Emergency Medical Services Arrival Time Research Articles

The association of early naloxone use with outcomes in non-shockable out-of-hospital cardiac arrest

Study ObjectiveEvaluate the association between early naloxone use and outcomes after out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythms. MethodsThis study was a secondary analysis of data collected in the Portland Cardiac Arrest Epidemiologic Registry, a database containing details of emergency medical services (EMS)-treated OHCA cases in the Portland, Oregon metropolitan region. Eligible patients had non-traumatic OHCA with an initial non-shockable rhythm and received naloxone by EMS or law enforcement prior to IV/IO access (exposure group). The primary outcome was ROSC at emergency department (ED) arrival. Secondary outcomes included survival to admission, survival to hospital discharge, and cerebral performance category score ≤2 at discharge (good neurologic outcome). We performed multivariable logistic regressions adjusting for age, sex, arrest location, witness status, bystander interventions, dispatch to EMS arrival time, initial rhythm, and county of arrest. ResultsThere were 1807 OHCA cases from 2018 to 2021 meeting eligibility criteria, with 57 receiving naloxone before vascular access. Patients receiving naloxone prior to vascular access attempts had higher adjusted odds (aOR [95% CI]) of ROSC at any time (2.14 [1.20–3.81]), ROSC at ED arrival (2.14 [1.18–3.88]), survival to admission (2.86 [1.60–5.09]), survival to discharge (4.41 [1.78–10.97]), and good neurologic outcome (4.61 [1.74–12.19]). ConclusionsPatients with initial non-shockable OHCA who received law enforcement or EMS naloxone prior to IV/IO access attempts had higher adjusted odds of ROSC at any time, ROSC at ED arrival, survival to admission, survival to discharge, and good neurologic outcome.

The Association Between the Number of Prehospital Providers On-Scene and Out-of-Hospital Cardiac Arrest Outcomes

Objective: The ideal number of emergency medical services (EMS) providers needed on-scene during an out-of-hospital cardiac arrest (OHCA) resuscitation is unknown. Our objective was to evaluate the association between the number of providers on-scene and OHCA outcomes. Methods: This was a secondary analysis of adults (18 years old) with non-traumatic OHCA from a 10-site North American prospective cardiac arrest registry (Resuscitation Outcomes Consortium) including a 2005–2011 cohort and a 2011–2015 cohort. The primary outcome was survival to hospital discharge. We calculated the median number of EMS providers on-scene during the first 10 minutes of the resuscitation and used multivariable logistic regression adjusting for age, sex, witness status, bystander CPR, arrest location, initial rhythm, and dispatch to EMS arrival time. Results: There were 30,613 and 41,946 patients with necessary variables in the 2005–2011 and 2011–2015 cohorts, respectively. Survival to hospital discharge (95% CI) was higher with 9 or more providers on-scene (17.2% [15.8–18.5] and 14.0% [12.6–15.4]) compared to 7–8 (14.1% [13.4–14.8] and 10.5% [9.9–11.1]), 5–6 (10.0% [9.5–10.5] and 8.5% [8.1–8.9]), 3–4 (10.5% [9.3–11.6] and 9.3% [8.5–10.1]), and 1–2 (8.6% [7.2–10.0] and 8.0% [7.1–9.0]) providers for the 2005–2011 and 2011–2015 cohorts, respectively. In multivariable logistic regressions, compared to 5–6 providers, there were no significant differences in survival to hospital discharge for 1–2 or 3–4 providers, while having 7–8 (adjusted odds ratios (aORs) 1.53 [1.39–1.67] and 1.31 [1.20–1.44]) and 9 or more (aORs 1.76 [1.56–1.98] and 1.63 [1.41–1.89]) providers were associated with improved survival in both the 2005–2011 and 2011–2015 cohorts, respectively. Conclusions: The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers.

