Prehospital Patients Research Articles

Effect of COVID19 on prehospital pronouncements and ED visits for stroke and myocardial infarction.

ObjectiveThe Novel Coronavirus19 (COVID19) arrived in northern New Jersey (NJ) in early March 2020, peaked at the beginning of April, and then declined. Starting in March, some patients who called 911 and required advanced life support (ALS) may have decompensated more rapidly than would have been expected, possibly because of concomitant COVID19 infection and/or delays in seeking medical care because of fear of exposure to the virus, and social isolation. In this study, our goal was to determine if there was an increase in prehospital ALS pronouncements and a decrease in ED visits for potentially serious conditions such as MI and stroke during the peak of the COVID-19 pandemic in northern NJ.Methods study designRetrospective cohort of prehospital patients pronounced dead by paramedics and patients with MI and stroke in the EDs of receiving hospitals of these paramedics. Study Setting and Population: Ten ground ALS units in northern NJ and nine receiving hospital EDs. Each ALS unit is staffed by two NJ-certified mobile intensive care paramedics and respond with a paramedic flycar in a two-tiered dispatch system. Data Analysis: We identified prehospital pronouncements using the EMSCharts electronic record (Zoll Medical, Chelmsford, Massachusetts). We tabulated the number of pronouncements by week from January 1 to June 30 in 2019 and 2020. We tabulated the combined total number of pronouncements and ED visits by month along with visits for MI and stroke and calculated the changes during the same timeframe. We used Chi-square to test for statistical significance for the monthly changes from 2019 to 2020.ResultsFor January through June in 2019 and 2020, there were 12,210 and 13,200 ALS dispatches, and 366 and 555 prehospital pronouncements, respectively. In 2020, pronouncements rose from a weekly baseline of 13 in early March, reached a peak of 45 at the beginning of April, then returned to the baseline level by the end of May. April 2020, the month with the most pronouncements, had 183% more pronouncements than April 2019 but total ED visits and visits for MI and stroke were 49%, 46% and 42% less, respectively (p < 0.0001 for each of these changes).ConclusionFollowing the arrival of the COVID-19 pandemic in northern NJ, we found pre-hospital ALS death pronouncements increased and ED visits for MI and stroke decreased. Although we have speculated about the reasons for these findings, further studies are needed to determine what the actual causes were.

Apnoeic oxygenation for emergency anaesthesia of pre-hospital trauma patients

BackgroundEfficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia.MethodsA prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups.ResultsOf 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation).Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 < =90%) for patients with initial SpO2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation.ConclusionApnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.

Physician-led prehospital management is associated with reduced mortality in severe blunt trauma patients: a retrospective analysis of the Japanese nationwide trauma registry

BackgroundAlthough the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.MethodsThis retrospective cohort study analyzed the data of Japan’s nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.ResultsA total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78–1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.ConclusionsPhysician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.

Probability assessment of intracerebral hemorrhage in prehospital emergency patients

BackgroundRouting of patients with intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) to the most appropriate hospital is challenging for emergency medical services particularly when specific treatment options are only provided by specialized hospitals and determination of the exact diagnosis is difficult. We aimed to develop a prehospital score – called prehospital-intracerebral hemorrhage score (ph-ICH score) – to assist in discriminating between both conditions.MethodsThe ph-ICH score was developed with data from patients treated aboard a mobile stroke unit in Berlin, Germany, between 2011 and 2013 (derivation cohort) and in 2018 (validation cohort). Diagnosis of ICH or AIS was established using clinical data and neuroradiological cerebral imaging. Diagnostic accuracy was measured with significance testing, Cohen’s d and receiver-operating-characteristics.ResultsWe analyzed 416 patients (32 ICH, 224 AIS, 41 transient ischemic attack, 119 stroke mimic) in the derivation cohort and 285 patients (33 ICH and 252 AIS) in the validation cohort. Systolic blood pressure, level of consciousness and severity of neurological deficits (i. e. certain items of the National Institutes of Health Stroke Scale) were used to calculate the ph-ICH score that showed higher values in the ICH compared to the AIS group (derivation cohort: 1.8 ± 1.2 vs. 1.0 ± 0.9 points; validation cohort: 1.8 ± 0.9 vs. 0.8 ± 0.7 points; d = 0.9 and 1.4, both p < 0.01). Receiver-operating-characteristics showed fair and good accuracy with an area under the curve of 0.71 for the derivation and 0.81 for the validation cohort.ConclusionsThe ph-ICH score can assist medical personnel in the field to assess the likelihood of ICH and AIS in emergency patients.

