the ambulance arrival at the scene to departure.ResultsOf the 60,309 people transported by ambulance during the study period, 20,069 with minor diseases or injuries were included in the analysis. A total of 1,241 patients (6.2%) experienced prolonged OSTs. Fire accidents (adjusted odds ratio [aOR]: 7.77, 95% confidence interval [CI]: 3.82–15.79), natural disasters (aOR: 28.52, 95% CI: 2.09–389.76), motor vehicle accidents (aOR: 1.63, 95% CI: 1.30–2.06), assaults (aOR: 2.91, 95% CI: 1.86–4.53), self-injuries (aOR: 5.60, 95% CI: 3.37–9.32), number of hospital inquiries ≥ 4 (aOR: 77.34, 95% CI: 53.55–111.69), and the COVID-19 pandemic (aOR: 2.01, 95% CI: 1.62–2.50) were associated with prolonged OSTs. Moreover, older and female patients had prolonged OSTs (aOR: 1.18, 95% CI: 1.01–1.36 and aOR: 1.12, 95% CI: 1.08–1.18, respectively).ConclusionsOlder age, female sex, fire accidents, natural disasters, motor vehicle accidents, assaults, self-injuries, number of hospital inquiries ≥ 4, and the COVID-19 pandemic influenced prolonged OSTs among patients with minor diseases or injuries. To improve community EMS, we should reconsider how to intervene with potentially modifiable factors, such as EMS personnel performance, the impact of the presence of allied services, hospital patient acceptance systems, and cooperation between general emergency and psychiatric hospitals.

Triage Accuracy Rates Using the New MCI Triage System of Regione Piemonte: What’s New?

Introduction:An adequate Mass-Casualty Incident (MCI) triage system is essential to provide the best possible health care to the greatest number of affected people and to optimize the management of the available resources in the context of a MCI.Method:In February 2022, Disaster Medicine Service 118 of Regione Piemonte adopted a new 5-color code-MCI triage system and Emergency Medical System (EMS) personnel was trained through a 3-hours-distance learning course. 515 medical doctors and nurses attended the course and completed the final test (triaging of 50 computer-based simulated patients/cases). Their performance was compared to intended triage designations. We collected the data and conducted a descriptive observational study.Results:A total of 25.750 evaluations were carried out: 1.030 white cases, 6.180 green cases, 6.180 yellow cases, 9.270 red cases and 3,090 black cases. Overall triage accuracy was 89,63%. The overall errors were 2.671 (10.37%). Concerning the type of error, there were 1.415 cases under-triaged (5.5%) and 1.256 cases over- triaged (4.88%). Based on color-code, the highest rate of error was in green cases (3.48%), while black patients showed the highest accuracy rate (0.32%). Based on type, the most frequent error was under-triage of red patients, while the less frequent was over-triage of black patients.Conclusion:The results of the final test performed by EMS personnel showed the accuracy rates of triage using new 5-color code-MCI triage systems of Regione Piemonte to be in range with data reported in the literature. A study limitation is the fact that the data analyzed are derived from online testing performed in no-time limited and no-stress conditions. Another potential limitation is the distance learning which doesn’t allow a discussion with the teacher or a request for clarification. For this reason, we would plan a future study defining the efficacy of the didactic methodology in comparison with face-to-face courses.

Impact of defibrillation with automated external defibrillator by bystander before defibrillation by emergency medical system personnel on neurological outcome of out-of-hospital cardiac arrest with non-cardiac etiology