Fewer tracheal intubation attempts are associated with improved neurologically intact survival following out-of-hospital cardiac arrest

BackgroundInternational guidelines emphasize advanced airway management during out-of-hospital cardiac arrest (OHCA). We hypothesized that increasing endotracheal intubation attempts during OHCA were associated with a lower likelihood of favorable neurologic survival at discharge. MethodsThis retrospective, observational cohort evaluated the relationship between number of intubation attempts and favorable neurologic survival among non-traumatic OHCA patients receiving cardiopulmonary resuscitation (CPR) from January 1, 2015–June 30, 2019 in a large urban emergency medical services (EMS) system. Favorable neurologic status at hospital discharge was defined as a Cerebral Performance Category score of 1 or 2. Multivariable logistic regression, adjusted for age, sex, witness status, bystander CPR, initial rhythm, and time of EMS arrival, was performed using the number of attempts as a continuous variable. ResultsOver 54 months, 1205 patients were included. Intubation attempts per case were 1 = 757(63%), 2 = 279(23%), 3 = 116(10%), ≥4 = 49(4%), and missing/unknown in 4(<1%). The mean (SD) time interval from paramedic arrival to intubation increased with the number of attempts: 1 = 4.9(2.4) min, 2 = 8.0(2.9) min, 3 = 10.9(3.3) min, and ≥4 = 15.5(4.4) min. Final advanced airway techniques employed were endotracheal intubation (97%), supraglottic devices (3%), and cricothyrotomy (<1%). Favorable neurologic outcome declined with each additional attempt: 11% with 1 attempt, 4% with 2 attempts, 3% with 3 attempts, and 2% with 4 or more attempts (AOR = 0.41, 95% CI 0.25–0.68). ConclusionsIncreasing number of intubation attempts during OHCA resuscitation was associated with lower likelihood of favorable neurologic outcome.

Can bystanders' gender affect the clinical outcome of out-of-hospital cardiac arrest: A prospective, multicentre observational study.

Out-of-hospital cardiac arrest (OHCA) is one of the most common causes of death in many countries. For OHCA patients to have a good clinical outcome, bystander cardiopulmonary resuscitation (CPR) is extremely significant. It is necessary to study the various characteristics of bystanders to improve bystander CPR quality. We aimed to evaluate the correlation between bystanders' gender and clinical outcomes of patients with OHCA. We conducted an observational study by using a prospective, multicenter registry of OHCA resuscitation, provided by the Korean Cardiac Arrest Research Consortium registry from October 2015 to June 2017. The following data were collected: patient's age, patient's gender, witnessed by a layperson, characteristics of the bystanders (age grouped by decade, gender, CPR education, compression method, and perception of automated external defibrillators), arrest place, emergency medical services arrival time, and initial electrocardiogram rhythms. Outcome variables were prehospital return of spontaneous circulation, survival discharge, and cerebral performance category status at discharge. A total of 691 patients were included in the study. There were significant differences in the initial shockable rhythm and previous CPR training between bystander's gender. Characteristics such as age, patient's gender, witnessed by a layperson, bystander's gender, initial shockable rhythm, and arrest place were significantly associated with neurologic outcome at discharge, using univariable analysis. However, in the multivariate logistic model, there was no significant correlation between bystander's gender and neurologic outcome. In the subgroup analysis using the multivariate logistic model with 291 patients without missing values of CPR education and bystander' age, there was a significant difference in neurologic outcome depending on bystander's CPR education status. There was no difference in the neurologic outcomes of OHCA patients based on bystanders' gender. However, according to subgroup analysis, there was a difference in the neurologic outcome depending on the status of bystanders' CPR education and females received less CPR education than males. Therefore, more active CPR education is required.

