Local Emergency Medical Services Research Articles

MP10: Implementation of the PulsePoint mobile device application in Kingston, Ontario, Canada: a pilot study on crowdsourcing bystander CPR for victims of out-of-hospital cardiac arrest

Introduction: Every year 40,000 out-of-hospital cardiac arrests (OHCA) occur in Canada. Only 1 in 10 survive. Early bystander cardiopulmonary resuscitation (CPR) and defibrillation can triple odds of survival. PulsePoint is a mobile device application designed to crowdsource bystander CPR and public access defibrillation for victims of OHCA. Kingston, Ontario was the first Canadian city to launch PulsePoint. The objective of this project was to determine feasibility of PulsePoint implementation in a Canadian setting and to describe system performance. Methods: This was a descriptive observational study. We included all 9-1-1 incidents involving PulsePoint system activation in Kingston, Ontario and all confirmed, public location OHCAs assessed by local emergency medical services (EMS) between March 23, 2015 to January 23, 2017. By using time and location data from PulsePoint system alert notifications, we attempted to link each PulsePoint activation to de-identified ambulance call records. Results: Between March 23, 2015 to January 23, 2017, there were 258 PulsePoint system activations in Kingston and a total of 32 cases of confirmed OHCAs. Only 58 (22%) of PulsePoint activations could be linked to EMS records with high confidence. Of these linked cases, 10 were confirmed OHCAs, reflecting 17% (10/58) of all linked PulsePoint activations and 31% (10/32) of all confirmed OHCAs. Of the remaining 48 cases that triggered PulsePoint activation numerous final paramedic problem codes were assigned of which 14% (8/58) were deemed alcohol intoxication, 10% (6/58) were active seizures, 7% (4/58) were behavioural/psychiatric events, among others. 10 incidents (17%) that triggered PulsePoint activation did not have an assigned final paramedic problem code. Conclusion: Implementation of PulsePoint is feasible in Canadian communities. Improved capabilities for linking with local EMS data will improve data capture, program monitoring capacity, and opportunity for research. The impact of PulsePoint on clinical outcomes remains uncertain and should be determined in future research.

Are You Ready for Emergency Medical Services in Your Oral and Maxillofacial Surgery Office?

Efficient responses to emergencies in the oral and maxillofacial surgery office require preparation, communication, and thorough documentation of the event and response. The concept of team anesthesia is showcased with these efforts. Emergency medical services training and response times vary greatly. The oral and maxillofacial surgery office should be prepared to manage the patient for at least 15minutes after making the call to 911. Patient outcomes are optimized when providers work together to manage and transport the patient. Oral and maxillofacial surgery offices should develop and rehearse emergency plans and coordinate these protocols with local Emergency medical services teams.

Primary Care Office Preparedness for Pediatric Emergencies.

Emergencies do occur in pediatric primary care offices. The American Academy of Pediatrics Committee on Pediatric Emergency Medicine recommends that primary care offices perform a self-assessment of office readiness for emergencies. Primary care offices should develop an emergency response plan to recognize, stabilize, and transfer sick children. They should also ensure their offices have the essential equipment, supplies, and medications readily available in case of emergencies. Primary care offices can prepare and practice for office emergencies through "mock codes" and by maintaining certification in basic and advanced life support courses. Partnership with local emergency medical services and emergency departments will allow seamless transfer of an acutely ill child. Careful planning and preparation will help improve outcomes for emergencies in the primary care setting. [Pediatr Ann. 2018;47(3):e93-e96.].

Triage by Resource Allocation for INpatients: A Novel Disaster Triage Tool for Hospitalized Pediatric Patients.

To develop a disaster triage tool for the evacuation of hospitalized neonatal and pediatric populations. We expanded an existing neonatal disaster triage tool for the evacuation of a children's hospital. We assessed inpatients using bedside visual assessments and chart review to categorize patients transport level based on local emergency medical services protocols and expert opinion. The tool was refined by using multiple Plan Do Study Act cycles. Primary outcome was the number of each level of transport required for hospital evacuation. Secondary outcome was improved efficiency of obtaining information about specific transport needs for evacuation. We evaluated 1382 patients both visually and through electronic chart review over 10 random days. Accordance between visual assessment and electronic chart review reached 96.3%. During a 2 hour statewide disaster drill, no hospital units completed self-assessed transport needs for their patients; a single nurse used Triage by Resource Allocation in INpatients to determine transportation needs in less than 1 hour. (Disaster Med Public Health Preparedness. 2018;12:692-696).

