A Comparison of Etomidate, Ketamine, and Methohexital in Emergency Department Rapid Sequence Intubation.

BACKGROUND: Rapid sequence intubation (RSI) is routinely used for emergent airway management in the emergency department (ED). It involves the use of induction, and paralytic agents help facilitate endotracheal tube placement. OBJECTIVE: In response to a previous national drug shortage resulting in the use of alternative induction agents for RSI, we describe the effectiveness and safety of ED RSI with ketamine or methohexital compared with etomidate. METHODS: We conducted a retrospective, single-center observational study from March 1-August 31, 2012 describing RSI with etomidate, ketamine, and methohexital. All adult patients undergoing RSI in the ED who received etomidate prior to its shortage and methohexital or ketamine during the shortage were included. RESULTS: The study included 47, 9, and 26 patients in the etomidate, ketamine, and methohexital groups, respectively. Successful intubation on the first attempt occurred in 74.5%, 55.6%, and 73.1% of the etomidate, ketamine, and methohexital groups, respectively. The mean number of intubation attempts and time to intubation seemed to be similar in all groups. At least three intubation attempts were required in 22.2% and 7.7% of the ketamine and methohexital groups, respectively, compared with none in the etomidate group. Two aspirations were observed in the etomidate group. CONCLUSION: Methohexital and etomidate had similar rates of successful intubation on the first attempt and seem to be more effective than ketamine. Etomidate may reduce the need for three or more intubation attempts. Larger, prospective studies are needed to determine if ketamine or methohexital are more effective than etomidate for RSI.

Characteristics of Patients with Recurrent Emergency Medical Services Utilization for Symptomatic Hypoglycemia in an Urban Setting.

Background: Symptomatic hypoglycemia frequently results in utilization of emergency medical services (EMS). Understanding the characteristics of hypoglycemic patients with high EMS utilization may help providers optimize resource allocation. Objective: To describe characteristics of patients utilizing EMS for hypoglycemia and to determine if any factors identifiable in the prehospital setting are associated with recurrent EMS utilization. Methods: A retrospective chart review of prehospital care records from an urban EMS system was performed. Patients who received oral glucose, parenteral glucose, or intramuscular glucagon for hypoglycemia over a one-year period were identified. Extracted information included demographics, prehospital treatment, disposition, zip code median income, and the number of subsequent EMS utilizations within 365 days. Results: We identified 549 subjects, mean age 55 years (range 5 to 104, 65% male). The mean glucose level for all patients was 44 mg/dl with standard deviation (SD) of 15. In total, 69% of patients received oral glucose, 26% received parenteral glucose, 3% received glucagon, and 2% received more than one medication. At the index visit, 81% of patients accepted hospital transportation. The rate of recurrent EMS utilization for hypoglycemia was 10%, and 3% of patients had 3 or more repeat utilizations within 365 days. The mean finger-stick glucose at index visit was 39 mg/dL (SD 15) for patients with multiple EMS utilizations and 44 mg/dL (SD 14) for those with one EMS visit (P = 0.006). Repeat utilizers were more likely to have received medications other than oral glucose at index visit, 51% vs. 28% (P < 0.001). Age, gender, median zip code income, and disposition were not associated with recurrent EMS utilization. The overall annual rate of hypoglycemia requiring EMS treatment per estimated diabetic population was 0.84%. Conclusion: A low proportion of patients utilizing EMS for hypoglycemia had subsequent EMS visits within 365 days. Those who did had lower initial blood glucose at the index visit and were more likely to have received prehospital treatment with medications other than oral glucose. Demographic characteristics did not yield any patterns predictive of repeat utilization. Refusing transport to the hospital after EMS treatment for hypoglycemia did not increase the risk of recurrent utilization.

The Use of Field Triage in Disaster and Mass Casualty Incidents: A Survey of Current Practices by EMS Personnel.