Effect of prehospital intraosseous combined with in-hospital intravenous access in out-of-hospital cardiac arrest

Objective: Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to compare the effectiveness of prehospital intraosseous infusion (IO) combined with in-hospital intravenous (IV) (pre-IO + in-IV) access versus the simple IV (pre-IV + in-IV) access in adult OHCA patients who do not achieve prehospital return of spontaneous circulation (ROSC). Methods: This retrospective observational study included adults with OHCA of presumed cardiac etiology between October 1, 2017-October 1, 2020 at an academic emergency department in China. All of the OHCA patients included within the study had Emergency Medical Services cardiopulmonary resuscitation and received prehospital epinephrine administration, but did not achieve prehospital ROSC. The study population were classified as either pre-IO + in-IV or IV (pre-IV + in-IV) based on their epinephrine administration route. The prehospital epinephrine routes were the first and only attempted route. The primary outcome investigated was sustained ROSC following arrival at the emergency department. The secondary outcome considered was the time from dispatch to the first epinephrine dose. Results: Of 193 included adult OHCA subjects who did not have prehospital ROSC, 128 received IV access only. The 65 pre-IO + in-IV-treated patients received epinephrine faster compared to IV-treated patients in terms of the median time from dispatch to the first injection of epinephrine (14.5 vs. 16.0 min, P = 0.001). In the pre-IO + in-IV group, 34 of 65 patients (52.3%) achieved sustained ROSC compared with 65 of 128 (50.8%) patients in the IV group (χ2 = 0.031, P = 0.841). There was no significant difference in sustained ROSC (adjusted OR1.049, 95% CI: 0.425-2.591, P = 0.918) between the two groups. Conclusion: A similar sustained ROSC rate was achieved for both the pre-IO + in-IV access group and the simple IV access group. Our results suggested that an IV route should be established quickly for prehospital IO-treated OHCA patients who do not achieve prehospital ROSC.

Effect of age on the interaction between heart rate and mortality in prehospital trauma care

Objectives: The association between tachycardia and age in prehospital trauma mortality has not been thoroughly studied. The purpose of this study was to evaluate the interaction effects of age between prehospital tachycardia and mortality in adult trauma patients. Methods: Adult trauma patients during 2012, 2013, and 2015 who were treated and transported by emergency medical services (EMS) were analyzed. Main exposure was tachycardia (&gt;90 beat/min) measured at the scene. The primary outcome was mortality, the secondary outcome was worsened disability. Multivariable logistic regression with interaction models between tachycardia and age was used to calculate the adjusted odds ratio (AOR) with 95% confidence intervals after adjusting for confounders. Results: A total of 35,542 patients were analyzed. Tachycardia had a significant association with mortality and worsened disability: 1.41 (1.28–1.54) for mortality and 1.25 (1.15–1.36) for worsened disability. In the interaction analysis, the AOR for mortality by tachycardia in age over 84 years was insignificant: 1.2 (1.11–1.3) for 15–64 years, 1.4 (1.29–1.52) for 65–84 years, 1.14 (0.92–1.42) for age over 85 years, respectively (p &lt; 0.01 for interactions). Conclusion: Tachycardia had a significant association with mortality and worsened disability in prehospital trauma patients and age over 85 years old had a significantly different interaction effect. Prehospital trauma care protocol should include recognizing severe cases based on the patient’s heart rate and age. It would be helpful in the decision-making at the scene such as trauma center transfer and advanced treatment.

