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A pinboard by
Matt Holland

This board is owned by Matt Holland, LKS ASE, Librarian. Contact Matt.Holland@nwas.nhs.uk.

PINBOARD SUMMARY

Hosts recent articles from research based journals. Pinboard started in September 2016.

Coverage

This board collates published research on the prehospital and paramedic Practice.

Audience

The board is aimed at those working in Ambulance Services and Prehospital Care. Anyone can look.

Updates

The board is updated regularly. Somewhere between daily and weekly depending on the volume of publication.

Who is responsible

This board is maintained and run by Matt Holland, Librarian LKS ASE Matt.Holland@nwas.nhs.uk.

More about LKS ASE

Check the LKS ASE website to find out more about us. Follow us on Twitter, our Twitter handle is @NWASLibrary.

1551 ITEMS PINNED

The distribution of sediment and water column nitrification potential in the hyper-turbid Ems estuary

Abstract: Estuaries, being transition zones between land and ocean, act as sink or source of nitrate and thus influence the conditions in adjacent coastal waters. Hence, nitrification, which is the process oxidizing ammonium via nitrite to nitrate and simultaneously consuming oxygen, is important in estuaries. The process has been studied in sediment and water column of many estuaries, but seldom in both estuarine compartments at the same time. In August 2014, we collected water and sediment samples during a sampling trip along the salinity gradient of the hyper-turbid Ems estuary, which ends up in the North Sea. We conducted nitrification incubations in microcosms to determine nitrification potentials and we measured a suite of abiotic factors like oxygen saturation, salinity, and dissolved inorganic nitrogen (DIN). Two approaches were used, one isotope dilution method for net (NNP) and gross (GNP) nitrification potentials and one method with substrate addition for substrate induced nitrification potentials (SNP). The long-term incubation set-ups of several days include inseparably nitrification-coupled processes like remineralization and nitrate consumption, as well as cell growth, and hence they do not represent in-situ rates of nitrification. DNA was also isolated and used for quantitative PCR of the archaeal and bacterial amoA genes, which encode for the ammonia-oxidizing enzyme ammonia monooxygenase (AMO). Nitrification varied over the salinity gradient of the estuary. GNP in water and sediments decreased with increasing salinity. No NNP could be measured in the sediments of the oligohaline part of the estuary, while SNP was four-fold higher than GNP in this part of the estuary. Generally, the gene abundance of the amoA gene was higher in the oligohaline/mesohaline area than in the polyhaline area, and archaea dominated the ammonia-oxidizing communities in all samples. The local similarity in partitioning of archaeal and bacterial amoA genes over the water column and sediment at each sampling station along the estuarine gradient implied a link between the archaeal and bacterial ammonia oxidizers in both compartments, which is likely due to resuspension of sediment particles in the water column of this hyper-turbid estuary.

Pub.: 05 Jul '18, Pinned: 12 Jul '18

Defining the plateau point: When are further attempts futile in out-of-hospital advanced airway management?

Abstract: We sought to characterize the number of attempts required to achieve advanced airway management (AAM) success. Using 4 years of data from a national EMS electronic health record system, we examined the following subsets of attempted AAM: 1) cardiac arrest intubation (CA-ETI), 2) non-arrest medical intubation (MED-ETI), 3) non-arrest trauma intubation (TRA-ETI), 4) rapid-sequence intubation (RSI), 5) sedation-assisted ETI (SAI), and 6) supraglottic airway (SGA). We determined the first pass and overall success rates, as well as the point of additional attempt futility ("plateau point"). Among 57,209 patients there were 64,291 AAM. CA-ETI performance was: first-pass success (FPS) 71.4% (95% CI: 70.9-71.9%), 4 attempts to reach 91.5% (91.2-91.9%) success plateau. MED-ETI performance was: FPS 66.0% (95% CI: 65.1-67.0%), 3 attempts to reach 79.2% (78.4-80.0%) success plateau. TRA-ETI performance was: FPS 61.6% (95% CI: 59.3-63.9%), 3 attempts to reach 75.8% (73.7-77.8%) success plateau. RSI performance was: FPS 76.1% (95% CI: 75.1-77.1%), 5 attempts to reach 95.8% (95.3-96.2%) success plateau. SAI performance was: FPS 66.9% (95% CI: 65.1-68.6%), 3 attempts to 85.3% (83.9-86.6%) success plateau. SGA performance was: FPS 88.7% (95% CI: 88.0-89.3%), 5 attempts to reach 92.8% (92.3-93.4%) success plateau. Multiple attempts are often needed to accomplish successful AAM. The number of attempts needed to accomplish AAM varies with AAM technique. These results may guide AAM practices. Copyright © 2018 Elsevier B.V. All rights reserved.

Pub.: 10 Jul '18, Pinned: 12 Jul '18

Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department.