Aim of the studyAlthough defibrillation using automated external defibrillator (AED) by bystander prior to emergency medical system (EMS) arrival was associated with favorable outcomes in out-of-hospital cardiac arrest (OHCA) of cardiac cause, whether it improves outcomes of OHCA due to non-cardiac cause is not clear. We aimed to investigate the impact of defibrillation with AED by bystander before defibrillation by EMS personnel on the outcomes of OHCA of presumed non-cardiac cause. MethodsThis was a retrospective cohort study using the All-Japan Utstein registry (reference period: 2013 to 2017). We included adult patients with OHCA of presumed non-cardiac cause, who had initial shockable rhythm, and who received witnessed arrest bystander cardiopulmonary resuscitation (CPR). Exposure variable was defibrillation with AED by bystander in comparison with initial defibrillation by EMS. Logistic regression analyses were conducted to assess the association between bystander AED shock and favorable neurological outcome (Cerebral Performance Category scale 1 or 2) at one month. ResultsAmong the 1,053 patients included for analysis, 57 (5.4%) received bystander AED shock. There was no statistically significant difference in the rate of favorable neurological outcome at one month between groups [9 (15.8%) vs 109 (10.9%), p = 0.26]. Logistic regression analysis adjusted for characteristics, intervention, and time course of CPR showed no association between bystander AED shock and favorable neurological outcome [OR (95% CI): 1.63 (0.70–3.77), p = 0.25]. ConclusionIn this study, defibrillation with AED by bystander before defibrillation by EMS personnel was not associated with the favorable outcomes of OHCA of presumed non-cardiac cause.

Differences in Perceived Occupational Stress by Demographic Characteristics, of European Emergency Medical Services Personnel during the COVID-19 Virus Pandemic-An International Study.

Objectives: The outbreak of the COVID-19 pandemic has brought commercial, social, and economic consequences in every country that has experienced substantial SARS-CoV-2 infection rates. The complete change in the environment that took place due to the outbreak of the pandemic can lead to stressful situations, especially among healthcare personnel. Material and methods: The research were conducted during the COVID-19 pandemic between the 27 March 2020 and the 20 April 2020. The research included 1984 employees of emergency medical systems in seven European countries. An internet-based questionnaire format was adopted for the study (ΩMc-Donald > 0.7). Results: The highest level of stress was experienced by personnel in the United Kingdom M = 4.03, and the lowest by Norwegian employees M = 2.89. High levels of stress were also experienced by nurses from Spain and Poland. Women actively working in the healthcare system during the pandemic experienced higher stress levels than men. Conclusions: Women working in European emergency medical systems are more vulnerable to work-related stress, while carrying out emergency medical procedures during the pandemic. Differences in the level of stress experienced while carrying out duties in pre-hospital conditions were only found among Spanish emergency medical system personnel.

Cognitive survey of telephone cardiopulmonary resuscitation among emergency personnel

Objectives To investigate the cognition of dispatcher-initiated telephone cardiopulmonary resuscitation (TCPR) among emergency medical system(EMS) personnel and compare the cognition of TCPR among EMS personnel in different economic status, and to understand the current situation of TCPR cognition of EMS personnel in China. Methods This study is a multicenter cross-sectional survey. The method of multi-level convenient sampling was adopted, and the test reliability and split half reliability of the questionnaire was tested. Questionnaire survey and data collection were conducted from December 2018 to June 2019. The ethical approval number is M2018264. SPSS 20.0 was used for analysis. χ2 test was used to analyze the differences between groups. Results A total of 1 191 electronic questionnaires were collected. Of them, 80.94% respondents knew TCPR, 97.82% respondents thought that TCPR should be implemented in cardiac arrest, 36.62% respondents thought that bystander cardiopulmonary resuscitation quality monitoring was needed in TCPR, and TCPR training courses were set up in the emergency department which recruited 25.83% respondents. Emergency personnel in developed areas had a better understanding of the criteria for judging patients' breathlessness (11.69% vs 7.89%, P=0.048), of TCPR need ncluding guidance of chest compression (92.45% vs 87.49%, P=0.012) and of bystander cardiopulmonary resuscitation (BCPR) quality monitoring including the frequency of artificial respiration (84.42% vs 74.87%, P=0.029) than those in underdeveloped areas, but there was no significant difference in other indicators (P>0.05). Conclusions TCPR knowledge of EMS personnel in China is unsatisfactory. Further training is needed to improve their understanding of the criteria for judging cardiac arrest in out-of-hospital cardiac arrest patients via telephone, TCPR content and bystander cardiopulmonary resuscitation quality monitoring. There is difference in TCPR knowledge between the EMS personnel in developed and undeveloped areas in China. Key words: Emergency medical services; Telephone guidance; Cardiopulmonary resuscitation; Bystander; Out-of-hospital cardiac arrest; Cognition; Economic status; Cross-sectional survey

Community-Based Pre-Hospital Electrocardiogram Transmission Program for Reducing Systemic Time Delay in Acute ST-Segment Elevation Myocardial Infarction