MP56: Intraosseous versus intravenous access in pediatric out-of-hospital cardiac arrest: an examination of prehospital vascular access methods and survival rates

Introduction: Intraosseous (IO) and intravenous (IV) access to the vascular system for the delivery of fluid and medication is a component of advanced pediatric resuscitation. Data describing the use of IV or IO vascular access methods and outcomes of pediatric out-of-hospital cardiac arrest (OHCA) are limited. Methods: We analyzed prospectively collected data of non-traumatic OHCA of the Resuscitation Outcomes Consortium registry in Canada and the USA (2011-2015). We included patients 17 years of age and younger who were treated by emergency medical services (EMS). We described the vascular access routes utilized, and the success rate of these attempts. We performed a logistic regression model, to evaluate the association of vascular access route and survival, adjusting for age, sex, shockable initial rhythm, witnessed status, public location, EMS arrival interval and time from 911 call to vascular access. In this model, we excluded patients with failed, multiple site or no vascular access attempts during the resuscitation. Results: Of 1549 non-traumatic pediatric OHCA, 822/895 (92%) and 345/488 (71%) had successful IO and IV vascular access attempts, respectively. IO access was more common in younger cases. Of 761 cases included in the regression model, 30/601 (5%) of IO-treated cases survived to hospital discharge, in comparison to 40/160 (25%) of IV-treated cases. Intraosseous access was associated with a decreased survival to hospital discharge (adjusted OR 0.46; 95% CI 0.21 to 0.98). Conclusion: In pediatric patients with OHCA, intraosseous vascular access was more commonly successful than IV placement and more common among younger cases. However, in cases with successful vascular access, IO use was associated with lower survival to hospital discharge.

Abstract TP381: Discrepancies in Arrival Time for Acute Ischemic Stroke Patients: An Opportunity for Improvement

Background: Current guidelines and national quality improvement efforts emphasize door-to-needle (DTN) time in stroke thrombolysis. Stroke center certifying bodies depend on hospital-reported DTN to appraise compliance and award designations. However, the validation of hospital reported arrival times against ambulance arrival times has not been previously reported. Objective: To determine differences in Emergency Medical Services (EMS) reported arrival time of stroke patients versus hospital documented arrival times at 10 primary and comprehensive stroke centers in Chicago. Methods: We performed a retrospective analysis of stroke admissions using the regional Get With The Guidelines (GWTG) Stroke registry of 10 Chicago hospitals between July 1 and December 31, 2013. We matched ambulance run numbers from EMS records to those in the GWTG-Stroke EMS special initiative tab. GWTG-Stroke data included arrival time, age, sex, race, initial NIHSS score, and whether tPA was administered. EMS data included hospital arrival time in addition to age, sex, hospital name, and clinical impression. We compared GWTG-Stroke and EMS reported arrival times overall and whether any clinical factors were associated with time discrepancy. Results: Among 308 matched EMS to GWTG-Stroke records, 51 (16.6%) received tPA. Overall, EMS documented arrival time was a median 5 minutes earlier than hospital documented arrival time (range -35 to +14min). There was no significant difference in time discrepancy by tPA administration, stroke type, NIHSS score, age, sex, race, insurance status, or hospital. Median DTN based on EMS data was 88m versus 82m for hospital-reported data (p&gt;0.05). The proportion with DTN times &lt;60 minutes was 22% based on EMS versus 29% based on hospital arrival times. Conclusions: EMS reported arrival time is on average 5 minutes earlier than hospital documented arrival time at 10 stroke centers in Chicago. Further studies should investigate factors contributing to discrepancies in DTN times between EMS and hospitals. Such investigation may lead to facilitating efficient hand-offs between EMS and hospital providers and promote earlier notification of receiving hospital stroke team in order to initiate care at time of EMS arrival.

Emergency Medical Services Response Times to Motor Vehicle Crashes Increased over the Period 1987 to 2015