BACKGROUND: Mass casualty incident (MCI) triage and the use of triage tags to assign treatment priorities are not fully implemented despite emergency medical services (EMS) personnel training during drills and exercises. OBJECTIVES: To compare current field triage practices during both training and actual MCIs and identify any potential barriers to use. METHODS: During training sessions from November 2015 through March 2016, an anonymous survey was distributed to personnel in 3 distinct types of paid full-time EMS systems: Boston EMS (2-tiered, municipal third-service); Portland Fire Department (fire department-based ALS); and Stokes County EMS (county-based ALS) combined with Forsyth County EMS (county-based ALS). Data included personnel demographics and previous participation experiences in both drill and actual MCIs. Personnel with any prior MCI experience were queried regarding triage tag use and type of algorithm used. Data on barriers to use of triage tags and methods of communication of patient information were also collected. Descriptive statistics were used to analyze responses. RESULTS: Overall survey participation rate was 77.9% (464/596). Among all respondents, 38.7% (179/464) reported participating in both a drill and actual MCI's. In these cases, respondents reported less likely use of triage tags during actual MCI's compared to drills, (34.1 vs. 91.8%, p < 0.01), less likely to complete full triage (16.3 vs. 68.7%, p < 0.01) and less likely to employ geographical triage (56.8 vs. 90.4% p < 0.01). Verbal report was the most common communication method to hospitals (93.1%) when triage tags were not used. Responders reported proximity to the hospital as the most common reason for not using triage tags during an actual MCI (29.5%). CONCLUSIONS: Despite being a fundamental skill in MCI response, triage and other standard practices have not always been utilized in actual events despite training. EMS educators and disaster planners should consider strategies to better incorporate MCI practices during real world events.

Tourniquet Use in a Civilian Emergency Medical Services Setting: A Descriptive Analysis of the Boston EMS Experience.

INTRODUCTION: Despite the resurgence of early tourniquet use for control of exsanguinating limb hemorrhage in the military setting, its appropriate role in civilian emergency medical services (EMS) has been less clear. OBJECTIVE: To describe the experience of prehospital tourniquet use in an urban, civilian EMS setting. METHODS: A retrospective review of EMS prehospital care reports was performed from January 1, 2005 to December 1, 2012. Data, including the time duration of prehospital tourniquet placement, EMS scene time, mechanisms of injury, and patient demographics, underwent descriptive analysis. Outcomes data for participating receiving hospitals were also reviewed. RESULTS: Ninety-eight cases of prehospital tourniquet use were identified. The most common causes of injury were penetrating gunshot or stabbing wounds (67.4%, 66/98); 7.1% (7/98) of cases were due to blunt trauma; 23.5% (23/98) of cases were from nontraumatic hemorrhage related to uncontrolled hemodialysis shunt or wound bleeding; 45.4% (44/97) of cases were placed on a lower extremity; 54.6% (53/97) were placed on an upper extremity. Placement was successful in hemorrhage control in 91% (87/95, 95%CI: 85.9-97.3%) of cases. The average prehospital tourniquet placement time was 14.9 minutes. Half of all tourniquet placements were performed by basic life support providers. Hospital follow-up was available for 96.9% (95/98) of cases. Of these, the tourniquet was removed by EMS in 3.2% (3/95), the emergency department in 54.7% (52/95), or in the operating room (OR) in 31.6% (30/95) of the time; 46.7% (14/30) of these OR cases had a documented vascular injury needing repair. Ten deaths with hospital follow-up data were identified, none of which were due to tourniquet use. There was one case of forearm numbness potentially due to nerve injury and one case with potential vascular complication, representing an overall complication rate of 2.1% (2/95). CONCLUSION: The early use of tourniquets for extremity hemorrhage in an urban civilian EMS setting appears to be safe, with complications occurring infrequently.

Emergency medical services response to active shooter incidents: provider comfort level and attitudes before and after participation in a focused response training program.

