Clinical trials are essential for generating evidence-based knowledge to support clinical practice. In the prehospital setting, particular challenges exist in clinical trial design that have a large impact on the quality of the results, including the appropriate and systematic allocation of assigned treatment arm. The Pediatric Prehospital Airway Resuscitation Trial is a multicenter clinical trial evaluating different paramedic airway management strategies on critically ill and injured children in the prehospital setting. The trial assigns airway management strategy using odd-even day pseudo-randomization, which pragmatically balances the rigor of a statistical design that minimizes bias with the complexities of operationalizing a clinical trial in the prehospital setting. We describe the development of 2 technologies to aid in treatment assignment adherence during the trial: (1) a quick response code-linked web application, and (2) a self-contained portable reminder device. These technologies offer novel approaches to support treatment allocation in acute care clinical trials.

Analgesic and Physiologic Effects of Ketamine Compared with Opioids in Prehospital Trauma Care: A Systematic Review and Meta-Analysis.

As there is no published review of video review use in cardiac arrest (CA) research, we set out to perform a scoping review to describe the demographics, settings, interventions, and outcomes in the literature. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for scoping reviews, we queried PubMed, Scopus, EMBASE, and Cochrane Library from inception through April 22, 2024, and then updated the query to cover publications through March 7, 2025, including adult CA studies using video-derived data from prehospital, emergency department, or intensive care settings, excluding pediatric and simulation studies. Independent screening and data extraction were both performed by 2 of the reviewers, with a third reviewer and principal investigator resolving discrepancies, respectively. Extracted data encompassed study aims, setting, patient demographics, video review reliability, and detailed information on outcomes, metrics (eg, chest compression fraction), and interventions (eg, intubation). From 3081 identified publications, 76 were included, with 64.5% being manuscripts. They originated from the USA (48.7%), Asia (31.6%), and Europe (19.7%). Studies were predominantly single center (98.7%), from urban settings (82.9%), with retrospective (47.4%) or prospective (31.6%) observational designs. There was marked heterogeneity in reporting methodologies. The median number of patients enrolled was 71. Interrater reliability was reported in only 12 studies. Common reported patient outcomes included return of spontaneous circulation (39.5%), key metrics such as duration of interruptions (52.6%), and time-to-events (51.3%). Frequently reported interventions included mechanical compression device use (36.8%), defibrillation (34.2%), and intubation (28.9%). Publication volume significantly increased over the last 2 decades. Video review enables a precise, multidomain assessment of resuscitation performance of CA that conventional data sources cannot provide. Future work should prioritize consensus definitions and establishing minimum reporting standards.

Prehospital prediction of mechanical circulatory support during hospital stay in cardiogenic shock: The FLAG score.

Unequal paths to care: How region, rurality, and deprivation determine transport to verified trauma centers among the critically injured.