Emergency Medical Services (EMS) response time to motor vehicle crashes (MVC’s) have been studied to determine if reducing the individual components of EMS response time (notification, arrival at the crash scene, and hospital arrival) may affect survival rates. It has been proposed that a reduction to 1 and 15- minute EMS notification and arrival times at the crash would result in 1.84% and 5.2% fewer fatalities. The aim of this study was to analyze the changes in EMS response times (notification, arrival at the crash scene, and hospital arrival) over the past three decades, both individually and overall. An important change in the past three decades is the increased use of cellular phones. Therefore, we hypothesized that EMSnotification time would have decreased over the timeframe, yielding an overall decrease in EMS response time. Our data are based on the Fatal Accident Reporting System (FARS) using the variables: Time of Crash, EMS Notification Time, EMS Arrival Time, EMS Hospital Arrival Time. This gives a total of 248,981 valid cases following the implementation of our inclusion criteria and truncation of the dataset to the 99th percentile to eliminate unexplainable outliers. We computed the individual and overall median EMS response times for each year from 1987 to 2015. Additionally, we analyzed the response times based on four separate crash factors: weather, total vehicles involved, time of day, and state population density. From 1987 to 2015 the individual EMS response times changed; while notification time has decreased, the arrival at both crash scene and hospital have steadily increased, resulting in overall increased total EMS response time.

Dispatcher CPR Instructions Across the Age Continuum.

Survival rates following out-of-hospital cardiac arrest (OHCA) increase two to three times when cardiopulmonary resuscitation (CPR) is started by bystanders, as compared to starting CPR when Emergency Medical Services (EMS) arrives. Municipalities that have implemented dispatcher-assisted bystander CPR programs have seen increased rates of bystander CPR. Cardiopulmonary resuscitation instructions are given for victims of all ages, but it is unknown if offering instructions results in similar rates of EMS-documented bystander CPR across the age continuum in these municipalities. The aim of this study was to determine if there is a difference in EMS-documented bystander CPR rates based on the age group of the OHCA victim when dispatcher CPR instructions are available in the community. This was a three-year, retrospective chart review of OHCA patients in two municipalities within a single county that provided dispatcher-assisted CPR instructions. Bystander CPR and patient age were determined based on EMS documentation. Age was stratified into three groups: child (0-12 years), adult (13-54 years), and geriatric (≥55 years). Chi square was used to compare the rate of bystander CPR in each age group. During the study period, 1,993 patients were identified as being in OHCA at the time of EMS arrival. The overall bystander CPR rate was 10%. The highest rate of bystander CPR was in the child age group (19%). The lowest rate of bystander CPR was in the geriatric age group (9%). There was a statistically significant difference between age groups (P≤.01). The rate of EMS-documented bystander CPR was low, even though these municipalities provided dispatcher-assisted CPR instructions. The highest rates of bystander CPR were observed in children (0-12 years). Future investigations should determine why this occurs and if there are opportunities to modify dispatcher coaching based on patient age so that bystander CPR rates improve. WeinmeisterKL, LernerEB, GuseCE, AteyyahKA, PirralloRG. Dispatcher CPR instructions across the age continuum. Prehosp Disaster Med. 2018;33(3):342-345.

Hypoglycemia Patients and Transport by EMS in Alameda County, 2013–15

Objective: To estimate the rate, characteristics, and dispositions of hypoglycemia events among persons who received care from Alameda County, California, Emergency Medical Services (EMS). Methods: This study was based on data for 601,077 Alameda County EMS encounters during 2013–15. Subjects were defined as having hypoglycemia if EMS personnel recorded a primary impression of hypoglycemia or low blood glucose (<60 mg/dl or “unspecified low”). The outcome of interest was patient transport or non-transport to an emergency department or other care setting; we excluded 33,177 (6%) encounters which lacked clear disposition outcomes. Results: Among 567,900 eligible encounters, 8,332 (1.47%) were attributed to hypoglycemia, of which 1,125 (13.5%) were not transported. Non-transport was more likely among males, adult patients age <60, initial blood glucose >60 mg/dl or EMS arrival time 18:00–6:00. Conclusions: Without an understanding of EMS encounters and non-transport rates, surveillance based solely on emergency department and hospital data will significantly underestimate rates of severe hypoglycemia. Additionally, given that hypoglycemia is often safely and effectively treated by non-physicians, EMS protocols should provide guidance for non-transport of hypoglycemic patients whose blood glucose levels have normalized.