Abstract: The aim of this study was to determine complication rates and possible risk factors of expert-performed endotracheal intubation (ETI) in patients with trauma, in both the prehospital setting and the emergency department. We also investigated how the occurrence of ETI-related complications affected the survival of trauma patients. This single-center retrospective observational study included all injured patients who underwent anesthesiologist-performed ETI from 2007 to 2017. ETI-related complications were defined as hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak, and mainstem bronchus intubation. Of the 537 patients included, 23.5% experienced at least one complication. Multivariable logistic regression analysis revealed that low Glasgow Coma Scale Score (adjusted odds ratio [AOR], 0.93; 95% confidence interval [CI], 0.88-0.98), elevated heart rate (AOR, 1.01; 95% CI, 1.00-1.02), and three or more ETI attempts (AOR, 15.71; 95% CI, 3.37-73.2) were independent predictors of ETI-related complications. We also found that ETI-related complications decreased the likelihood of survival of trauma patients (AOR, 0.60; 95% CI, 0.38-0.95), independently of age, male sex, Injury Severity Score, Glasgow Coma Scale Score, and off-hours presentation. Our results suggest that airway management in trauma patients carries a very high risk; this finding has implications for the practice of airway management in injured patients.

Pub.: 10 Jul '18, Pinned: 12 Jul '18

Acute harms associated with inhalant misuse: Co-morbidities and trends relative to age and gender among ambulance attendees.

Abstract: Inhalant misuse is the deliberate inhalation of products containing toluene to induce intoxication. Chronic harms associated with inhalant misuse are well described; including alcohol and other drug use, mental health disorders, and suicidal behaviours. However, the nature of the acute harms from inhalants and characteristics of people who experience those harms are not well understood. Therefore, this study aimed to identify the acute harms associated with inhalant misuse attendances, and to determine whether these differ by age or gender. Ambulance attendance data (Victoria, Australia) from January 2012 to June 2017 were extracted from a database of coded ambulance records. 779 ambulance attendances involving inhalant misuse were identified. Attendance characteristics were categorised by age and gender. Co-morbidities of current mental health, self-harm and suicidal behaviour were assessed, plus the involvement of alcohol and other drugs. Overall, attendances related to the acute harms of inhalant misuse have decreased over time, although that trend has reversed from January 2015. Gender differentiated the acute harms associated with inhalant misuse. Males were older and presented with concurrent alcohol and other drug use. Females were younger and presented with concurrent suicidal ideation and self-injury. Attendances for under 15-year-olds are increasing; this age group was over-represented, predominantly female, with a strong association with self-injury. Ambulance presentations related to inhalant misuse were associated with acute and serious harms. This study highlights that the acute treatment needs of those misusing inhalants are complex and may need to be tailored to gender and age groups. Copyright © 2018 Elsevier B.V. All rights reserved.

Pub.: 10 Jul '18, Pinned: 12 Jul '18

A review on ambulance offload delay literature.

Abstract: Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.

Pub.: 10 Jul '18, Pinned: 12 Jul '18

Acute pain in the prehospital setting: a register-based study of 41.241 patients.

Abstract: Acute pain is a frequent symptom, but little is known about the frequency and causes of acute pain in the prehospital population. The objectives of this study were to investigate the frequency of moderate to severe pain among prehospital patients and the underlying causes according to primary hospital diagnose codes. This was a register-based study on 41.241 patients transported by ambulance. Information on moderate to severe pain [Numeric Rating Scale (NRS, 0-10) > 3 or moderate pain or higher on 4-point likert scale] was extracted from a national electronic prehospital patient record. Patient information was merged with primary hospital diagnose codes based on the 10th version of the International Classification of Diseases (ICD-10) to investigate underlying causes of pain. 11.430 patients (27.7%) reported moderate to severe pain during ambulance transport. As a measure of opioid demanding acute pain, 3.275 of 41.241 patients (7.9%) were treated with intravenous fentanyl. Underlying causes of pain were heterogenic according to ICD-10 chapters with injuries being the largest group of patients with moderate to severe pain (XIX: 42.8% of 8.041 patients), followed by non-specific diagnoses (XVIII: 28.5% of 7.101 patients and XXI: 31.6% of 5.148 patients), diseases of the circulatory system (IX: 22.1% of 4.812 patients) and other (20.3% of 16.139 miscellaneous patients). Due to the high frequency of moderate to severe pain affecting a wide range of patients, more attention on acute pain is necessary. Whether ambulance personnel have sufficient options for treating various pain conditions might be a subject of future evaluation. Non-specific diagnoses accounted for surprisingly many patients with moderate to severe pain, of which many were treated with intravenous fentanyl. This may be substance of further investigation. Moderate to severe pain is a highly frequent and probably underestimated symptom among patients transported by ambulance. Underlying causes of pain are heterogenic as described by primary hospital diagnose codes. More focus on the treatment of acute pain is needed.

Pub.: 05 Jul '18, Pinned: 08 Jul '18

Diagnostic Accuracy of Prehospital Tele-Electrocardiography in Acute Coronary Syndrome.

Abstract: Tele-electrocardiography (tele-ECG) is a powerful ally in the screening of acute ischemic lesions. Evidence that confirms the correlation between the diagnosis of acute coronary syndrome (ACS) determined in the prehospital setting and the confirmation of the diagnosis in the hospital setting is scarce. This study compares the presumed diagnosis of ACS in the prehospital setting based on electrocardiographic changes, such as ST-segment deviation, with the diagnosis confirmed in a hospital setting. Retrospective, cross-sectional analysis of medical records of patients who sought emergency ambulance services of a distinguished public healthcare service in the city of Porto Alegre from September 2013 to August 2014. Data were collected from tele-ECG recordings and medical records available at the database of the Secretary of Health. The study was based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Among the 1,338 prehospital examinations performed, a total of 250 admissions in tertiary hospitals were registered. There was a significant agreement (p < 0.01) of 71% of the electrocardiographic changes identified in the prehospital setting with the diagnosis of ACS confirmed in the hospital setting. These changes were more prevalent in men (p = 0.048) and in patients aged 60 years or older (p = 0.006). The tele-ECG allows the early diagnosis of ACS, reducing the delay to definitive treatment, be it reperfusion, chemical, or mechanical therapy. Seventy-two percent of the prehospital diagnosis of ACS based on electrocardiographic changes was later confirmed in the hospital setting.