ABSTRACT OBJECTIVES Previous studies have suggested that intranasal (IN) naloxone is less effective than intramuscular (IM) naloxone at reversing opioid toxicity but may result in a lower prevalence of precipitated withdrawal. Because limited real-world comparisons have been performed, we aimed to compare initial strategies of IM or IN naloxone administration by emergency medical services (EMS) clinicians using a nationwide dataset. METHODS We included all adult (>18 years of age) patients in the 2023-2024 ESO Data Collaborative research datasets who received intranasal or intramuscular (IN or IM) naloxone from EMS following a 9-1-1 call. We used multilevel mixed-effects logistic regression with EMS agency as a random intercept to estimate the association between initial naloxone route and the outcomes of post-naloxone cardiac arrest, hypoxia (SpO2 < 90%), additional naloxone dosing, return to a respiratory rate >12, return to a Glasgow Coma Scale (GCS) >12, treatment for nausea/vomiting or agitation, and EMS transport. We included age, sex, race/ethnicity, time to naloxone (dispatch to drug administration), overdose location, documented history of intravenous drug use, and treatment year in our regression models. RESULTS We analyzed 16,550 patients treated by 1,481 EMS agencies, of whom 3,286 (20%) received their first dose of naloxone via the IM route. In comparison to patients treated with an initial strategy of IN administration, patients who received IM naloxone had lower odds of receiving additional naloxone (aOR: 0.39 [0.35, 0.44]), lower odds of receiving EMS transport (aOR: 0.82 [0.71, 0.95]), and higher odds of returning to a GCS >12 (aOR: 1.15 [1.01, 1.30]). The initial route of naloxone administration was not associated with the odds of cardiac arrest (aOR: 0.84 [0.57, 1.26]), hypoxia (aOR: 0.90 [0.80, 1.00]) return to a respiratory rate >12 (aOR: 1.02 [0.83, 1.26]), or treatment for nausea/vomiting (aOR: 0.97 [0.80, 1.17]) or agitation (aOR: 1.06 [0.81, 1.39]). CONCLUSIONS In this large cohort, initial IM naloxone administration was associated with more favorable physiologic and operational outcomes compared with an initial IN strategy. Importantly, IM administration was not associated with increased EMS treatment for agitation or nausea/vomiting, which suggests no observed increase in precipitated withdrawal in the prehospital setting.

Sepsis remains a leading cause of global morbidity. Early recognition is frequently delayed due to heterogeneous clinical presentations and the absence of definitive diagnostic tools, particularly in the pre-hospital setting. This study assessed the knowledge, attitudes, and practices (KAP) of pre-hospital emergency medical care (PHEMC) practitioners at Hamad Medical Corporation Ambulance Service (HMCAS) in Qatar to evaluate sepsis recognition and inform context-specific strategies for improving pre-hospital care. A cross-sectional study was conducted within HMCAS using a 53-item survey developed through literature synthesis, expert review, and pilot testing. Analyses were primarily descriptive, with exploratory bivariate testing of associations between practitioner characteristics and KAP measures. A multiple linear regression model was constructed to identify predictors of diagnostic confidence using confidence in prompt and accurate sepsis diagnosis as the dependent variable. Of the 221 licensed practitioners who completed the survey, most were male (90%) and aged 31-40 years. Only 33.5% of respondents correctly determined that the patient in Scenario 1 did not have sepsis, whereas 79.2% correctly identified sepsis in Scenario 2, which represented a more overt septic presentation. Although 59.7% reported considering sepsis even in the absence of fever or a clear source of infection, scenario-based accuracy did not reflect this self-reported awareness. Awareness of screening tools was common, but their use was predominantly reactive, occurring after clinical suspicion had already been established. Diagnostic confidence was highest among practitioners who had received recent/up-to-date sepsis training (p < 0.001). Despite widespread awareness and training, early-stage sepsis recognition among PHEMC practitioners in Qatar remains inconsistent and largely reactive. Self-reported confidence and familiarity with screening tools did not reliably translate into accurate determination of whether sepsis was present, highlighting a gap between perceived and actual competence. These findings suggest that improving pre-hospital sepsis recognition may require system-level and behavioural interventions in addition to education.

Intracranial hypertension is a life-threatening complication of acute brain injuries such as traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). In low-income and middle-income countries (LMICs), limited resources can delay timely neurocritical interventions. Smartphone-based quantitative pupillometry offers a scalable solution for early detection of elevated intracranial pressure (ICP). Here, we assessed its ability to (1) detect raised optic nerve sheath diameter (ONSD), a noninvasive surrogate for elevated ICP, and (2) classify severe TBI. Thirty-eight Nepali ICU patients with TBI (n=16), SAH (n=10), or ICH (n=12) underwent daily sonographic ONSD and pupillary light reflex (PLR) assessments through the PupilScreen app (Apertur Inc., Seattle, WA) over 7 days. Machine learning classifiers were trained on PLR features to detect elevated ONSD (>6.0mm). To identify severe TBI (Glasgow Coma Scale [GCS] ≤8 on admission), classifiers were trained on PLR features, ONSD, or both. For ONSD >6.0mm, a random forest model achieved an AUC of 0.66, with a sensitivity of 0.31 and specificity of 0.80. For identifying severe TBI, the optimal classifier was a random forest model incorporating ONSD and a subset of PLR metrics, with a sensitivity of 0.93, specificity of 1.00, and AUC of 0.96. In this pilot study, smartphone-based pupillometry showed modest ability for detecting elevated ONSD. However, its high performance in severe TBI classification warrants further evaluation. Larger, multicenter studies evaluating triage utility in prehospital and resource-limited settings are warranted to validate and extend these findings.