Abstract TP219: Can Pre-hospital Intervention Improve Rural Stroke Care?

Background: In the stroke belt, local rural hospitals have reported 29 - 32% tissue plasminogen activator (tPA) treatment within 60 minutes for ischemic strokes. Since 2008, telemedicine has improved the door to treatment time from 120+ minutes to 70 minutes. A six month pilot program was initiated to determine the feasibility of a pre-hospital intervention to reach the American Stroke Association (ASA) target of 50% treatment within 60 minutes. Nine rural hospital sites were designated as Stroke Ready Hospitals (SRHs). Local emergency medical service (EMS) providers to these sites received additional education to evaluate and transport suspected stroke patients to the SRH in their area. The study also evaluated the early acute hospital patient care for improvements in treatment rates and data reporting at each SRH site. Hypothesis: Within six months, the SRHs will have 30-50% improvement rates in pre-notification by their local EMS providers and these will correspond to decreased triage time. Methods: This study assessed the benefit of early pre-notification by local EMS providers on decreased time to treatment and improved triage time as an improved process of care after implementation in nine SRH designated sites. To measure improvements in time to treatment and treatment rates, we compared time and treatment rates before (baseline was 11 months pre-study) and after study implementation in the same hospital sites. Results: A total of 6,049 transports were made by the EMS services with 117 patients suspected as strokes. A medical public safety answering point (PSAP) communication network provided stability in EMS data acquisition and stroke code notification to SRHs. The study showed improvements in mean triage and transport time vs. baseline (30.7 vs. 74 min, n=48 and n=22, respectively), Door to CT time vs. baseline (21 vs. 26 min, n=151 and =218, respectively) and Door to tPA time vs. baseline (65 vs. 78 min, n=13 and =22, respectively). While the ASA goal of 50% was not met, the % of treated ≤ 60 min increased from baseline at 24.8 to 38%. Pilot study code stroke % pre-notification increased from 38 to 69%. Conclusions: Pre-hospital intervention with local EMS providers improved pre-notification, first medical contact to CT time and the arrival time to treatment.

Abstract TP374: EMS Simulation: Engaging Medics through Stroke Simulation

Background: Advanced Practice Nurses from a community hospital provided education using a realistic stroke simulation scenario to local Emergency Medical Service (EMS) providers. EMS pre-hospital notification is one of the Target: Stroke best practice strategies. Rapid and accurate recognition of stroke in the pre-hospital setting is a key component of ensuring a stroke patient receives efficient and timely care. Purpose: To increase pre-hospital paramedic’s confidence in accurately identifying possible stroke patients using a simulation scenario. Methods: This was a program evaluation project. A stroke simulation scenario developed from an actual case was used to engage the paramedics in a realistic stroke scenario they could encounter in the pre-hospital setting. A standardized patient was used in the simulation scenario. A care confidence scale was used pre-simulation and post-simulation to evaluate each participant’s confidence in identifying stroke signs and symptoms, identifying the patient’s last known normal time, and performing the Cincinnati Prehospital Stroke Scale. An overall simulation evaluation was also completed by participants. Fifteen paramedics participated in the simulations. Results: There was increase in confidence in two out of the three measures. There was an overall 4.54% increase in the confidence of appropriately identifying stroke signs and symptoms. There was an overall 4.76% increase in the confidence in identifying the patient’s last known normal from pre-simulation to post-simulation. There was no difference in the confidence of assessing a patient using the Cincinnati Prehospital Stroke Scale. 15 simulation evaluations were completed. Each participant strongly agreed simulation was a valuable way to practice EMS skills and teamwork. Participants also strongly agreed they would like to see more simulation offerings in the future. Conclusions: Simulation is an effective intervention to increase paramedic’s confidence in identifying stroke signs and symptoms, and the patient’s last known normal time.

Process of Development of a County-wide Crisis Care Plan - Riverside County, California, 2016-7.