Background and ObjectivesIn acute ST-segment elevation myocardial infarction (STEMI), on-site transmission of electrocardiogram (ECG) has been shown to reduce systemic time delay to reperfusion and improve outcomes. However, it has not been adopted in community-based emergency transport system in Korea.MethodsBusan Regional Cardio-cerebrovascular Center and Busan Metropolitan City Fire and Safety Headquarters (BMFSH) jointly developed and conducted a pre-hospital ECG transmission program. Seven tertiary hospitals and 22 safety stations of BMFSH participated. Systemic time delay to reperfusion of STEMI patients in the program was compared with that of 95 patients transported by 119 emergency medical system (EMS) before the program was implemented.ResultsDuring the study period, 289 ECG transmissions were made by 119 EMS personnel, executed within 5 minutes in 88.1% of cases. Of these, 42 ECGs were interpreted as ST-segment elevation. Final diagnosis of STEMI was made in 20 patients who underwent primary percutaneous coronary intervention. With the program, systemic time delay to reperfusion was significantly reduced (median [interquartile range; IQR], 76.0 [62.2–98.7] vs. 90.0 [75.0–112.0], p<0.01). Significant reduction of door-to-balloon time was also observed (median [IQR], 45.0 [34.0–69.5] vs. 58.0 [51.0–68.0], p=0.03). The proportion of patients with systemic time delay shorter than 90 minutes rose (51.6% vs. 75.0%, p=0.08) with pre-hospital ECG transmission.ConclusionsWe developed and implemented a community-based pre-hospital ECG transmission program for expeditious triage of STEMI patients. Significant reductions of systemic time delay and door-to-balloon time were observed. The expanded use of pre-hospital ECG transmission should be encouraged to realize the full potential of this program.

Opioid Overdose Outbreak - West Virginia, August 2016.

On August 15, 2016, the Mayor's Office of Drug Control Policy in Huntington, West Virginia, notified the Cabell-Huntington Health Department (CHHD) of multiple calls regarding opioid overdose received by the emergency medical system (EMS) during 3 p.m.-8 p.m. that day. A public health investigation and response conducted by the West Virginia Bureau for Public Health (BPH) and CHHD identified 20 opioid overdose cases within a 53-hour period in Cabell County; all cases included emergency department (ED) encounters. EMS personnel, other first responders, and ED providers administered the opioid antidote naloxone to 16 (80%) patients, six of whom were administered multiple doses, suggesting exposure to a highly potent opioid. No patients received referral for recovery support services. In addition to the public health investigation, a public safety investigation was conducted; comprehensive opioid toxicology testing of clinical specimens identified the synthetic opioid fentanyl* and novel fentanyl analogs, including carfentanil,† which had been used by patients who overdosed in Huntington. Results of these two investigations highlight the importance of collaboration between public health and public safety agencies to provide in-depth surveillance data from opioid overdose outbreaks that involve high-potency fentanyl analogs. These data facilitated a public health response through increased awareness of powerful opioid substances requiring multiple naloxone doses for reversal, and improved patient linkage to recovery support services and a harm reduction program from the ED after opioid overdose.