Real-time Geolocation Platforms for Access to Automated External Defibrillators in Out-of-Hospital Cardiac Arrest: A Scoping Review.

ObjectivesVisual problems are common in acute stroke, however no standardised vision screening tool is routinely used in pre-hospital or emergency department settings. This study evaluated the V-FAST (vision-face-arm-speech-time) checklist for detecting visual impairment in patients admitted with suspected stroke.DesignProspective, service evaluation study.SettingOne emergency department.ParticipantsAbout 282 consecutive patients with suspected stroke.Main measuresAll patients were assessed with the National Institutes of Health Stroke Scale, V-FAST checklist, and reference standard orthoptic assessment. Main outcomes included visual impairment detection rates and diagnostic performance (sensitivity, specificity, predictive values, and agreement).ResultsOf 282 screened patients (mean (SD) age 73 (11) years; 51.5% females), 158 (56.2%) had stroke confirmed. Among these, visual impairment was detected in 64.0% by orthoptists, 34.0% by the National Institutes of Health Stroke Scale (κ = 0.22), and 47.0% by V-FAST (κ=0.34). In FAST-positive strokes, National Institutes of Health Stroke Scale and V-FAST detected visual impairment in 83.3% and 76.0%, respectively; in FAST-negative strokes, detection was 16.7% and 24.0%, respectively, compared to orthoptic assessments. V-FAST showed better diagnostic performance than National Institutes of Health Stroke Scale, with sensitivity, specificity, positive/negative predictive values and kappa of 78.7%, 97.2%, 83.6%, 90.0%, and 0.79, respectively.ConclusionThe V-FAST checklist demonstrates fair agreement with orthoptist assessment and complements the National Institutes of Health Stroke Scale for detecting visual impairment in stroke admissions in the emergency department, with particular benefit in FAST-negative strokes. These findings support integrating a standardised screening checklist for visual impairment detection into emergency department stroke pathways.

Appropriate, evidence-based care of traumatically injured patients in the prehospital setting is essential to saving lives and yielding better outcomes. There exists mixed evidence on the outcome differences between ambulance and helicopter prehospital transport, and on the effects of transport time on outcomes. The purpose of this paper is to examine these in patients presenting to an urban Level-1 trauma center. A retrospective analysis was conducted with three years of patient information from a trauma registry maintained by a Level-1 trauma center in St. Louis, Missouri (USA). Propensity matching was used to compare helicopter versus ground ambulance outcomes, while regression analysis was used to investigate transport time. After propensity matching to injury severity, helicopter transport was associated with improved prehospital survival (OR = 4.1; [95% CI, 1.2-21]; P = 0.02), though no difference in in-hospital survival (OR = 0.9; [95% CI, 0.4-1.8]; P = 0.71), intensive care unit (ICU) stay (difference = 0.8 days; [95% CI, -0.9-2.5]; P = 0.36), or hospital length-of-stay (difference = 51 hours; [95% CI, -7-109]; P = 0.08). Decreased transport time was not associated with increased survival (P = 0.31), but when transport times were less than 30 minutes, further reductions were significantly associated with shorter hospital stays (r2 = 0.02; P = 0.05) and fewer ICU days (r2 = 0.02; P = 0.05). Decreased injury to hospital arrival time and increased use of helicopter transport in specific situations may improve patient outcomes; this indicates the need for prospective studies.