Pub.: 06 Jul '18, Pinned: 08 Jul '18

Implementation and use of computerised clinical decision support (CCDS) in emergency pre-hospital care: a qualitative study of paramedic views and experience using Strong Structuration Theory.

Abstract: Computerised clinical decision support (CCDS) has been shown to improve processes of care in some healthcare settings, but there is little evidence related to its use or effects in pre-hospital emergency care. CCDS in this setting aligns with policies to increase IT use in ambulance care, enhance paramedic decision-making skills, reduce avoidable emergency department attendances and improve quality of care and patient experience. This qualitative study was conducted alongside a cluster randomised trial in two ambulance services of the costs and effects of web-based CCDS system designed to support paramedic decision-making in the care of older people following a fall. Paramedics were trained to enter observations and history for relevant patients on a tablet, and the CCDS then generated a recommended course of action which could be logged. Our aim was to describe paramedics' experience of the CCDS intervention and to identify factors affecting its implementation and use. We invited all paramedics who had been randomly allocated to the intervention arm of the trial to participate in interviews or focus groups. The study was underpinned by Strong Structuration Theory, a theoretical model for studying innovation based on the relationship between what people do and their context. We used the Framework approach to data analysis. Twenty out of 22 paramedics agreed to participate. We developed a model of paramedic experience of CCDS with three domains: context, adoption and use, and outcomes. Aspects of context which had an impact included organisational culture and perceived support for non-conveyance decisions. Experience of adoption and use of the CCDS varied between individual paramedics, with some using it with all eligible patients, some only with patients they thought were 'suitable' and some never using it. A range of outcomes were reported, some of which were different from the intended role of the technology in decision support. Implementation of new technology such as CCDS is not a one-off event, but an ongoing process, which requires support at the organisational level to be effective. ISRCTN Registry 10538608 . Registered 1 May 2007. Retrospectively registered.

Pub.: 06 Jul '18, Pinned: 08 Jul '18

Identification of the technical and medical requirements for HEMS avalanche rescue missions through a 15-year retrospective analysis in a HEMS in Switzerland: a necessary step for quality improvement.

Abstract: Avalanche rescues mostly rely on helicopter emergency medical services (HEMS) and include technical rescue and complex medical situations under difficult conditions. The adequacy of avalanche victim management has been shown to be unexpectedly low, suggesting the need for quality improvement. We analyse the technical rescue and medical competency requirements of HEMS crewmembers for avalanche rescue missions, as well as their clinical exposure. The study aims to identify areas that should be the focus of future quality improvement efforts. This 15-year retrospective study of avalanche rescue by the Swiss HEMS Rega includes all missions where at least one patient had been caught by an avalanche, found within 24 h of the alarm being raised, and transported. Our analyses included 422 missions (596 patients). Crews were frequently confronted with technical rescue aspects, including winching (29%) and patient location and extrication (48%), as well as multiple casualty accidents (32%). Forty-seven percent of the patients suffered potential or overt vital threat; 29% were in cardiac arrest. The on-site medical management of the victims required a large array of basic and advanced medical skills. Clinical exposure was low, as 56% of the physicians were involved in only one avalanche rescue mission over the study period. Our data provide a solid baseline measure and valuable starting point for improving our understanding of the challenges encountered during avalanche rescue missions. We further suggest QI interventions, that might be immediately useful for HEMS operating under similar settings. A coordinated approach using a consensus process to determine quality indicators and a minimal dataset for the specific setting of avalanche rescue would be the logical next step.

Pub.: 06 Jul '18, Pinned: 08 Jul '18

Impact of prehospital medical evacuation (MEDEVAC) transport time on combat mortality in patients with non-compressible torso injury and traumatic amputations: a retrospective study.

Abstract: In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality. Limited data exist on the influence of transport time on patient outcomes with specific injury types. The objective of this study was to determine the impact of the duration of time from the initial request for medical evacuation to arrival at a medical treatment facility on morbidity and mortality in casualties with traumatic extremity amputation and non-compressible torso injury (NCTI). We completed a retrospective review of MEDEVAC patient care records for United States military personnel who sustained traumatic amputations and NCTI during Operation Enduring Freedom between January 2011 and March 2014. We grouped patients as traumatic amputation and NCTI (AMP+NCTI), traumatic amputation only (AMP), and neither AMP nor NCTI (Non-AMP/NCTI). Analysis was performed using chi-squared tests, Fisher's exact tests, Cochran-Armitage Trend tests, Shapiro-Wilks tests, Wilcoxon and Kruskal-Wallis techniques and Cox proportional hazards regression modeling. We reviewed 1267 records, of which 669 had an injury severity score (ISS) of 10 or greater and were included in the analysis. In the study population, 15.5% sustained only amputation injuries (n=104, AMP only), 10.8% sustained amputation and NCTI (n=72, AMP+NCTI), and 73.7% did not sustain either an amputation or an NCTI (n=493, Non-AMP/NCTI). AMP+NCTI had the highest mortality (16.7%) with transport time greater than 60 min. While the AMP+NCTI group had decreasing survival with longer transport times, AMP and Non-AMP/NCTI did not exhibit the same trend. A decreased transport time from the point of injury to a medical treatment facility was associated with decreased mortality in patients who suffered a combination of amputation injury and NCTI. No significant association between transport time and outcomes was found in patients who did not sustain NCTI. Priority for rapid evacuation of combat casualties should be given to those with NCTI.