381 Predictors of Good Outcomes After Pediatric Cardiac Arrest

To determine which aspects of out-of-hospital care impact outcomes after pediatric cardiac arrest. Pediatric cardiac arrest remains a major public health problem, with over 5000 cases per year in the United States alone. The chain of survival focuses on bystander intervention, high-quality CPR, and aggressive post-resuscitation care. In this study, the authors examine 5 years of consecutive data from their county emergency medical system (EMS), to identify predictors of good outcome, including return of spontaneous circulation (ROSC), survival to hospital admission (HA) and survival to hospital discharge (HD). Logistic regression models were performed using JMP 12.0 for Mac. From January 1, 2012 to December 31, 2016, a total of 133 children suffered cardiac arrest. The median age was 12 months, with an IQR of 3 to 24 months, and a range of 0 to 10 years. In 95% of cases, the arrest was determined by a bystander, rather than EMS. The cause of arrest was drowning (41%); respiratory (44%); trauma (8%); seizure (3%) cardiac/medical (2%); and choking (2%). 58% were ventilated with either a non-rebreather mask (NRM) or a bag valve mask (BVM). 40% of children were intubated, either by ETT (predominantly), or a supraglottic airway (I-gel). There was ROSC in 29% of cases overall, with 26% making it to hospital admission, and 20% making it alive out of the hospital. The interquartile range (IQR) for time to arrival was 16-47 min, with a range of 0-490 minutes. A shorter time from arrest to EMS arrival was significantly associated with ROSC, HA, and HD (all P<0.0001). In 95% of cases, the arrest was determined by a bystander, rather than EMS. Chest compressions were performed by a bystander in 59% of cases, and by EMS personnel in 41% of cases. CPR by EMS personnel was significantly associated with ROSC, HA, and HD (all P<0.0001). There was some form of treatment before EMS arrival in 54% of cases. Any treatment before EMS arrival was significantly associated with ROSC, HA, and HD (all P<0.0001). An AED was placed 50% of the time, and 13% of the arrests were witnessed. Neither of these factors was statistically significant with regard to any of the outcomes. Shorter EMS arrival; times from time of arrest, performance of CPR prior to EMS arrival, and any treatment before EMS arrival resulted in significantly higher rates of return of spontaneous circulation, survival to hospital admission, and survival beyond hospital discharge.

Abstract W P275: Minimizing Door to Needle Times for Administration of rt-PA in Acute Ischemic Stroke

Background: A substantial opportunity exists to improve timeliness of IV rt-PA bolus administration within desired 60 minutes of Emergency Department triage presentation time in Ischemic Stroke patients. In 2010 only 21.4% (3/14) of eligible patients presenting to our 250 bed non-academic nonprofit community hospital received the IV rtPA bolus within time this time target. Purpose: The purpose of this study was to demonstrate that implementation of best practices shown to minimize door-to-needle (DTN) time for administration of rt-PA in eligible Ischemic Stroke patients will result in significant improvement in percentage of patients receiving rtPA within 60 minutes of Emergency Department arrival. Methods: A review of published data showing successful improvement methods to minimize DTN times was compiled to develop clinical practice guidelines which were implemented to increase staff commitment to implementation of best practices. Each thrombolytic stroke case was reviewed by members of Stroke Steering Committee throughout 2011, 2012 and 2013 to identify root causes contributing to delays, which allowed rapid performance data feedback to team members. Results: The baseline DTN time for 2010 of 89.4 minutes, decreased to 68.8 minutes in 2011, and achieved a mean of 61 minutes in 2012 with 17/26 patients, or 65% of patients receiving IV rtPA within 60 minutes of arrival time. During Q1 and Q2 2013, 100% of the six eligible ischemic stroke patients presenting at this hospital received IV rtPA in less that 60 minutes. Conclusions: Significant improvement in compliance for under 60 minutes DTN time for IV rtPA administration can be achieved with implementation of published best practices which encompasses collaboration with emergency medical system personnel to ensure rapid assessment for stroke signs and symptoms and pre-notification of our hospital to allow early activation of Laboratory and Imaging Department staff to ready for potential thrombolytic stroke patients, utilization of “thrombolytic stroke box” to facilitate prompt preparation of IV rtPA weight-based dose, and leveraging newly implemented electronic medical record to minimize documentation time.

Strategies to reduce time delays in patients with acute coronary heart disease treated with primary PCI. The STOP WATCH study