IntroductionIn France, cervical spine trauma frequently results in systematic prehospital immobilisation with a cervical collar, despite a low incidence of clinically significant injuries. This practice may lead to unnecessary discomfort, delayed care and emergency department (ED) overcrowding. The Canadian C-Spine Rule (CCR) is a validated tool for identifying patients at low risk of cervical injury but its use is currently limited to ED settings. An adapted version (CCRa) has been validated in Canada for prehospital use, demonstrating safe reduction in immobilisation rates. This study aims to evaluate the feasibility, safety and clinical impact of CCRa implementation in the French prehospital emergency setting. The objectives are to assess whether the implementation of the CCRa by French prehospital emergency teams can safely reduce unnecessary cervical spine immobilisation in stable trauma patient, optimise imaging use and decrease ED overcrowding while maintaining patient safety.Methods and analysisThis is multicentre, cluster-randomised-controlled trial involving 16 Emergency Medical Call Center and their affiliated prehospital emergency services in France. Each centre will be randomised to either implement the CCRa or usual care with standard immobilisation practices. Alert adult patients (18–65 years) with suspected closed cervical spine trauma and Glasgow Coma Scale score of 15 will be included. The primary outcome is the proportion of patients with suspected cervical spine trauma who are transported to the ED. Secondary outcomes include the appropriateness of cervical spine immobilisation, use of cervical imaging, ED visits for neck pain, immobilisation-related complications, healthcare costs at 30 days, and feasibility and acceptability of CCRa implementation among prehospital professionals (effectiveness-implementation hybrid type 1 design). Quantitative data will be collected during prehospital care, ED admission and follow-up at days 14 and 30, while implementation outcomes will be assessed at the end of the intervention period using questionnaires and qualitative interviews.Ethics and disseminationThe study has been approved by a national ethics committee (CPP), the French competent authority and registered to the French National Authorities (ID-RCB 2024-A00636-41). It is funded by the French Ministry of Health via the 2023 PREPS programme (DGOS). Results will be published in a peer-reviewed journal and presented at relevant scientific meeting. The sponsor of the study is Rennes University Hospital. The findings may support broader CCRa implementation in European EMS systems.Trial registration numberNCT06983873.

Pediatric trauma team activation (TTA) is intended to ensure timely management of severely injured children, yet both prehospital visitation practices and in-hospital TTA criteria vary across trauma systems. The aim of this study was to describe and compare pediatric TTA criteria, organizational models, and injury severity across all Danish level I trauma centers. We conducted a retrospective multicenter cohort study including all pediatric trauma patients (< 18 years) admitted via TTA at the four Danish level I trauma centers between 2014 and 2024. Center-specific prehospital and in-hospital TTA protocols were obtained through structured inquiries. Injury severity was assessed using Injury Severity Score (ISS) and Abbreviated Injury Scale (AIS). Overtriage was defined as TTA in patients with ISS < 15. A total of 3,452 pediatric trauma patients were included. Two distinct TTA models (single-criterion and point-based) and four organizational structures were identified. Overall, 14% of patients had ISS ≥ 15, corresponding to high overtriage across all centers. Overtriage rates ranged from 81% to 95% and were highest at centers using point-based TTA models. Mortality was low and did not differ significantly between centers. Among the most severely injured patients (ISS ≥ 25), head and thoracic injuries predominated. Pediatric trauma triage in Denmark shows substantial inter-center variation combined with consistently high overtriage. These findings suggest a misalignment between current TTA practices and pediatric injury severity profiles. Greater alignment of pediatric-specific triage criteria across prehospital and in-hospital settings may support more accurate TTA, promote consistent care, and improve resource utilization across trauma centers.