Medical Capacity Building in War-Torn Nations: Kurdistan, Iraq as a Model

Medical capacity building is an arduous endeavor, particularly in war-torn, politically unstable regions. Regardless, medical capacity can be built through perseverance and careful deliberation. We present our 28-year experience of capacity building in Kurdistan, Iraq. Methods: We annotated our experience with surgical capacity building in Kurdistan, Iraq since 1992. Annually, 1-2 trips were undertaken. Prior to each trip, colleagues with desired surgical expertise were invited. A symposium was also organized at the end of each trip. Results: Over 80% of cholecystectomies are now done laparoscopically, compared to none prior to our arrival. Other advanced laparoscopic operations include adrenalectomy, splenectomy, nephrectomy, Nissen fundoplication, and gynecologic procedures. More than 3,000 renal transplantations have been performed since 2004. Complex neurosurgical procedures such as craniotomy, spinal decompression/stabilization, and complex HPB and surgical oncology operations such as Whipple, liver resections, gastrectomies, and pelvic exenterations are now routinely performed. Care of trauma patients includes prehospital patient care, mass casualty triage, and management of patients exposed to chemical weapons. Other accomplishments include helping local surgeons to gain membership to the American College of Surgeons, supporting the establishment of a medical journal, and assisting with the creation of a new medical school. Conclusion: With good intentions and perseverance, it is possible to empower war-torn nations to build advanced surgical programs. What we have achieved in Kurdistan over two decades is testament to effective and meaningful collaboration with major stakeholders.

The prehospital patient pathway and experience of care with acute heart failure: a comparison of two health care systems.

AimsThis study aimed to analyse community management of patients during the symptomatic period prior to admission with acute decompensated heart failure (ADHF).Methods and resultsWe conducted a prospective, two‐centre, two‐country observational study evaluating care pathways and patient experience in patients admitted to hospital with ADHF. Quantitative and qualitative data were gathered from patients, carers, and general practitioners (GPs). From the Irish centre, 114 patients enrolled, and from the English centre, 50 patients. Symptom duration longer than 72 h prior to hospitalization was noted among 70.4% (76) Irish and 80% (40) English patients, with no significant difference between those with a new diagnosis of HF [de novo HF (dnHF)] and those with known HF [established HF (eHF)] in either cohort. For the majority, dyspnoea was the dominant symptom; however, 63.3% (31) of these Irish patients and 47.2% (17) of these English patients did not recognize this as an HF symptom, with no significant difference between dnHF and eHF patients. Of the 46.5% (53) of Irish and 38% (19) of English patients reviewed exclusively by GPs before hospitalization, numbers prescribed diuretics were low (11.3%, six; and 15.8%, three, respectively); eHF patients were no more likely to receive diuretics than dnHF patients. Barriers to care highlighted by GPs included inadequate access to basic diagnostics, specialist support and up‐to‐date patient information, and lack of GP comfort in managing HF.ConclusionThe aforementioned findings, consistent across both health care jurisdictions, show a clear potential to intervene earlier and more effectively in ADHF or to prevent the need for hospitalization.

Эффективность различных способов временной остановки наружного кровотечения на догоспитальном этапе оказания помощи

Objective. To estimate the efficiency of different methods of temporary external hemostasis at the pre-hospital stage of emergency medical care, taking into account the localization of injuries. Material and Methods. The cases (n=86) of prehospital emergency medical care for patients with external bleeding were studied. The data on the victims (age, gender), clinical status (type and location of injuries, type of bleeding), the volume of emergency care, the hemostasis methods used to control bleeding, their efficiency, side effects, difficulty of use were collected, and the duration of the pre-hospital stage were also taken into account. Results. The study found out that the most common cause of external bleeding is domestic accident (45.35%) of cases. By the nature of tissue damage, the cut wounds prevailed. Multiple or combined injuries occurred in 13.95% of cases. A tourniquet was the main method of hemostasis. Contact hemostatic agents were used only in 2.32% of cases at the pre-hospital stage. In some cases, when attempting to control the external bleeding, several hemostatic agents were sequentially used due to the lack of their efficacy. In 17.4% of cases, the victims with multiple or combined injuries received intravenous administrationof the systemichemostatic agents. In the complex of anti-shock measures in patients with severe trauma 77.91% of the prehospital patients underwent infusion therapy. Isotonic crystalloid solutions were used. A reliable increase in the duration of the prehospital stage of victims who underwent to a combination of hemostasis methods and intravenous infusion has been registered. The increase in the length of the prehospital stay occurs at the expense of the time required for creation of venous access and initiate infusion. The authors propose the algorithm for temporal control of external bleeding during emergency medical care at the pre-hospital stage. Conclusion. The main principles that need to be guided in the choice of any methods for stopping of bleeding are the speed and reliability of hemostasis for entire time of evacuation and the minimum damaging effect on the tissues. What this paper adds The effectiveness of various methods for temporal external hemostasis at the pre-hospital stage of emergency medical treatment taking into account the localization of injuries was estimated. It has been established that the main principles that must be followed in choosing any of the methods for stopping the bleeding are the speed and reliability of hemostasis for the entire duration of evacuation and the minimal tissue damage.

Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review

PurposeSpinal collars were introduced in 1967 into the management of spinal trauma care as it was thought that this technique of immobilisation would prevent any further neurological or spinal damage in high-risk patients. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature.MethodsA systematic search of the literature was conducted between 1990 and 2020, screening PubMed, Medline, Science Direct and Google Scholar. The consequent findings were then qualitatively synthesised with the aim of effectively evaluating the evidence to resolve the discrepancy between current practice and literature.ResultsOf the nine eligible studies, six deemed that spinal collars should not be used in pre-hospital trauma patients with the remaining three reporting uncertainty if spinal collars were best practice. Our results suggest that there is a discrepancy between current guidance and practice in that although the guidelines recommend the use of spinal collars in the pre-hospital setting the majority of the studies were against the use of spinal collars. Importantly, none of the studies reported any benefits of spinal collars.ConclusionOur study shows a disparity between current guidelines and the published literature and warrants further direct research to obtain a more comprehensive view of the use of spinal collars in a pre-hospital setting.

Decision Support Capabilities of Telemedicine in Emergency Prehospital Care: Systematic Review.

BackgroundTelemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation.ObjectiveOur objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care.MethodsThis systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies–of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently.ResultsOut of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use; however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes.ConclusionsThe information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.

Random forest machine learning method outperforms prehospital National Early Warning Score for predicting one-day mortality: A retrospective study

Aim of the studyThe National Early Warning Score (NEWS) is a validated method for predicting clinical deterioration in hospital wards, but its performance in prehospital settings remains controversial. Modern machine learning models may outperform traditional statistical analyses for predicting short-term mortality. Thus, we aimed to compare the mortality prediction accuracy of NEWS and random forest machine learning using prehospital vital signs. MethodsIn this retrospective study, all electronic ambulance mission reports between 2008 and 2015 in a single EMS system were collected. Adult patients (≥ 18 years) were included in the analysis. Random forest models with and without blood glucose were compared to the traditional NEWS for predicting one-day mortality. A ten-fold cross-validation method was applied to train and validate the random forest models. ResultsA total of 26,458 patients were included in the study of whom 278 (1.0%) died within one day of ambulance mission. The area under the receiver operating characteristic curve for one-day mortality was 0.836 (95% CI, 0.810−0.860) for NEWS, 0.858 (95% CI, 0.832−0.883) for a random forest trained with NEWS variables only and 0.868 (0.843−0.892) for a random forest trained with NEWS variables and blood glucose. ConclusionA random forest algorithm trained with NEWS variables was superior to traditional NEWS for predicting one-day mortality in adult prehospital patients, although the risk of selection bias must be acknowledged. The inclusion of blood glucose in the model further improved its predictive performance.

Ketamine as a rescue treatment for severe acute behavioural disturbance: A prospective prehospital study.

Rapidly and safely managing severe acute behavioural disturbance (ABD) in the prehospital setting is important for the welfare of both patient and prehospital clinician alike. We investigated the safety and effectiveness of ketamine as rescue sedation in patients with severe ABD. This prospective observational study investigated ketamine use by a state ambulance service as rescue sedation for patients with severe ABD who remained agitated following droperidol administration. The primary outcome was the proportion of adverse events (vomiting, hypersalivation, emergence, over-sedation, airway obstruction, laryngospasm, hypoxia, bradypnoea and intubation). Secondary outcomes included time to sedation, requirement for additional sedation and rate of successful sedation. There were 105 presentations (males 69/102 [69%]; median age 31 years (16-83 years). The commonest causes of ABD were illicit drug (39%) and alcohol (33%) intoxication. The median total dose of intramuscular ketamine was 200 mg (interquartile range [IQR] 150-200 mg). There were 64 adverse events in 40 (38%) patients. Four had vomiting, two had hypersalivation, two had emergence, 15 were oversedated, four had hypoxia, three had bradypnoea and 16 were intubated. Sedation was achieved in 103 (98%) patients at a median time post-ketamine of 8min (IQR 5-13 min). Additional sedation was administered to 41 patients (nine prehospital and 37 within 1 h of arriving to hospital). In 44 (42%) patients, ketamine successfully sedated the patient with no adverse effects and no ongoing sedation requirement. The use of ketamine as rescue sedation in prehospital patients with severe ABD is effective. Adverse events are common but can be managed supportively.