Background: Though rapid coronary reperfusion reduces mortality in patients with ST-elevation myocardial infarction (STEMI), reperfusion therapy continues to be administered to late. A six-year action research study was conducted to reduce healthcare delay through multiple intervention activities. Objectives: We hypothesized that identification of delays followed by targeted reorganisation of logistics and personal feedback on delays to staff involved in STEMI care would lead to a reduction in healthcare delay time. The aim with the study was to identify and evaluate system delay times in a STEMI network. Design and setting: The study was carried out between 2006 and 2011 in one University hospital in Sweden and designed as a multistage action research project. Three study phases were used; exploration (pre-intervention phase), tailored intervention, and evaluation (post-intervention phase). Methods and interventions: Areas of delays were identified through participant observations and collaborative discussions with leading physicians in the network and representatives from the Emergency Medical System (EMS). Awareness of the delay factor and time is muscle was performed through repetitive meetings and continuous feedback on delays. Interventions done were 1) prioritised ECG recording by EMS personnel, 2) central evaluation of ECG in all patients with suspected STEMI, and 3) start of PCI procedure when two out of three PCI team members were on site. Multiple point measurements was done in patients admitted with STEMI for primary Percutaneous Coronary Intervention (PCI) before (N=67) and after (N=89) the intervention. Results: Time from ECG to decision for primary PCI was reduced by 6 minutes, p=0.004 and from ECG to cath-lab arrival by 11 minutes, p=0.02. Time from First Medical Contact (FMC) to a patent artery and from FMC-to-cath-lab arrival decreased by 6 and 12 minutes respectively (ns). Conclusion: Action research can be used as an effective tool to identify delays in a STEMI network and contribute to awareness of delay factors and facilitate reorganisation of logistics. Together with continuous feedback on delays that stimulates reflective clinical behaviour system delay times could be reduced significantly.

Promoting early diagnosis of hemodynamic instability during simulated hemorrhage with the use of a real-time decision-assist algorithm

This study aimed to test the hypothesis that the addition of a real-time decision-assist machine learning algorithm by emergency medical system personnel could shorten the time needed to identify an unstable patient during a hemorrhage profile as compared with vital sign information alone. Fifty emergency medical team-paramedics from a large, urban fire department participated as subjects. Subjects viewed a monitor screen on two occasions as follows: (1) display of standard vital signs alone and (2) with the addition of an index (Compensatory Reserve Index) associated with estimated central blood volume status. The subjects were asked to push a computer key at any point in the sequence they believed the patient had become unstable based on information provided by the monitor screen. The average difference in time to identify hemodynamic instability between experimental and control groups was assessed by paired, two-tailed t test and reported with 95% confidence intervals (95% CI). The mean (SD) amount of time required to identify an unstable patient was 18.3 (4.1) minutes (95% CI, 17.2-19.4 minutes) without the algorithm and 10.7 (4.2) minutes (95% CI, 9.5-11.9 minutes) with the algorithm (p < 0.001). In a simulated patient encounter involving uncontrolled hemorrhage, the use of a monitor that estimates central blood volume loss was associated with early identification of impending hemodynamic instability. Physiologic monitors capable of early identification and estimation of the physiologic capacity to compensate for blood loss during hemorrhage may enable optimal guidance for hypotensive resuscitation. They may also help identify casualties benefitting from forward administration of plasma, antifibrinolytics and procoagulants in a remote damage-control resuscitation model.

Organization of a United States County System for Comprehensive Acute Stroke Care

Organized systems of care have the potential to improve acute stroke care delivery. The current report describes the experience of implementing a county-wide system of spoke-and-hub stroke neurology receiving centers (SNRC) that incorporated several comprehensive stroke center recommendations. Observational study of patients with suspected stroke of <5 hours duration transported by emergency medical system personnel to an SNRC during the first year of this system. A total of 1360 patients with suspected stroke were evaluated at 9 hub SNRC, of which 553 (40.7%) had a discharge diagnosis of ischemic stroke. Of these 553, intravenous tissue-type plasminogen activator was administered to 110 patients (19.9% of ischemic strokes). Care at the 6 neurointerventional-ready SNRC was a major focus in which 25.1% (99/395) of the patients with ischemic stroke received acute intravenous or intra-arterial reperfusion therapy, and in which provision of such therapies was less common with milder stroke, older age, and Hispanic origin. The door-to-needle time for intravenous tissue-type plasminogen activator met the <60-minute target in only 25% of patients and was 37% longer (P=0.0001) when SNRC were neurointerventional-ready. A stroke system that incorporates features of comprehensive stroke centers can be effectively implemented with substantial rates of acute reperfusion therapy administration. Experiences potentially useful to broader implementation of comprehensive stroke centers are considered.