Estimating the effect of emergency care on early survival after traffic crashes

IntroductionTraffic crash mortality is higher in rural areas, but it is unclear whether this is due to greater injury severity, time delays, or Emergency Medical Services (EMS) deficiencies. MethodsData from 2002–2003 were combined from the Fatality Analysis Reporting System (FARS) and an “expanded version” of the National Automotive Sampling System (NASS) Crashworthiness Data System (CDS). Weighted Cox and Weibull models for survival time (tSURV) were estimated, with time-varying covariates (TVC) having constant effects for specified time intervals following EMS arrival time (tEMS) and hospital arrival time (tHOS). The Weibull model was repeated with tSURV interval-censored to reflect uncertainty about the exact time of death, using an imputation method to accommodate interval censoring along with TVC. ResultsFARS contained records for 92,718 persons with fatal or incapacitating injuries, and NASS/CDS contained 5517 (weighted population of 642,716) with incapacitating injuries. All models associated mortality with increasing age, male sex, belt nonuse, higher speeds, and vehicle rollover. The interval-censored model associated EMS intervention with a beneficial effect until tEMS+30min, but not thereafter; hospital intervention was associated with a strongly beneficial effect that increased with time. Rural location was associated with a higher baseline hazard; a 50% reduction in rural prehospital time would theoretically reduce 4-h mortality by about 7%. ConclusionRural/urban disparity in crash mortality is mostly independent of time delays and EMS effects. However, survival models with TVC support clinical intuition of a “golden hour” in EMS care, and the importance of timely transport to a hospital.

AP027 Resuscitation in EMS-witnessed prehospital traumatic cardiac arrest

Background: Prehospital traumatic cardiac arrest (TCA) is undoubtedly associated with poor prognosis. The subgroup of patients with detectable vital signs (VS) upon Emergency Medical Services (EMS) arrival and a subsequent EMS-witnessed TCA is of special interest, since it might be associated with better outcome. Materials and Methods: Sixty patients with EMS-witnessed prehospital TCA (Male/Female: 45/15, Mean age: 34.0±21.4 years, Median age: 25 years) were managed by EMS physicians in the area of Thessaloniki during a 10-year period (01.01.1995–31.12.2004). All patients had palpable carotid pulse and organized ECG activity upon EMS arrival and suffered a subsequent, at the scene or during transport, EMS-witnessed TCA. Results: Mean EMS arrival time was 8.3±5.5 min. All patients but one, suffered blunt trauma. Palpable peripheral pulse was detected in 22 (36.67%) cases. Initial median GCS score was 6 (3–15). Pupils were found normal sized in 39 (65.0%) and dilated in 21 (35.0%) patients. Pupillary reflexes were present in 21 (35.0%) patients. During cardiopulmonary resuscitation, all patients received Advanced Life Support interventions by means of endotracheal intubation, fluid resuscitation and chest tube drainage as appropriate. In 25 (41.67%) cases, resuscitation efforts were terminated before arrival at hospital. In total, 35 (58.33%) patients exhibited return of spontaneous circulation. Thirty-two (53.33%) of them died, 12 in the Emergency Department, 17 in the Operating Room and 3 in the Intensive Care Unit. Finally, 3 (5.0%) patients survived to hospital discharge, but only 1 (1.67%) – suffering penetrating neck trauma – with full neurological recovery. Autopsy causes of death revealed severe isolated or multiple organ injuries. Conclusions: The results of our study are in accordance to other similar literature studies and confirm the extremely poor survival rate after TCA. Moreover, resuscitation, even in EMS-witnessed TCA, seems to be in the majority of the cases futility.