Gender and location disparities in prehospital bystander AED usage

BackgroundWith bystander AED usage being critical for prehospital cardiac arrest patient outcomes, it is important to analyze if the gender and location disparities found in bystander CPR rates also exist for bystander AED usage. MethodsUsing the National Emergency Medical Services Information System (NEMSIS) database, 1,144,969 bystander AED cases were analyzed on the basis of gender and location. Chi-squared testing checked for statistical significance and effect size was measured using relative risk (RR). ResultsUsing female patients as a baseline, the RR for bystander AED usage for male patients was 1.34 (95% CI [1.3310, 1.3557], p < 0.001) indicating male patients are 34% more likely to receive bystander AED usage compared to female patients. Analyzing bystander AED usage per urbanity region using urban patients as a baseline, resulted in a RR of 0.87 for suburban patients (95% CI [0.8572, 0.8833], p < 0.001), 0.39 for rural patients (95% CI [0.3849, 0.3971], p < 0.001), and 0.36 for frontier patients (95% CI [0.3515, 0.3726], p < 0.001) showing a sharp decline in the chance of bystander AED usage in rural and frontier areas. ConclusionsFemale patients are less likely to receive bystander AED usage compared to male patients. To resolve these disparities increased public awareness is necessary that supports AED usage on females as socially acceptable and necessary for patient outcomes. Furthermore, given bystander AED usage among males and females declined as cardiac arrest locations became more remote, improvements in rural and frontier AED availability and training are necessary to increase bystander AED usage rates in those regions.

How accurate is the prehospital diagnosis of hyperventilation syndrome?

Background: The literature suggests that hyperventilation syndrome (HVS) should be diagnosed and treated prehospitally. Aim: To determine diagnostic accuracy of HVS by paramedics and emergency medical technicians using hospital doctors' diagnosis as the reference standard. Methods: A retrospective audit was carried out of routine data using linked prehospital and in-hospital patient records of adult patients (≥18 years) transported via emergency ambulance to two emergency departments in the UK from 1 January 2012–31 December 2013. Accuracy was measured using sensitivity, specificity, positive and negative predictive values (NPV/PPVs) and likelihood ratios (LRs) with 95% confidence intervals. Results: A total of 19 386 records were included in the analysis. Prehospital clinicians had a sensitivity of 88% (95% CI [82–92%]) and a specificity of 99% (95% CI [99–99%]) for diagnosing HVS, with PPV 0.42 (0.37, 0.47), NPV 1.00 (1.00, 1.00), LR+ 75.2 (65.3, 86.5) and LR− 0.12 (0.08, 0.18). Conclusions: Paramedics and emergency medical technicians are able to diagnose HVS prehospitally with almost perfect specificity and good sensitivity.

Progression of vital signs during ambulance transport categorised by a paediatric triage model: a population-based historical cohort study

ObjectivesTo examine the severity and progression of acute illness or injury in children using vital signs obtained during ambulance transport and categorised according to a paediatric triage model.DesignA population-based historical...

Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm

BackgroundFew publications have addressed prehospital use of ketamine in analgesic doses. We aimed to assess the effect and safety profile of ketamine compared with other analgesic drugs (or no drug)...

The PaCO2-ETCO2 gradient in pre-hospital intubations of all aetiologies from a single UK helicopter emergency medicine service 2015-2018.