Introduction: Disasters with substantial impacts to the health care and public health systems can have multiple reverberating effects, including the need to alter the medical standard of care as well as centrally control scarce medical resources. A current crisis care plan can help to establish an ethical and operational framework for stakeholders before such a disaster takes place. However, there are few examples of such a plan that cover large areas and health jurisdictions. This article describes the process of developing such a “Crisis Care Plan.”Methods: Plan developers from the Riverside County Department of Public Health and Riverside County Emergency Management Department first developed an ethical framework for decision making, followed by the development of a full operational crisis care plan with conditions for activation, life cycle and deactivation. The plan was then reviewed by major county stakeholders, including local emergency medical services, the county medical association and the hospital association, and additional comments incorporated. Before the final plan is implemented it will be submitted for public review and provider training materials will be developed.Results: The development of a prerequisite ethical framework helped to reduce the risk that the operational plan would cause or exacerbate care disparities by informing a blinded, objective process for evaluating resource requests centrally prior to distribution. The ethical framework served to establish the grounding principle of all lives having an equal claim on value. Stakeholders recognized the need for such a Crisis Care Plan and agreed with the underlying ethical principles. Stakeholders also contributed useful recommendations to enable the plan to operate in as successful a manner as possible under the difficult conditions within which it would exist.Discussion: The development of a clear ethical framework and the early identification and involvement of stakeholders can enable even very large health jurisdictions to construct crisis care plans that enable the best care under difficult circumstances, while protecting individual rights and incorporating the concerns of the public and the health care community.

Resuscitation of Out-of-Hospital Cardiac Arrest Victims in Lebanon: The Experience and Views of Prehospital Providers.

Background:The survival rate of out-of-hospital cardiac arrest (OHCA) victims in Lebanon is much lower than those seen internationally. In this study, we examined the attitudes and practices of prehospital providers in resuscitation.Methods:We devised a cross-sectional survey with questions adopted from the literature including a study out of Lebanon. Questionnaires were mailed to 300 volunteers who were recruited from 10 centers of local emergency medical services (EMS).Results:A total of 258 questionnaires were returned (86% response rate). Most participants (>80%) were younger than 30 years, and males (60%). Over half reported witnessing up to 10 arrests per year, with 72.5% reporting prehospital return of spontaneous circulation in <6% of cases. Futile resuscitation was frequently (91%) practiced. Participants believed resuscitation should be withdrawn when prolonged (55.4%) or in the presence of advanced directives (34.1%) or terminal illness (27.5%). Reported resuscitation challenges were related to the reaction of witnesses (70.1%), to delay in calling EMS (84.4%), and to traffic delays (30%). Participants recommended training lay persons in resuscitation (79%), training prehospital providers in advanced airway management (68.2%) and intravenous skills (60.1%), providing medications in ambulances (57.7%), and adjusting traffic laws (52%).Conclusion:Prehospital providers in Lebanon face several challenges in their resuscitation practices. A multi-faceted strategy to improve resuscitation practices is needed in Lebanon. In addition to policy development, structural changes should be put in place for improved outcomes in OHCA victims.

Developing a Mass Casualty Surge Capacity Protocol for Emergency Medical Services to Use for Patient Distribution.

Metropolitan areas must be prepared to manage large numbers of casualties related to a major incident. Most US cities do not have adequate trauma center capacity to manage large-scale mass casualty incidents (MCIs). Creating surge capacity requires the distribution of casualties to hospitals that are not designated as trauma centers. Our objectives were to extrapolate MCI response research into operational objectives for MCI distribution plan development; formulate a patient distribution model based on research, hospital capacities, and resource availability; and design and disseminate a casualty distribution tool for use by emergency medical services (EMS) personnel to distribute patients to the appropriate level of care. Working with hospitals within the region, we refined emergency department surge capacity for MCIs and developed a prepopulated tool for EMS providers to use to distribute higher-acuity casualties to trauma centers and lower-acuity casualties to nontrauma hospitals. A mechanism to remove a hospital from the list of available resources, if it is overwhelmed with patients who self-transport to the location, also was put into place. The number of critically injured survivors from an MCI has proven to be consistent, averaging 7% to 10%. Moving critically injured patients to level 1 trauma centers can result in a 25% reduction in mortality, when compared with care at nontrauma hospitals. US cities face major gaps in the surge capacity needed to manage an MCI. Sixty percent of "walking wounded" casualties self-transport to the closest hospital(s) to the incident. Directing critically ill patients to designated trauma centers has the potential to reduce mortality associated with the event. When applied to MCI responses, damage-control principles reduce resource utilization and optimize surge capacity. A universal system for mass casualty triage was identified and incorporated into the region's EMS. Flagship regional coordinating hospitals were designated to coordinate the logistics of the disaster response of both trauma-designated and undesignated hospitals. Finally, a distribution tool was created to direct the flow of critically injured patients to trauma centers and redirect patients with lesser injuries to centers without trauma designation. The tool was distributed to local EMS personnel and validated in a series of tabletop and functional drills. These efforts demonstrate that a regional response to MCIs can be implemented in metropolitan areas under-resourced for trauma care.