Pub.: 07 Jul '18, Pinned: 08 Jul '18

Prehospital non-invasive ventilation in acute respiratory failure is justified even if the distance to hospital is short

Abstract: Publication date: Available online 2 July 2018 Source:The American Journal of Emergency Medicine Author(s): Mario Hensel, Mike Sebastian Strunden, Sascha Tank, Nina Gagelmann, Sebastian Wirtz, Thoralf Kerner Aims Evaluation of the efficacy of prehospital non-invasive ventilation (NIV) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema (CPE). Material and methods Consecutive patients who were prehospitally treated by Emergency Physicians using NIV were prospectively included. A step-by-step approach escalating NIV-application from continuous positive airway pressure (CPAP) to continuous positive airway pressure supplemented by pressure support (CPAP-ASB) and finally bilevel inspiratory positive airway pressure (BIPAP) was used. Patients were divided into two groups according to the prehospital NIV-treatment-time (NIV-group 1: ≤15 min, NIV-group 2: >15 min). In addition, a historic control group undergoing standard care was created. Endpoints were heart rate, peripheral oxygen saturation, breathing rate, systolic blood pressure, and a dyspnoe score. Results A total of 99 patients were analyzed (NIV-group 1: n = 41, NIV-group 2: n = 58). The control group consisted of 30 patients. The majority of NIV-patients (90%) received CPAP-ASB, while CPAP without ASB was conducted in 8% and BIPAP-ventilation in 2% of all cases. Technical application of NIV lasted 6.1 ± 3.8 min. NIV-treatment-time was as follows: NIV-group 1: 13.1 ± 3.2 min, NIV-group 2: 22.8 ± 5.9 min. Differences between baseline- and hospital admission values of all endpoints showed significantly better improvement in NIV-groups compared to the control group (p < 0.001). The stabilizing effect of NIV in terms of vital parameters was comparable between both NIV-groups, independent of the duration of treatment (n.s.). Conclusion Prehospital NIV-treatment should be performed in patients with COPD-exacerbation and CPE, even if the distance between emergency scene and hospital is short.

Pub.: 03 Jul '18, Pinned: 08 Jul '18

Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial.

Abstract: Out-of-hospital analgosedation in trauma patients is challenging for emergency physicians due to associated complications. We compared peripheral nerve block (PNB) with analgosedation (AS) as an analgetic approach for patients with isolated extremity injury, assuming that prehospital required medical interventions (e.g. reduction, splinting of dislocation injury) using PNB are less painful and more feasible compared to AS. Thirty patients (aged 18 or older) were randomized to receive either ultrasound-guided PNB (10 mL prilocaine 1%, 10 mL ropivacaine 0.2%) or analgosedation (midazolam combined with s-ketamine or with fentanyl). Reduction-feasibility was classified (easy, intermediate, impossible) and pain scores were assessed using numeric rating scales (NRS 0-10). Eighteen patients were included in the PNB-group and twelve in the AS-group; 15 and 9 patients, respectively, suffered dislocation injury. In the PNB-group, reduction was more feasible (easy: 80.0%, impossible: 20.0%) compared to the AS-group (easy: 22.2%, intermediate: 22.2%, impossible: 55.6%; p = 0.01). During medical interventions, 5.6% [1/18] of the PNB-patients and 58.3% [7/12] of the AS-patients experienced pain (p<0.01). Recorded pain scores were significantly lower in the PNB-group during prehospital medical intervention (median[IQR] NRS PNB: 0[0-0]) compared to the AS-group (6[0-8]; p<0.001) as well as on first day post presentation (NRS PNB: 1[0-5], AS: 5[5-7]; p = 0.050). All patients of the PNB-group would recommend their analgesic technique (AS: 50.0%, p<0.01). Prehospital ultrasound-guided PNB is rapidly performed in extremity injuries with high success. Compared to the commonly used AS in trauma patients, PNB significantly reduces pain intensity and severity.

Pub.: 03 Jul '18, Pinned: 05 Jul '18

A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services.

Abstract: Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation. A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence. The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training. HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

Pub.: 05 Jul '18, Pinned: 05 Jul '18

Medical Attention Seeking After Transient Ischemic Attack and Minor Stroke Before and After the UK Face, Arm, Speech, Time (FAST) Public Education Campaign: Results From the Oxford Vascular Study.