Time needed for a regional emergency medical system to implement resuscitation Guidelines 2005—The Netherlands experience

Introduction In December 2005, updated resuscitation Guidelines (G) were introduced worldwide and will be revised again in 2010. This study sought to elucidate how long it takes to implement new guidelines. Methods This was a prospective observational study. From July 2005 to January 2008, we included all patients with an out-of-hospital cardiac arrest of suspected cardiac cause. We analyzed Emergency Medical System (EMS) Guideline usage via defibrillator recordings of the continuous ECG and impedance signals. We excluded patients with missing or otherwise unusable ECGs. All shocks and CPR cycles were individually classified. The same Guideline needed to be applied for at least 75% of all shocks and CPR cycles. If no shocks had been given, continuous ECGs were classified by its CPR status only. Continuous ECGs were classified as G1992, G2000 or G2005. If at least 75% of the shocks were given according to G2000 and at least 75% of the CPR was according to G2005, the Guideline protocol was classified as intermediate. All analyses that did not fulfil any Guideline criteria were classified as indeterminate. Results Of 1672 analyzable resuscitations, 31 (2%) used G1992, 826 (49%) G2000, 608 (36%) G2005, and 125 (7%) intermediate Guidelines. The Guideline protocol could not be identified for the remaining 81 (5%) patients. It took 17 months (from publication) until EMS personnel applied GL2005 in over 80% of cases. Conclusion Our experience shows it took one-and-a-half years to effectively implement new resuscitation Guidelines. We believe improvements in implementation can shorten this to six months.

Development of a Metropolitan Matrix of Primary Stroke Centers

In 1998, 2947 patients in metropolitan Phoenix were hospitalized for acute cerebral infarction. Only 2 of the 26 regional hospitals satisfied criteria for primary stroke center (PSC) designation. Fewer than 1% of patients with ischemic stroke received tissue plasminogen activator for thrombolysis. We sought to develop and evaluate the effectiveness of a metropolitan prehospital emergency medical system for effectively identifying and transporting patients with acute stroke to a matrix of predesignated PSCs and increasing to 20% the proportion of all such patients receiving tissue plasminogen activator. The American Stroke Association Phoenix Operation Stroke partnered with the Arizona Emergency Medical Systems in 1998 to 1999 to list goals and objectives, identify key stakeholders, and develop committees to address community education, emergency medical system training, and PSC designation. Over 8 years, emergency medical system personnel were trained to identify and transport patients with acute stroke to PSCs, 8 hospitals met PSC criteria, the metropolitan matrix of PSCs became operational (in 2003), and 18% of patients with acute ischemic stroke received thrombolysis. It is feasible to develop and operationalize a successful metropolitan-wide matrix of PSCs to accommodate emergency medical system-identified and transported patients with acute stroke in a 9000-square-mile region with a population of 3.5 million people.

Continuous passive oxygen insufflation results in a similar outcome to positive pressure ventilation in a swine model of out-of-hospital ventricular fibrillation

The deleterious effects of positive pressure ventilation may be prevented by substituting passive oxygen insufflation during advanced cardiac life support (ACLS) cardiopulmonary resuscitation (CPR). We compared 24-h neurologically normal survival among three different ventilation scenarios for ACLS in a realistic swine model of out-of-hospital prolonged ventricular fibrillation (VF) cardiac arrest. No bystander CPR was provided during the first 8 min of untreated VF before the simulated arrival of an emergency medical system (EMS). Thirty-six swine were randomly assigned to one of three experimental groups. Group I (standard ventilation) was mechanically ventilated at 10 respirations per minute (RPM) at a tidal volume (TV) of 10 ml/kg with 100% oxygen. Group II (hyperventilation) was ventilated at 35 RPM at a TV of 20 ml/kg with 100% oxygen. In Group III (insufflation) animals, a nasal cannula was placed in the oropharynx to administer oxygen continuously at 10 l/min. There was no significant difference in the 24h neurologically normal survival among groups (standard: 2/12, hyperventilation: 2/12, insufflation: 4/12; p=.53). Passive insufflation may be an acceptable alternative to the currently recommended positive pressure ventilation during resuscitation efforts for out-of-hospital VF cardiac arrest. Potential advantages of this technique include: (1) easier to teach, (2) easier to administer, (3) prevention of the adverse effects of positive pressure ventilation and (4) allows EMS personnel to concentrate upon other critically important duties.