Relation of Medical History to the Pediatric Out-of-Hospital Cardiac Arrest Managed by Emergency Medical Services.

The aim of this study was to examine the medical history of the pediatric out-of-hospital cardiac arrest (OHCA) patients to determine preexisting conditions that may relate to a later OHCA. The study was a retrospective population-based cohort study in Helsinki (population 595,000) served by a single emergency medical service (EMS) system. All OHCA patients aged between 0 and 17 met by the local EMS from 2002 to 2011 were included. Medical records of the Helsinki University Hospital and its clinics were examined to find preexisting medical or surgical conditions. Forty-three patients experienced an EMS-treated OHCA. The annual incidence of an EMS-treated OHCA was 4.4 per 100,000 population younger than the age of 18 years. The mean age of patients was 7.9 years, largest age groups being younger than 1 year (30.2%) and 17 years (23.2%). The leading cause of OHCA was trauma (30.2%) followed by sudden infant death syndrome (18.6%) and cardiac reasons (14.0%). Nine patients (20.9%) survived to hospital, and 5 (11.6%) were discharged alive. Of the 43 patients, 28 (65.1%) had prior medical records in Helsinki University Hospital considering suspected or diagnosed chronic or otherwise significant conditions. The most common conditions were perinatal adaptation abnormalities (20.9%), psychiatric treatment (16.3%), and epilepsy (13.9%). Five patients had previous cardiac conditions. Trauma as a cause of OHCA was frequently represented among patients with prior psychiatric diagnosis or treatment. Among 17-year-old OHCA patients, 5 of 10 had psychiatric records. Majority of the patients had prior medical records. Psychiatric disorders were strongly presented.

Local emergency medical response after a terrorist attack in Norway: a qualitative study

IntroductionOn 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to...

Outcomes of Cardiac Arrest in Residential Care Homes for the Elderly in Hong Kong

ABSTRACTObjective: Studies done in the 1990's suggested nursing home residents with cardiac arrest had minimal chance of survival and resuscitation was not recommended. More recent studies showed opposing results. In Hong Kong, the proportion of elderly living in the residential care homes for the elderly is increasing. There is no study of out-of-hospital cardiac arrest outcomes in this population. This study aimed at evaluating the prognosis of out-of-hospital cardiac arrest occurring in the residential care homes for the elderly. It is hoped that the findings may inform the local emergency medical service concerning the issue of futility of resuscitating the residents with cardiac arrest in the residential care homes. Methods: This study was a retrospective analysis of a database of all patients aged 65 years or above with atraumatic out-of-hospital cardiac arrest and who were attended by the emergency medical service in a 12-month period. Data in the database were prospectively collected by the emergency medical service. The characteristics of patients and cardiac arrests, timeliness of the emergency medical service, and survival were analyzed. Comparison was made between elderly living in and not living in the residential care homes. Predictors of survival were evaluated with logistic regression. Results: 3919 patients aged ≥ 65 years were analyzed. There were 1506 cases of cardiac arrest occurring in the residential care homes for the elderly. Resuscitation was discontinued at the emergency department in over 70% of these cases. The survival to hospital admission rate and the 30-day survival rate were 9.6% and 0.3% respectively. Both were lower than patients not residing in the residential care homes. Younger age, witnessed arrest, bystander defibrillation, and shorter call to ED interval were associated with higher chance of surviving to hospital admission. Conclusion: Elderly suffering from cardiac arrest in residential care homes had a poor chance of survival. Except age, witnessed arrest, bystander defibrillation, and call to ED interval are modifiable predictors of survival. It is inappropriate to declare that resuscitating elderly in residential care homes is futile unless those factors have been fully addressed.

The American College of Surgeons Needs-Based Assessment of Trauma Systems: Estimates for the State of California.

In 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California. Trauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers. A total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results. Estimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool. Economic, level V.