Abstract: Risk of major stroke is high during the hours and days after transient ischemic attack (TIA) and minor stroke but is substantially reduced by urgent medical treatment. Public education campaigns have improved the response after major stroke, but their association with behavior after TIA and minor stroke is uncertain. The number of potentially preventable early recurrent strokes in patients who delay or fail to seek medical attention is unknown. To investigate the association of public education with delays and failure in seeking medical attention after TIA and minor stroke. Prospective population-based study of all patients with TIA or stroke who sought medical attention between April 1, 2002, and March 31, 2014, registered at 9 general practices in Oxfordshire, United Kingdom. Data analysis took place from July 1, 2013, to March 2, 2015. Face, Arm, Speech, Time (FAST) public education campaign in the United Kingdom. Number of early recurrent strokes in patients who delayed or failed to seek medical attention, as well as the odds of seeking urgent attention after TIA and minor stroke before vs after initiation of the public education campaign. Among 2243 consecutive patients with first TIA or stroke (mean [SD] age, 73.6 [13.4] years; 1126 [50.2%] female; 96.3% of white race/ethnicity), 1656 (73.8%) had a minor stroke or TIA. After the FAST campaign, patients with major stroke more often sought medical attention within 3 hours (odds ratio [OR], 2.56; 95% CI, 1.11-5.90; P = .03). For TIA and minor stroke, there was no improvement in use of emergency medical services (OR, 0.79; 95% CI, 0.50-1.23; P for interaction = .03 vs major stroke) or time to first seeking medical attention within 24 hours (OR, 0.75; 95% CI, 0.48-1.19; P for interaction = .006 vs major stroke). Patient perception of symptoms after TIA and minor stroke was associated with more urgent behavior, but correct perception declined after the FAST campaign (from 37.3% [289 of 774] to 27.6% [178 of 645]; OR, 0.64; 95% CI, 0.51-0.80; P < .001). One hundred eighty-eight patients had a stroke within 90 days of their initial TIA or stroke, of whom 93 (49.5%) followed unheeded TIAs for which no medical attention was sought, similar before and after the FAST campaign (43 of 538 [8.0%] before vs 50 of 615 [8.1%] after, P = .93). This study suggests that in contrast to major stroke, extensive FAST-based public education has not improved the response to TIA and minor stroke in the United Kingdom, emphasizing the need for campaigns that are tailored to transient and less severe symptoms.

Pub.: 05 Jul '18, Pinned: 05 Jul '18

Shooting up? Analysis of 182 gunshot injuries presenting to a London major trauma centre over a seven-year period.

Abstract: Introduction Metropolitan Police data, and those from the emergency department at a London major trauma centre show a resurgence in gun crime. The aim of this study was to collect data on all gunshot injuries over a seven-year period at South-East London's trauma hub. Materials and methods This was a retrospective observational study of all gunshot injuries between 1 January 2010 and 31 December 2016 at a London major trauma centre. Information regarding patient demographics, morbidity and mortality was collected. Data from the English indices of multiple deprivation were reviewed in relation to shooting locations and socioeconomic status in South-East London. Results A total of 182 patients from 939,331 emergency admissions presented with firearm injuries. Males comprised 178 (97.8%) victims and 124 (68.1%) were documented as being Black or Afro-Caribbean. The median age was 22 years. Some 124 (71.7%) victims were shot within a 4 km radius of the hospital. The mean indices of multiple deprivation decile ranking in shooting locations compared with non-shooting locations was 2.6 (± 0.1384) and 3.8 (± 0.1149), respectively. A total of 122 (67.0%) patients underwent specialist operative intervention and 111 (61.0%) suffered only superficial or musculoskeletal injuries. Six patients required emergency thoracotomies; three (50.0%) survived to discharge. The median length of stay was 4 days (interquartile range 2-9 days) and 35 (24.0%) were admitted to intensive care. Ten (5.5%) patients died. Discussion and conclusion Firearms injuries are increasing and place a significant burden on hospital resources. Care provided to gunshot victims has improved as a result of recent trauma management initiatives at South-East London's major trauma centre.

Pub.: 03 Jul '18, Pinned: 04 Jul '18

Preventing Emergency Vehicle Crashes: Status and Challenges of Human Factors Issues.

Abstract: This study reports current status of knowledge and challenges associated with the emergency vehicle (police car, fire truck, and ambulance) crashes, with respect to the major contributing risk factors. Emergency vehicle crashes are a serious nationwide problem, causing injury and death to emergency responders and citizens. Understanding the underlying causes of these crashes is critical for establishing effective strategies for reducing the occurrence of similar incidents. We reviewed the broader literature associated with the contributing factors for emergency vehicle crashes: peer-reviewed journal papers; and reports, policies, and manuals published by government agencies, universities, and research institutes. Major risk factors for emergency vehicle crashes identified in this study were organized into four categories: driver, task, vehicle, and environmental factors. Also, current countermeasures and interventions to mitigate the hazards of emergency vehicle crashes were discussed, and new ideas for future studies were suggested. Risk factors, control measures, and knowledge gaps relevant to emergency vehicle crashes were presented. Six research concepts are offered for the human factors community to address. Among the topics are emergency vehicle driver risky behavior carryover between emergency response and return from a call, distraction in emergency vehicle driving, in-vehicle driver assistance technologies, vehicle red light running, and pedestrian crash control. This information is helpful for emergency vehicle drivers, safety practitioners, public safety agencies, and research communities to mitigate crash risks. It also offers ideas for researchers to advance technologies and strategies to further emergency vehicle safety on the road.