Incidence andSignificance of Upper Body Cyanosis in Nontraumatic Cardiac Arrest

Objective. Upper body cyanosis is a physical finding sometimes noted at the time of cardiac resuscitation. We attempted to determine the incidence andsignificance of upper body cyanosis in cases of nontraumatic cardiac arrest. Methods. This was a retrospective case-control study. We reviewed all nontraumatic cardiac arrests evaluated by King County, Washington emergency medical system (EMS) personnel during 2000–2004 andidentified patients with upper body or nipple-line cyanosis. Those patients who were autopsied comprised the cases for our study. Cases were age andsex matched with controls who also had cardiac arrest with an autopsy but no mention of cyanosis. Results. EMS personnel treated 3,526 patients, age 18 andolder, for nontraumatic out-of-hospital cardiac arrest. One hundred eight (3.1%) had specific mention of upper chest or nipple-line cyanosis, of whom 38 had autopsy. Among the 38 autopsy cases, 6 were died of hemopericardium compared to none in age-and sex-matched controls. Conclusion. Cardiac arrest with upper chest or nipple-line cyanosis had a higher incidence of hemopericardium or dissecting thoracic aortic aneurysm than patients without mention of cyanosis.

Isolated transient loss of consciousness is an indicator of significant injury.

To determine if isolated transient loss of consciousness is an indicator of significant injury. University-based level I trauma center. Phase 1 retrospective case series of all patients with trauma admitted directly from the emergency department to the operating room or an intensive care unit who had transient loss of consciousness as their only trauma triage criterion. Phase 2 prospective case series of all trauma patients transported by emergency medical system personnel with transient loss of consciousness as their only trauma triage criterion. Emergency operation and intensive care unit admission. Phase 1: From January 1, 1992, to March 31, 1995, we admitted 10255 patients with trauma. Three hundred seven (3%) met the enrollment criteria and were admitted to the operating room (n = 168) or intensive care unit (n = 139). Of these, 58 (18.9%) were taken to the operating room emergently to manage life-threatening injuries: 11 (4%) had craniotomies and 47 (15%) had non-neurosurgical operations. Phase 2: From July 1 to December 31, 1996, 2770 trauma patients were transported to our facility; 135 (4.9%) met the enrollment criteria. Forty-one (30.4%) of these required admission, and 6 (4.4%) were taken emergently to the operating room from the emergency department (1 [1%] for a craniotomy, 3 [2.2%] for intra-abdominal bleeding, and 2 [1.5%] for other procedures). Two (1.5%) of the 135 patients died. Patients with isolated transient loss of consciousness are at significant risk of critical surgical and neurosurgical injuries. These patients should be triaged to trauma centers or hospitals with adequate imaging, surgical, and neurosurgical resources.

Logistics in acute stroke management.

Results from the two National Institute of Neurological Disorders and Stroke (NINDS) studies indicate that administration of alteplase (recombinant tissue-type plasminogen activator; rt-PA) within 3 hours of symptom onset to appropriately selected patients with acute ischaemic stroke improves patient outcome. Several factors that delay time to treatment in patients with stroke have been identified, the most important of which is probably the failure of the patient (or family member) to recognise the signs and symptoms of stroke. Once the need for help is recognised, the initial point of access to emergency medical systems should be the local emergency number (e.g. 911 in the US) rather than the family physician. Patients with suspected stroke should be evaluated and treated by a physician as soon as possible, but this will depend to some extent on the level of expertise of the attending physicians and on available resources. The NINDS-sponsored National Symposium on the Rapid Identification and Treatment of Acute Stroke has recommended ideal time goals for all hospitals that treat patients with acute stroke. These goals include 25 minutes from arrival at an emergency department to computerised tomography scan, and 60 minutes from arrival to treatment. Recommendations for enhancing the logistics of treatment for patients with stroke may involve the following: improved education programmes for at-risk populations and their families and emergency medical system personnel, identification of acute stroke as a level one emergency similar to acute myocardial infarction or trauma, and modelling of treatment algorithms accordingly, acceptance of, and commitment to, the time guidelines recommended by the National Symposium on the Rapid Identification and Treatment of Acute Stroke. Effective and safe use of alteplase will also depend on rapid access to the highest level of neurological and radiological expertise. This may require major changes in the educational curriculum of emergency department residency and ongoing continuing education programmes, and/or more intensive radiological training for neurologists and neurologists-in-training.