Abstract TP225: Predicting Large Vessel Occlusion in the Real World: Use of the Cincinnati Pre-hosptial Stroke Severity Score in Patients with Suspected Acute Ischemic Stroke

Background: The Colorado Stroke Advisory Board (COSAB) asked three Joint Commission (JC) comprehensive stroke centers (CSC) and one primary stroke center (PSC) to assist with determining the usefulness of the Cincinnati Pre-Hospital Stroke Severity Score (CPSSS) in predicting large vessel occlusion (LVO) in patients with acute stroke symptoms. Purpose: The purpose of the study was to determine the real world applicability of the CPSSS in predicting LVO. Methods: CPSSS and LVO data was collected by stroke coordinators at three CSCs and one PSC for all patients brought to their respective emergency departments via local emergency medical services (EMS) from June 2016 to July 2016 as stroke alerts. The CPSSS was calculated retrospectively using the initial documented neurological exam and LVO was determined by initial computed tomography (CT) imaging results or physician notes in the electronic medical record. Results: Our study included 235 patients that were brought to 4 certified stroke centers in the Denver metropolitan area during a two month period in 2016. Eighty percent of patients (N=187/235) correctly screened negative on the CPSSS. Ten percent (N=23/235) of patients screened positive and were later determined to have LVO based on initial imaging. Four patients went on for endovascular treatment at a CSC that initially screened negative using the CPSSS. Nine percent (N=21/235) of patients screened false-positive for LVO. Top reasons for false positive CPSSS include intracerebral hemorrhage, altered mental status, seizure, and brain stem stroke. Conclusion: CPSSS is a reasonable screening tool to assess for LVO. More study is recommended to determine how to avoid missing LVO in stroke patients with mild symptoms on initial presentation.

Abstract TP383: Use of Plan-Do-Study-Act and Clinical Simulation Methodology to Develop a Mobile Prehospital Telestroke System

Background: When early and accurate identification of stroke occurs in the field by Emergency Medical Service (EMS) providers, the chances of reperfusion increases dramatically. Telestroke has made significant strides over the years and hold promise for potential use in the prehospital setting. However, the introduction of such a novel technology within a healthcare system can be complex. Purpose: To describe the use of the combination of clinical simulation and Plan-Do-Study-Act (PDSA) methodology in the design of a mobile prehospital telestroke system. Methods: A multi-stakeholder team with representation from the Departments of Neurology and Emergency Medicine, Office of Telemedicine, Center of Human Simulation and Patient Safety, local EMS agency and a telemedicine developer collaborated to develop a mobile prehospital telestroke system over a 6 month time period. Modifications to telemedicine equipment, teleconferencing software and protocol were implemented based on the results of serial PDSA cycles and clinical simulation testing. We used data collected via direct observation notes, survey results and informal interviews during serial PDSA cycles and clinical simulation to test changes to improve our mobile prehospital telestroke system. Results: (see image of PDSA chart) Conclusion: The combined clinical simulation and PDSA model led to the identification of technical and operational barriers not considered in the original design of the mobile telemedicine platform and placement. Before implementation and financial investment in a mobile prehospital telestroke program, the use of combined clinical simulation and PDSA methodology can improve the quality and optimize the system use. Further PDSA and simulation cycles are needed to improve the design of our mobile system.

Abstract TP242: A Brief Educational Intervention Improves Paramedic Stroke Knowledge

Introduction: Emergency Medical Services (EMS) are an important component of stroke systems of care. EMS transport has been associated with faster emergency department (ED) stroke evaluations and higher t-PA delivery rates, especially among EMS recognized cases with hospital prenotification. However, delivery of high quality care including hospital prenotification requires that paramedics received regular education and training to improve their ability to identify and treat stroke cases. Methods: We identified opportunities for improvement in EMS care of suspect stroke patients through a review of local EMS stroke-related performance data and focus group discussions with paramedics. We then developed a 20-minute online educational module that reviewed basic stroke pathophysiology, discussed acute stroke therapies, and stressed the importance of performing stroke screening examinations and hospital prenotification for suspect stroke cases. The training was provided to all paramedics in a single agency. Scores on 10 item multiple-choice assessment were compared before and after receipt of the online training module using Fisher Exact tests and Wilcoxon Rank Sum Tests. Results: A total of 40 paramedics underwent the training. Overall quiz scores improved from a median of 9 (interquartile range [IQR] 7 to 9) to 10 (IQR 9 to 10, p=0.0002). Prior to training, only 43% of paramedics correctly identified 4.5 hours as the window for t-PA treatment, with 43% choosing 6 hours. Correct t-PA window identification improved significantly following education (43% to 87.5%, p&lt;0.0001). Improvements were also seen for questions regarding the most common presenting complaints among EMS missed strokes (72.5% to 90%) and the recommended time frame for verbal hospital prenotification (80% to 95%), although these differences were not statistically significant. Conclusions: Overall, paramedics demonstrated good baseline knowledge regarding stroke, however important misconceptions regarding the time frame for t-PA eligibility were common. A brief, on-line educational intervention improved stroke knowledge. Further work is needed to determine the impact of stroke education on real world paramedic performance.