Pub.: 03 Jul '18, Pinned: 04 Jul '18

Building A Longitudinal Cohort From 9-1-1 to 1-Year Using Existing Data Sources, Probabilistic Linkage, and Multiple Imputation: A Validation Study.

Abstract: To describe and validate construction of a population-based, longitudinal cohort of injured older adults from 911 call to 1-year follow-up using existing data sources, probabilistic linkage, and multiple imputation. This was a descriptive cohort study conducted in seven counties in Oregon and Washington from January 1, 2011 through December 31, 2011, with follow-up through December 31, 2012. The primary cohort included all injured adults ≥ 65 years served by 44 EMS agencies. We used nine existing databases to assemble the cohort, including: EMS data, two state trauma registries, two state discharge databases, two state vital statistics databases, the Oregon Physician Order for Life-Sustaining Treatment registry, and Medicare claims data. We matched data files using probabilistic linkage and handled missing values with multiple imputation. We independently validated data processes using 1,350 randomly-sampled records for probabilistic linkage and 3,140 randomly-sampled records for variables created from existing data sources. There were 15,649 injured older adults in the primary cohort, with 13,661 (87.3%) total matched records and 9,337 (59.7%) matches to the index ED/hospital visit. The sensitivity of linkage was 99.9% (95% CI 99.3-100%) for any match and 98.3% (95% CI 96.2-99.4%) for index event matches. The specificity of linkage was 95.7% (95% CI 93.7-97.2%) for any match and 100% (95% CI 99.2-100%) for index event matches. Name, date of birth, home zip code, age, and hospital had the highest yield for linkage. Patients with matched records tended to be higher acuity than unmatched patients, suggesting selection bias if unmatched patients were excluded. Compared to hand-abstracted values, the sensitivity of electronically-derived variables ranged from 18.2% (abdominal-pelvic AIS ≥ 3) to 97.4% (in-hospital mortality), with specificity 88.0%-99.8%. A population-based emergency care cohort with long-term outcomes can be constructed from existing data sources with high accuracy and reasonable validity of resulting variables. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Pub.: 04 Jul '18, Pinned: 04 Jul '18

Prehospital personnel's attitudes to pain management.

Abstract: Objectives Pain is one of the most common reasons for patients to seek acute medical care. The management of pain is often inadequate both in the prehospital setting and in the emergency department. Our aim was to evaluate the attitudes towards pain management among prehospital personnel in two Scandinavian metropolitan areas. Methods A questionnaire with 36 items was distributed to prehospital personnel working in Helsinki, Finland (n=70) and to prehospital personnel working in Stockholm, Sweden (n=634). Each item was weighted on a five-level Likert scale. Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Six scales were constructed (Hesitation, Encouragement, Side effects, Evaluation, Perceptions, Pain metre). A Student's t-test, ANOVA, and Pearson Correlation were used for analysis of significance. The response rate among the Finnish prehospital personnel was 66/70 (94.2%) while among the Swedish personnel it was 127/634 (20.0%). The prehospital personnel from Sweden showed significantly more Hesitation to administer pain relief compared to the Finnish personnel (mean 2.01 SD 0.539 vs. 1.67 SD 0.530, p < 0.001). Those who had received pain education at their workplace showed significantly less Hesitation than those who had not participated in education. There was a significant negative correlation (p < 0.01) between Hesitation and Side effects. There was also astatistically significant(p < 0.01) correlation between Perceptions and Hesitation, indicating that a stoic attitude towards pain was associated with indifference to possible Side effects of pain medication (p < 0.05). Conclusions The results show that there was a significant correlation between the extent of education and the prehospital personnel's attitudes to pain management. Gender and age among the prehospital personnel also affected the attitudes to pain management. The main discrepancy between the Swedish and Finnish personnel was that the participants from Stockholm showed statistically significantly more hesitation about administering pain medication compared to the participants from Helsinki. Implications The results of the study highlight the need for continuous medical education (CME) for prehospital personnel. CME and discussions among prehospital personnel may help to make a change in the personnel's attitudes towards pain and pain management in the prehospital context.

Pub.: 19 Jun '18, Pinned: 01 Jul '18

Comparing the Efficacy of Methods for Immobilizing the Cervical Spine.

Abstract: This was a prospective simulator study with 16 healthy male subjects. To compare the relative efficacy of immobilization systems in limiting involuntary movements of the cervical spine using a dynamic simulation model. Relatively few studies have tested the efficacy of immobilization methods for limiting involuntary cervical movement, and only one of these studies used a dynamic simulation system to do so. Immobilization configurations tested were cot alone, cot with cervical collar, long spine board (LSB) with cervical collar and head blocks, and vacuum mattress (VM) with cervical collar. A motion platform reproduced shocks and vibrations from ambulance and helicopter field rides, as well as more severe shocks and vibrations that might be encountered on rougher terrain and in inclement weather (designated as an "augmented" ride). Motion capture technology quantitated involuntary cervical rotation, flexion/extension, and lateral bend. The mean and 95% CI of the mean was calculated for the root mean square (RMS) of angular changes from the starting position and for the maximum range of motion (ROMMAX). All configurations tested decreased cervical rotation and flexion/extension relative to the cot alone. However, the LSB and VM were significantly more effective in decreasing cervical rotation than the cervical collar, and the LSB decreased rotation more than the VM in augmented rides. The LSB and VM, but not the cervical collar, significantly limited cervical lateral bend relative to the cot alone. Under the study conditions, the LSB and the VM were more effective in limiting cervical movement than the cervical collar. Under some conditions, the LSB decreased repetitive and acute movements more than the VM. Further studies using simulation and other approaches will be essential for determining the safest, most effective configuration should providers choose to immobilize patients with suspected spinal injuries. 3.