Artificial intelligence in the prehospital setting – potentials, challenges, and practice-relevant fields of application in emergency medical services

Objectives Emergency medicine (EM) residency curricula are designed to prepare future physicians for independent practice. Although the Accreditation Council for Graduate Medical Education requires that EM residents have prehospital experiences, very few programs augment this experience with a dedicated resident response vehicle. There are minimal data demonstrating the utility of such an approach. Our residency program staffs a dedicated response vehicle with a PGY-2/3 resident 24/7/365 to respond to high-acuity emergency medical services (EMS) calls. Additionally, from 0800 to 2300, the on-duty resident provides on-line medical control (OLMC) for the county. Each resident averages one 24-h shift per 4-week EM block. The purpose of this study is to describe the prehospital educational experiences and curricular contributions that this program provides. Methods We used a retrospective observational study design of administrative patient care records over a 5-year period. The primary outcomes were the number of unique encounters and patient experiences per resident per cohort year. The secondary outcomes included characterization of the prehospital experiences among all residents: physician role, patient age-group and sex, problem type, scene location, and procedures. Descriptive statistics were computed to quantify the number, type, and characteristics of the prehospital encounters. Results Ninety unique resident users were identified in the charting system. The mean number of encounters per resident was grouped by graduation year and spanned from 28.7 (SD 15) for 2018 to 79.2 (SD 49.2) for 2022, with a range of 2–222 encounters per resident documented. Over the study period, our residents managed 1313 out-of-hospital cardiac arrests (34 pediatric), 1048 refusals, 596 death pronouncements, 172 critical trauma patients, and answered 2053 complex OLMC consults. Conclusions This study quantified the prehospital experiences of our senior EM residents with the addition of a physician response vehicle to our longitudinal EMS curriculum. This has allowed our residents to gain valuable first-hand exposure to out-of-hospital adult and pediatric cardiac arrests, refusals of care, altered mental status, and respiratory emergencies, in addition to prehospital scenarios not likely to be seen within the hospital walls, including motor vehicle collisions with entrapment and mass casualty incidents.

Diagnostic uncertainty is a major barrier to the timely treatment of heart failure (HF) in the prehospital setting. We aimed to develop and validate a decision support tool using readily available clinical variables to predict the probability of HF among dyspnoeic patients transported by emergency medical services (EMS). A population-based cohort of all adults transported by EMS for dyspnoea in Victoria, Australia was chronologically split into derivation (2015-2017) and temporal validation (2018-2019) cohorts. Two models were developed: (1) a full multivariable logistic regression model using adaptive least absolute shrinkage and selection operator regression, and (2) a simplified points-based RAPID-CHF score derived from the nine most predictive variables. Among 271,204 patients with dyspnoea (176,269 derivation; 94,935 validation), 9.4% and 9.0% had HF, respectively. The full model included 19 variables and demonstrated excellent discrimination (AUC 0.861 derivation; 0.862 validation) and calibration. The RAPID-CHF score (range 0-13; comprising age, ECG rhythm, prior HF, conscious state, oxygen saturation, blood pressure, temperature, peripheral oedema, and crackles) retained strong performance (AUC 0.835 derivation; 0.836 validation) and calibration. HF prevalence increased across predefined risk categories: low (score 0-5; HF prevalence 1.7%), moderate (6-9; 13.6%) and high (10-13; 46.4%). Decision curve analysis demonstrated greater net benefit across clinically relevant thresholds than current EMS diagnosis or "treat all"/"treat none" strategies. A risk score derived from routinely collected prehospital variables accurately estimates HF probability among EMS-transported patients with dyspnoea. The RAPID-CHF score may facilitate earlier diagnosis and timely initiation of HF therapy in EMS workflows.