Operation Canine Lifeline: Recommendations for Enhancing Prehospital Care for Government Working Dogs

Operation Canine Lifeline was a tabletop exercise developed by students and faculty of Boston University School of Medicine's Healthcare Emergency Management master's program. The tabletop exercise led to discussion on current protocols for canines working in the field, what occurs if a canine encounters a toxin in the field, and what to do in situations of national security that require working with civilian agencies. This discussion led to the creation of a set of recommendations around providing prehospital veterinary care to government working dogs. The recommendations include a government-run veterinary toxicology hotline for the sole use of the government, issuing handlers deployment kits and preprogrammed smartphones that contain information on the care practices for dogs, and an increased effort for civilian integration, through local emergency medical services, in the emergency care of government canines. (Disaster Med Public Health Preparedness. 2017;11:15-20).

D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study

Introduction: Prehospital first responders historically have used an IV bolus of 50 mL of 50% dextrose solution (D50) for the treatment of hypoglycemia in the field. A local Emergency Medical Services (EMS) system recently approved a hypoglycemia treatment protocol of IV 10% dextrose solution (D10) due to occasional shortages and higher cost of D50. We use the experience of this EMS system to report the feasibility, safety, and efficacy of this approach. Methods: Over the course of 104 weeks, paramedics treated 1,323 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 1,157 (87.5%) patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 871 (75%) of these 1,157. We captured the 871 patients’ capillary glucose response to initial infusion of 100 mL of D10 and fit a linear regression line between elapsed time and difference between initial and repeat glucose values. We also explored the need for repeat glucose infusions as well as feasibility, and safety. Results: The study cohort included 469 men and 402 women with a median age of 66. The median initial field blood glucose was 37 mg/dL, while the subsequent blood glucose had a median of 91 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100mL D10 infusion. Of 871 patients, 200 (23.0%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia and seven (0.8%) patients required a third dose. There were no reported deaths or other adverse events related to D10 administration for hypoglycemia. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation. Conclusions: The results of one local EMS system over a 104-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative to D50. D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. Additionally, our data suggest that there may be little or no short-term decrease in blood glucose results after D10 administration.

Age-specific prognostication after out-of-hospital cardiac arrest - The ethical dilemma between 'life-sustaining treatment' and 'the right to die' in the elderly.

While prognostic values on survival after out-of-hospital cardiac arrest have been well investigated, less attention has been paid to their age-specific relevance. Therefore, we aimed to identify suitable age-specific early prognostication in elderly patients suffering out-of-hospital cardiac arrest in order to reduce the burden of unnecessary treatment and harm. In a prospective population-based observational trial on individuals suffering out-of-hospital cardiac arrest, a total of 2223 patients receiving resuscitation attempts by the local emergency medical service in Vienna, Austria, were enrolled. Patients were stratified according to age as follows: young and middle-aged individuals (<65 years), young old individuals (65-74 years), old individuals (75-84 years) and very old individuals (>85 years). There was an increasing rate of 30-day mortality (+21.8%, p < 0.001) and unfavourable neurological outcome (+18.8%, p < 0.001) with increasing age among age groups. Established predictive variables lost their prognostic potential with increasing age, even after adjusting for potential confounders. Independently, an initially shockable electrocardiogram proved to be directly associated with survival, with an adjusted hazard ratio (HR) of 2.04 (95% confidence interval (CI) 1.89-2.38, p = 0.003) for >85-year-olds. Frailty was directly associated with mortality (HR 1.22, 95% CI 1.01-1.51, p = 0.049), showing a 30-day survival of 5.6% and a favourable neurological outcome of 1.1% among elderly individuals. An initially shockable electrocardiogram proved to be a suitable tool for risk assessment and decision making in order to predict a successful outcome in elderly victims of out-of-hospital cardiac arrest. However, the outcomes of elderly patients seemed to be exceptionally poor in frail individuals and need to be considered in order to reduce unnecessary treatment decisions.

Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making.

Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.