Pub.: 20 Jun '18, Pinned: 01 Jul '18

Paramedic determination of appropriate emergency department destination.

Abstract: Freestanding emergency departments (FSED) are equipped to care for most emergencies, but do not have all the resources that hospital-based emergency departments (ED) offer. As the number of FSEDs grows rapidly, emergency medical services (EMS) must routinely determine whether a FSED is an appropriate destination. Inappropriate triage may delay definitive care, potentially increasing morbidity, mortality, and resource utilization. We sought to evaluate paramedics' ability in determining whether a FSED is the most appropriate destination. We conducted a retrospective study of two county EMS agencies and two FSEDs over a 25-month period in Alachua and Levy County, Florida, USA. Both EMS agencies allow paramedic discretion in determining transport destination. To determine whether paramedics can correctly identify patients that can be cared for fully at a FSED, our primary outcome was the percentage of patients transported to FSEDs by EMS that were discharged without additional hospital-based resources. We identified 1247 EMS patients that had a selected destination of FSED. We excluded patients that did not arrive at their selected FSED destination, left before FSED disposition, or were transferred from the FSED to unaffiliated hospitals. A total of 1184 patients were included for analysis, and 885 (74.7%) did not require additional hospital resources. Comparing the two EMS agencies yielded similar results. In this study, involving two EMS agencies over a 25-month period, we found that 3 out of 4 patients deemed appropriate for transport to a FSED by a paramedic did not require additional hospital-based services. Copyright © 2018 Elsevier Inc. All rights reserved.

Pub.: 24 Jun '18, Pinned: 01 Jul '18

Effects of prehospital epinephrine administration on neurologically intact survival in bystander-witnessed out-of-hospital cardiac arrest patients with non-shockable rhythm depend on prehospital cardiopulmonary resuscitation duration required to hospital arrival.

Abstract: The effects of prehospital epinephrine administration on post-arrest neurological outcome in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm remain unclear. To examine the time-dependent effectiveness of prehospital epinephrine administration, we analyzed 118,396 bystander-witnessed OHCA patients with non-shockable rhythm from the prospectively recorded all-Japan OHCA registry between 2011 and 2014. Patients who achieved prehospital return of spontaneous circulation without prehospital epinephrine administration were excluded. Patients with prehospital epinephrine administration were stratified according to the time from the initiation of cardiopulmonary resuscitation (CPR) by emergency medical service (EMS) providers to the first epinephrine administration (≤ 10, 11-19, and ≥ 20 min). Patients without prehospital epinephrine administration were stratified according to the time from CPR initiation by EMS providers to hospital arrival (≤ 10, 11-19, and ≥ 20 min). The primary outcome was 1-month neurologically intact survival (cerebral performance category 1 or 2; CPC 1-2). Multivariate logistic regression analysis demonstrated that there was no significant difference in the chance of 1-month CPC 1-2 between patients who arrived at hospital in ≤ 10 min without prehospital epinephrine administration and patients with time to epinephrine administration ≤ 19 min. However, compared to patients who arrived at hospital in ≤ 10 min without prehospital epinephrine administration, patients with time to epinephrine administration ≥ 20 min and patients who arrived at hospital in 11-19, and ≥ 20 min without prehospital epinephrine administration were significantly associated with decreased chance of 1-month CPC 1-2 (p < 0.05, < 0.05, and < 0.001, respectively). In conclusion, when prehospital CPR duration from CPR initiation by EMS providers to hospital arrival estimated to be ≥ 11 min, prehospital epinephrine administered ≤ 19 min from CPR initiation by EMS providers could improve neurologically intact survival in bystander-witnessed OHCA patients with non-shockable rhythm.

Pub.: 25 Jun '18, Pinned: 01 Jul '18

A potential termination of resuscitation rule for EMS to implement in the field for out-of-hospital cardiac arrest: an observational cohort study.