Control of the arterial partial pressure of carbon dioxide (PaCO2) is important in the ventilated patient. End-tidal carbon dioxide (ETCO2) levels are often used as a proxy, but are clinically limited. The difference between the PaCO2 and ETCO2 has been suggested to be 0.5-1.0 kPa. However, this has not been consistently reflected in the physiologically unstable pre-hospital patient. This study aims to elucidate the PaCO2-ETCO2 gradient for pre-hospital intubated patients. This was a retrospective, cohort study using data identified from the HEMSbase 2 database (Feb 2015-Nov 2018). Patients were included if they had documented ETCO2 and arterial PaCO2 measurements. Arterial PaCO2 data that could not be linked to within 5 minutes of ETCO2 were excluded. Bland-Altman plots were calculated to describe agreement. A total of 73 patients were identified. Aetiology was arranged into three categories: 13 (17.8%) medical, 22 (30.1%) traumatic and 38 (52.1%) out-of-hospital cardiac arrest (OHCA). The median PaCO2-ETCO2 gradient was 2.0 [1.3-3.1] kPa. A PaCO2-ETCO2 gradient of 0-1 kPa was seen for only 11 (15.1%) of total patients. The Bland-Altman agreement for all aetiologies was more than the accepted gradient of 0-1 kPa with the largest bias and widest limits of agreement seen for OHCA (-3.2 [0.3 - -6.8]). The magnitude of the differences between the ETCO2 and PaCO2, levels of variation and inability to predict this suggest that ETCO2 is not a suitable surrogate upon which to base ventilatory settings in conditions where pH or PaCO2 require precise control.

A ripple effect in prehospital stroke patient care

ABSTRACT We examine a ripple effect in prehospital stroke care processes. Stroke patient care in prehospital stages is provided by emergency medical services (EMS). We divide EMS processes into three segments: dispatcher, field provider service without a patient (i.e., en route to the patient scene), and field provider service with a patient (i.e., transporting the patient to a hospital). We use both empirical and analytical models in this study. The results of the empirical analysis suggest that the dispatcher's stroke identification can influence the time performance of the dispatch center itself and of the subsequent downstream processes of the prehospital stroke care, indicating a potential ripple effect in the care system. Our analytical models demonstrate the impact of misidentification (i.e., a disruptive event at the dispatcher stage) and the unavailability of an Advanced Life Support (ALS) ambulance (i.e., a disruptive event at the field provider stage) on the severity of the stroke patient's prehospital condition. The models indicate that there is an optimal diagnostic time on the part of the dispatcher that minimizes the adverse consequences throughout the prehospital stages of care under disruptive events, and that a centralized system can mitigate a ripple effect in prehospital stroke care.

Survival in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction

Background Field identification and treatment of ST-segment elevation myocardial infarction (STEMI) by paramedics is an important component of care for these patients. There is a paucity of studies in the setting of paramedic-identified STEMI. This study investigated mortality and factors associated with mortality in a large state-wide prehospital STEMI sample. Methods: Included were adult STEMI patients identified and treated with reperfusion therapy by paramedics in the field between January 2016 and December 2018 in Queensland, Australia. 30-day and one-year all-cause mortality was compared between two prehospital reperfusion pathways: prehospital fibrinolysis versus direct referral to a hospital for primary percutaneous coronary intervention (direct percutaneous coronary intervention [PCI] referral). For prehospital fibrinolysis patients, factors associated with failed fibrinolysis were investigated. For direct PCI referral patients, factors associated with mortality were examined. Results: The 30-day mortality was 2.2% for prehospital fibrinolysis group and 1.8% for direct PCI referral group (p = 0.661). One-year mortality for the two groups was 2.7% and 3.2%, respectively (p = 0.732). Failed prehospital fibrinolysis was observed in 20.1% of patients receiving this therapy, with male gender and history of heart failure being predictors. For direct PCI referral group, low left ventricular ejection fraction (LVEF) on admission and cardiogenic shock prior to PCI were predictors of both 30-day and one-year mortality. Aboriginal and Torres Strait Islander status, and impaired kidney function on admission, were associated with one-year but not 30-day mortality. Being overweight was associated with lower 30-day mortality. Conclusions: Mortality in STEMI patients identified and treated by paramedics was low, and the prehospital fibrinolysis treatment pathway was effective with a mortality rate comparable to that of patients undergoing primary PCI. Key words: prehospital; Queensland; cardiac reperfusion; STEMI