Stroke trials conducted in prehospital settings face inherent complexities in patient screening, timely intervention delivery, and outcome assessment. The INTEnsive ambulance-delivered blood pressure Reduction in hyper-acute stroke Trial (INTERACT4) investigated the effect of prehospital blood pressure (BP) lowering initiated within 2 hours of symptom onset in suspected acute stroke across multiple sites in China. This process evaluation aimed to examine implementation outcomes and contextual mechanisms influencing delivery. A mixed-methods approach with a convergent parallel design. Quantitative data on fidelity, dose, and reach were obtained from case report forms and monitoring logs, including protocol deviations and BP target achievement. Qualitative data on acceptability, appropriateness, and adoption were collected through semi-structured interviews with ambulance and hospital staff from eight sampled hospitals, and a focus group discussion with project implementers. Data were analyzed descriptively and thematically, guided by the Medical Research Council complex intervention framework for process evaluation and normalization process theory. A total of 34 participants (19 ambulance staff and 15 hospital doctors) across 8 sites were interviewed. Fidelity was generally acceptable, with nearly 90% of eligible patients receiving the first urapidil dose. Dose achievement was modest, with 31.7% of patients achieving the prehospital systolic BP target of <140 mmHg. Qualitative findings provided further explanation. Staff regarded the intervention as meaningful, safe, and compatible with workflows, and reported increasing proficiency through training and quality control. System-level differences were evident: in centralized dispatch systems, very short transfer times and frequent handovers with rotating junior physicians contributed to protocol deviations. Conversely, hospital-based systems, with stable doctor-nurse teams and longer transfer times, facilitated better adherence. BP lowering in the prehospital setting is feasible and acceptable, but fidelity varied by the ambulance model. Hospital-based systems achieved higher adherence, highlighting the role of system design and training in prehospital stroke interventions.

Quick clots for tiny spots: Hemostatic agents in action.

A rapid and accurate tool to identify large vessel occlusion stroke (LVO) for use by prehospital emergency medical services responders could support direct access to time-critical thrombectomy at regional Comprehensive Stroke Centers. This study evaluated the accuracy of D-dimer and GFAP (glial fibrillary acidic protein) detected by lateral flow tests (LFT) to identify LVO stroke. This hospital-based prospective observational cohort study recruited adults within 6 hours of onset of at least 1 face, arm, or speech test (FAST) symptom. The LFTs use fingerprick capillary blood and give an overall positive (ie, LVO stroke predicted) or negative LFT outcome. Independent adjudication of brain imaging and clinical data established LVO or non-LVO. Specificity, sensitivity, negative and positive predictive values were calculated for (1) LFT outcome for participants with >1 FAST symptoms (primary analysis population); (2) a combined decision rule where participants with 1 FAST symptom were rule negative, patients with >1 FAST symptoms rule positive or negative according to LFT outcome; (3) FAST symptoms alone split by 1 symptom versus >1 symptom. The study involved 382 participants (age [mean], 72.4 years; female, 50.8%; National Institutes of Health Stroke Scale score [median], 6; time from onset to LFT [median], 130 minutes). Of 278 participants who met the primary analysis population, 202 of 278 had both LFT outcome and LVO/non-LVO assigned. Analysis gave specificity 79% (95% CI, 72%-85%), sensitivity 53% (95% CI, 39%-67%), negative predictive value 86% (95% CI, 79%-90%), and positive predictive value 42% (95% CI, 30%-55%). For 382 participants with 1 to 3 FAST symptoms, 290 of 382 had both a combined decision rule result and LVO/non-LVO assigned giving specificity 86% (95% CI, 82%-90%), sensitivity 51% (95% CI, 37%-65%), negative predictive value 90% (95% CI, 86%-93%), positive predictive value 42% (95% CI, 30%-55%). FAST symptoms alone (n=318) gave specificity 33% (95% CI, 27%-38%), sensitivity 96% (95% CI, 87%-99%), negative predictive value 98% (95% CI, 92%-99%), positive predictive value 23% (95% CI, 18%-29%). LFT outcome combined with FAST symptoms gave high specificity for LVO identification. This approach could be considered for facilitation of direct access to thrombectomy providers. However, further research is required to evaluate test performance in the prehospital setting and consider technological improvements to boost sensitivity without compromising specificity. URL: https://www.isrctn.com/; Unique identifier: ISRCTN12414986.

Cerebral blood flow autoregulation during prehospital post-resuscitation care.