Abstract: Despite international guidelines recommending termination of resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA), their implementation remains low. We aimed to develop and validate a new TOR rule that could allow emergency medical service (EMS) personnel to immediately and objectively decide whether to withhold further resuscitation attempts after their arrival. This observational study evaluated data from OHCA cases in a prospectively collected nationwide Utstein-style Japanese database (2008-2012). Patients were divided into a development cohort (2008-2010, n = 342,055) and a validation cohort (2011-2012, n = 247,283). A new TOR was developed based on multivariable logistic regression analysis of factors that were associated with unfavourable neurological outcomes. Validation was performed based on specificity, the positive predictive value (PPV), and the area under the receiver operating characteristic curve (AUC). Three factors were strongly associated with unfavourable neurological outcomes at one month after OHCA: unshockable initial rhythm (adjusted odds ratio [aOR]: 6.09, 95% confidence interval [CI]: 5.81-6.38), unwitnessed by bystanders (aOR: 5.27, 95% CI: 4.99-5.57), and age of ≥73 years (adjusted OR: 2.34, 95% CI: 2.24-2.45). In the validation cohort, the new TOR rule provided specificity of 0.955 (95% CI: 0.950-0.959), a PPV of 0.996 (95% CI: 0.996-0.997), and an AUC of 0.828 (95% CI: 0.824-0.833). Based on three objective variables: unshockable initial rhythm, unwitnessed by bystanders, and age ≥73 years, which can be collected immediately after the arrival of EMS personnel at the scene, a new TOR can be developed. Our potential new TOR rule provided an excellent PPV (>99%) for unfavourable neurological outcomes at one month after OHCA. Copyright © 2018. Published by Elsevier B.V.

Pub.: 26 Jun '18, Pinned: 01 Jul '18

The role of point of care ultrasound in prehospital critical care: a systematic review.

Abstract: In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations - a large part of these needs to be supervised.

Pub.: 27 Jun '18, Pinned: 01 Jul '18

Prognostic benefit of acute heart failure associated with atherosclerosis: the importance of prehospital medication in patients with severely decompensated acute heart failure.

Abstract: Atherosclerotic diseases sometimes contribute to acute heart failure (AHF). The aim of the present study is to elucidate the prognostic impact of AHF with atherosclerosis. A total of 1226 AHF patients admitted to the intensive care unit were analyzed. AHF associated with atherosclerosis was defined by the etiology: atherosclerosis-AHF group (n = 708) (patients whose etiologies were ischemic heart disease or hypertensive heart disease) or AHF not associated with atherosclerosis (non-atherosclerosis-AHF) group (n = 518). Kaplan-Meier curves showed that the survival rate of the atherosclerosis-AHF group was significantly better than that of the non-atherosclerosis-AHF group within 730 days of follow-up. Regarding pre-hospital medications, atherosclerosis-AHF patients were more likely to be administered nitroglycerin (20.3 vs. 13.7%, p = 0.003), nicorandil (18.8 vs. 7.5%, p < 0.001), angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) (46.5 vs. 38.6%, p = 0.006), β-blocker (33.2 vs. 26.6%, p = 0.014) and statin (30.1 vs. 22.4%, p = 0.003) because of a previous coronary event or atherosclerotic diseases. In sub-group analysis of medication including administered ≥ 3 drugs within 5 medications and ACE-I/ARB, atherosclerosis-AHF significantly decreased the rate of all-cause death within 180 days (hazard ratio (HR) 0.215, 95% CI 0.078-0.593 and HR 0.395, 95% CI 0.244-0.641, respectively) with a significant interaction (p value for interaction 0.022 and 0.005, respectively). Kaplan-Meier curves showed that the 180-days survival rate of the atherosclerosis-AHF group with ACE-I/ARB and ≥ 3 drugs were significantly better than other groups. The AHF patients associated with atherosclerosis lead to be a good long-term outcome. A relationship may exist between efficient treatment including ACE-Is before admission and a good outcome in mid-term.

Pub.: 27 Jun '18, Pinned: 01 Jul '18

Symptoms awareness, emergency medical service utilization and hospital transfer delay in myocardial infarction.

Abstract: The length of time between symptom onset and reperfusion therapy in patients with ST-segment elevation acute myocardial infarction (STEMI) is a key determinant of mortality. Information on this delay is scarce, particularly for developing countries. The objective of the study is to prospectively evaluate the individual components of reperfusion time (RT) in patients with STEMI treated at a University Hospital in 2012. Medical records were reviewed to determine RT, its main (patient delay time [PDT] and system delay time [SDT]) and secondary components and hospital access variables. Cognitive responses were evaluated using a semi-structured questionnaire. A total of 50 patients with a mean age of 59 years (SD = 10.5) were included, 64% of whom were male. The median RT was 430 min, with an interquartile range of 315-750 min. Regarding the composition of RT in the sample, PDT corresponded to 18.9% and SDT to 81.1%. Emergency medical services were used in 23.5% of cases. Patients treated in intermediate care units showed a significant increase in SDT (p = 0.008). Regarding cognitive variables, PDT was approximately 40 min longer among those who answered "I didn't think it was serious" (p = 0.024). In a Brazilian tertiary public hospital, RT was higher than that recommended by international guidelines, mainly because of long SDT, which was negatively affected by time spent in intermediate care units. Emergency Medical Services underutilization was noted. A patient's low perception of severity increased PDT.

Pub.: 27 Jun '18, Pinned: 01 Jul '18

Ambulance-attended opioid overdoses: an examination into overdose locations and the role of a safe injection facility.

Abstract: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited. We used prospective data from ambulance journals in Oslo, Norway to describe the patterns, severity, and outcomes of opioid overdoses, and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses. Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%) and the median age was 35 (range 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median = 4 breaths per minute) when compared to other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those that overdosed in public locations (OR = 1.66, 95% CI= 1.17-2.35), and when the facility was closed (OR = 1.4, 95% CI= 1.04-1.89), were more likely to receive transport for further treatment. Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.

Pub.: 28 Jun '18, Pinned: 01 Jul '18