AP028 The impact of delayed transfer to inpatient units for successfully resuscitated out-of-hospital cardiac arrest patients on survival to discharge

Background: Prehospital traumatic cardiac arrest (TCA) is undoubtedly associated with poor prognosis. The subgroup of patients with detectable vital signs (VS) upon Emergency Medical Services (EMS) arrival and a subsequent EMS-witnessed TCA is of special interest, since it might be associated with better outcome. Materials and Methods: Sixty patients with EMS-witnessed prehospital TCA (Male/Female: 45/15, Mean age: 34.0±21.4 years, Median age: 25 years) were managed by EMS physicians in the area of Thessaloniki during a 10-year period (01.01.1995–31.12.2004). All patients had palpable carotid pulse and organized ECG activity upon EMS arrival and suffered a subsequent, at the scene or during transport, EMS-witnessed TCA. Results: Mean EMS arrival time was 8.3±5.5 min. All patients but one, suffered blunt trauma. Palpable peripheral pulse was detected in 22 (36.67%) cases. Initial median GCS score was 6 (3–15). Pupils were found normal sized in 39 (65.0%) and dilated in 21 (35.0%) patients. Pupillary reflexes were present in 21 (35.0%) patients. During cardiopulmonary resuscitation, all patients received Advanced Life Support interventions by means of endotracheal intubation, fluid resuscitation and chest tube drainage as appropriate. In 25 (41.67%) cases, resuscitation efforts were terminated before arrival at hospital. In total, 35 (58.33%) patients exhibited return of spontaneous circulation. Thirty-two (53.33%) of them died, 12 in the Emergency Department, 17 in the Operating Room and 3 in the Intensive Care Unit. Finally, 3 (5.0%) patients survived to hospital discharge, but only 1 (1.67%) – suffering penetrating neck trauma – with full neurological recovery. Autopsy causes of death revealed severe isolated or multiple organ injuries. Conclusions: The results of our study are in accordance to other similar literature studies and confirm the extremely poor survival rate after TCA. Moreover, resuscitation, even in EMS-witnessed TCA, seems to be in the majority of the cases futility.

Glasgow coma scale in acute poisonings before and after use of antidote in patients with history of use of psychotropic agents

Data on emergency interventions in poisonings are scarce. Objective To determine the effectiveness of antidote therapy in acute poisoning-related emergency medical services (EMS) interventions. A prospective observational study included all poisoning-related intervention cases over 3 years (1999-2001) in the Celje region, Slovenia, covering 125,000 inhabitants. Data were recorded on an EMS form. Psychoactive agents were present in 56.5% out of 244 poisoning-related EMS interventions. Prescription drugs were a cause of intoxication in 93 (39.2%) cases alone or in combination with alcohol or illegal drugs. More than one fifth of poisonings were due to the use of illegal drugs in 52 (21.9%) cases, 43 (18.1%) out of them heroin related. At the time of EMS arrival, more patients who ingested illegal drugs were in coma or comatose than the rest. 24 (45.3%) vs. 32 (17.3%) of poisoned patients were in coma (p < 0.001). Glasgow Coma Scale (GCS) at the first contact was lower in patients who ingested illegal drugs than in the remaining patients (9.0 vs. 11.6, p = 0.001). In 23.2% of the cases, an antidote was administered. In 29 (12.2%) naloxone and in 16 (6.7%) flumazenil was administered. Mean GCS after intervention was higher in all cases but significantly higher in illegal drug cases, 13.4 vs. 12.2 (p = 0.001), with a mean positive change in GCS of 4.5 vs. 0.6 (p < 0.001). In illegal drug users, mean change after antidote administration was 8.2 vs. 0.5 without antidote administration (p < 0.001). High rate of successful antidote use during the intervention indicated the importance of good EMS protocols and the presence of a skilled doctor in the EMS team.

Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance

Objective To measure the time to analgesia for patients with painful, isolated extremity injuries brought to the emergency department (ED) by emergency medical services (EMS). Methods A retrospective chart review of all patients presenting with isolated, painful extremity injuries during an 18-month period to a Level 1 trauma center. Medical records were reviewed by diagnostic codes for extremity injuries. Inclusion criteria: patients 18 years or older transported to the ED by EMS; isolated, painful extremity injuries; received parenteral analgesia in the ED or by EMS. Excluded: multiple trauma patients, interfacility transfers, hemodynamically unstable patients, head-injured patients, intoxicated patients, and patients with mental status changes. Data elements: age, sex, EMS arrival time, EMS medication time, hospital triage time, and ED medication time. All “times to analgesia” were calculated from the EMS arrival time on scene. Results Extremity injuries were identified in 706 patients. Of these, 104 patients with painful, isolated, extremity injuries met all inclusion criteria. Thirteen (12.5%) of 104 received analgesia by EMS during prehospital care. Ninety-one patients (88%) first received parenteral analgesia in the ED. The mean time to analgesia for EMS treated patients was 23 minutes (95% CI 16.7–30.2). Mean time to analgesia for patients treated in the ED was 113 minutes (95% CI 99.2–128.1). Mean time to analgesia after triage in this group was 75 minutes (95% CI 60.8–89.7). Conclusion In this study, patients received analgesia sooner when administered by EMS during prehospital care. There was a significant time delay after triage for patients first medicated in the ED.

T IME TO A NALGESIA FOR P ATIENTS WITH P AINFUL E XTREMITY I NJURIES T RANSPORTED TO THE E MERGENCY D EPARTMENT BY A MBULANCE

Objective. To measure the time to analgesia for patients with painful, isolated extremity injuries brought to the emergency department (ED) by emergency medical services (EMS). Methods. A retrospective chart review of all patients presenting with isolated, painful extremity injuries during an 18-month period to a Level 1 trauma center. Medical records were reviewed by diagnostic codes for extremity injuries. Inclusion criteria: patients 18 years or older transported to the ED by EMS; isolated, painful extremity injuries; received parenteral analgesia in the ED or by EMS. Excluded: multiple trauma patients, interfacility transfers, hemodynamically unstable patients, head-injured patients, intoxicated patients, and patients with mental status changes. Data elements: age, sex, EMS arrival time, EMS medication time, hospital triage time, and ED medication time. All “times to analgesia” were calculated from the EMS arrival time on scene. Results. Extremity injuries were identified in 706 patients. Of these, 104 patients with painful, isolated, extremity injuries met all inclusion criteria. Thirteen (12.5%) of 104 received analgesia by EMS during prehospital care. Ninety-one patients (88%) first received parenteral analgesia in the ED. The mean time to analgesia for EMS treated patients was 23 minutes (95% CI 16.7−30.2). Mean time to analgesia for patients treated in the ED was 113 minutes (95% CI 99.2−128.1). Mean time to analgesia after triage in this group was 75 minutes (95% CI 60.8−89.7). Conclusion. In this study, patients received analgesia sooner when administered by EMS during prehospital care. There was a significant time delay after triage for patients first medicated in the ED.

P REHOSPITAL A DMINISTRATION OF M ORPHINE FOR I SOLATED E XTREMITY I NJURIES : A C HANGE IN P ROTOCOL R EDUCES T IME TO M EDICATION

Objective. To evaluate the effect of a new protocol allowing paramedics to administer morphine without a physician order to patients with extremity trauma with respect to time of morphine administration, scene time, morphine amount and number of doses per patient, and proportion of patients receiving morphine. Methods. Data were abstracted from transport forms for a ten-month period prior to the implementation of the new protocol and for nine months after implementation. Data elements included patient age and sex, date, time of EMS arrival on scene, amount and number of morphine doses, and total number of patients transported. Results. Implementation of the new protocol was associated with a decrease in time between emergency medical services (EMS) arrival on scene and administration of the first dose of morphine from 18.8 to 16.7 minutes, a difference of 2.1 minutes [95% confidence interval (95%CI) 1.3, 2.9]. The proportion of patients receiving analgesia at the scene, rather than during transport, increased from 62.7% before the protocol change to 69.5% after, an increase of 6.8% (95% CI 2.7, 11.0). Transports before and after implementation of the new protocol did not differ with respect to patient sex, age, or chief complaint; number of morphine doses or total morphine administered per patient; or proportion of prehospital patients receiving morphine. Conclusions. A change in protocol that permits trained paramedics to administer morphine without physician approval reduces time to analgesia administration without influencing the amount of morphine delivered per patient or the rate of prehospital morphine use. Further study should measure the effect on base hospital physician interruptions and patient outcome.

Potential time savings by prehospital administration of activated charcoal

Objective. Activated charcoal (AC) has been proven useful in many toxic ingestions. Theoretically, administration of AC in the prehospital environment could save valuable time in the treatment of patients who have sustained potentially toxic oral ingestions. The purpose of this study was to determine the frequency of prehospital AC administration and to identify time savings that could potentially result from field AC administration.Methods. Adult patients with a chief complaint of toxic ingestion who had complete emergency medical services (EMS) and emergency department (ED) records and no medical treatment (gastric emptying, AC administration) prior to EMS arrival were eligible for inclusion. Data obtained from EMS and ED records included time of EMS departure from the scene, time of EMS arrival at the ED, and time of administration of AC in the ED. Since most EMS agencies in this system do not insert gastric tubes, patients requiring gastric tube placement for administration of AC were excluded.Results. Twenty-nine of 117 (24.8%) adult patients received oral AC with no other intervention. None of the 117 patients received AC in the prehospital setting. The EMS transport time for these patients ranged from 5 to 43 minutes (mean 16.2 ± 9.7 minutes). The delay from ED arrival to AC administration ranged from 5 to 94 minutes (mean 48.8 ± 24.1 minutes), and was more than 60 minutes for 14 (48.2%) of the patients. The total time interval from scene departure to ED AC administration ranged from 17 to 111 minutes (mean 65.0 ± 25.9 minutes). Conclusions. In a selected subset of patients who tolerate oral AC, prehospital administration of AC could result in earlier and potentially more efficacious AC therapy. Prospective study of the benefits and feasibility of prehospital AC administration is indicated.

From Roadside to Bedside

To determine the current role of rural hospitals and prehospital agencies in the care of motor vehicle crash victims in a remote, rural county prior to the statewide regionalization of trauma care. Specifically, we determined the proportion of crashes that required a response by emergency medical services (EMSs), the timeliness of the response, the proportion of patients treated in local hospitals, and the factors that predicted referral to trauma centers. Population-based retrospective cohort study linking emergency medical services, emergency department, and hospital discharge data to police motor vehicle crash reports and coroner data. Okanogan County, Washington. All motor vehicle occupants, pedestrians or pedalcyclists who were involved in a motor vehicle collision with a response by emergency medical system personnel or the county coroner. None. EMS response times, emergency department and hospital discharge disposition, Injury Severity Scores, hospital length of stay, procedures, deaths. Twelve percent of 669 crashes reported to the police led to the dispatch of EMS. Crashes with EMS involvement were more likely to include occupants without restraints, who were ejected from the vehicle or who had alcohol as a contributing circumstance. The median interval between crash and EMS dispatch was 5 minutes (95th percentile: 40 minutes), the median scene time was 15 minutes (95th percentile: 35 minutes), and the median interval between dispatch and emergency department arrival was 48 minutes (95th percentile: 95 minutes). Among the 210 patients treated by EMSs, 67 (32%) were admitted to local hospitals, and 19 (9%) were referred to a distant trauma center. Of these, 17 were referred directly from the emergency department, one from the scene, and one after local admission. Compared with patients who were admitted locally, referred patients had a significantly higher mean Injury Severity Score (14.4 vs. 5.1), hospital length of stay (9.1 vs. 1.8 days), and rate of operative procedures (37% vs. 9%). Of the 13 crash-related deaths during the year, nine were declared dead at the scene before EMS arrival, three were asystolic at the time of EMS arrival at the scene, and one died at a referral hospital. The linkage of data from police, prehospital agencies, and hospitals can reveal important information about the sequence of health care for trauma patients. The rural hospitals in this county currently play a major role in the stabilization and treatment of motor vehicle crash victims.