INTRODUCTION: Emergency Medical Services (EMS) routinely stage in a secure area in response to active shooter incidents until the scene is declared safe by law enforcement. Due to the time-sensitive nature of injuries at these incidents, some EMS systems have adopted response tactics utilizing law enforcement protection to expedite life-saving medical care. OBJECTIVE: Describe EMS provider perceptions of preparedness, adequacy of training, and general attitudes toward active shooter incident response after completing a tactical awareness training program. METHODS: An unmatched, anonymous, closed-format survey utilizing a five-point Likert scale was distributed to participating EMS providers before and after a focused training session on joint EMS/police active shooter rescue team response. Descriptive statistics were used to compare survey results. Secondary analysis of responses based on prior military or tactical medicine training was performed using a chi-squared analysis. RESULTS: Two hundred fifty-six providers participated with 88% (225/256) pretraining and 88% (224/256) post-training surveys completed. Post-training, provider agreement that they felt adequately prepared to respond to an active shooter incident changed from 41% (92/225) to 89% (199/224), while agreement they felt adequately trained to provide medical care during an active shooter incident changed from 36% (82/225) to 87% (194/224). Post-training provider agreement that they should never enter a building with an active shooter changed from 73% (165/225) to 61% (137/224). Among the pretraining surveys, significantly more providers without prior military or tactical experience agreed they should never enter a building with an active shooter until the scene was declared safe (78% vs 50%, P = .002), while significantly more providers with prior experience felt both adequately trained to provide medical care in an active shooter environment (56% vs 31%, P = .007) and comfortable working jointly with law enforcement within a building if a shooter were still inside (76% vs 56%, P = .014). There was no difference in response to these questions in the post-training survey. CONCLUSIONS: Attitudes and perceptions regarding EMS active shooter incident response appear to change among providers after participation in a focused active shooter response training program. Further studies are needed to determine if these changes are significant and whether early EMS response during an active shooter incident improves patient outcomes.

The impact of heat waves on transport volumes in an urban emergency medical services system: a retrospective review.

INTRODUCTION: Heat waves pose a serious public health risk to particular patient populations, especially in urban areas. Emergency Medical Services (EMS) in many urban areas constitute the first line of regional preparation and response to major heat wave events; however, little is known on heat wave operational impact to the EMS system, such as call volume or demand. OBJECTIVE: To examine the effect of heat wave periods on overall urban EMS system call volume and transport volume as well as the nature of the call types. METHODS: Retrospective review of all emergency medical calls to an urban, two-tiered EMS system performed over a 5-year period from 2006-2010. Heat wave days (HWD) defined as two or more consecutive days of hot weather >32.2°C (90°F) were compared with similar non-heat wave days (nHWD) of the previous year to also include two calendar days prior to and after the heat wave. National Weather Service (NWS) temperature data, daily EMS call volume data, and call type codes were collected and underwent descriptive analysis. RESULTS: Thirty-one HWD were identified and compared with 93 nHWD. The mean maximum temperature for HWD was 34°C (93.2°F) compared with 25.3°C (77.6°F) for nHWD (P < .001). Average daily medical emergency calls (318.4 vs 296.3, P < .001) and actual patients transported per day (247.5 vs 198.3, P < .001) were significantly higher during HWD. There was no difference in daily medical emergency call volume or EMS transports between weekdays or weekend days. No significant differences on various call types were observed between HWD and nHWD except for "heat" related calls (7.7 vs 0.5, P < .001). CONCLUSION: Emergency Medical Services call volumes were significantly increased during heat waves, however there was minimal change in the types of calls received.

Effectiveness of and Adherence to Triage Algorithms During Prehospital Response to Mass Casualty Incidents.

Mass casualty incidents (MCIs) can rapidly exhaust available resources and demand the prioritization of medical response efforts and materials. Principles of triage (i.e., sorting) from the 18th century have evolved into a number of modern-day triage algorithms designed to systematically train responders managing these chaotic events. We reviewed reports and studies of MCIs to determine the use and efficacy of triage algorithms. Despite efforts to standardize MCI responses and improve the triage process, studies and recent experience demonstrate that these methods have limited accuracy and are infrequently used.

A descriptive analysis of occupational health exposures in an urban emergency medical services system: 2007-2009.

INTRODUCTION: Prehospital providers are exposed to various infectious disease hazards. Examining specific infectious exposures would be useful in describing their current trends as well as guidance with appropriate protective measures an emergency medical services (EMS) system should consider. OBJECTIVE: To describe the types of infectious occupational health exposures and associated outcomes reported at an urban EMS system. METHODS: A retrospective review of all reported exposures was performed for a three-year period from January 1, 2007, to December 31, 2009. Descriptive analysis was performed on data such as provider demographics, types of exposures reported, confirmation of exposure based on patient follow-up information, and outcomes. RESULTS: Three hundred ninety-seven exposure reports were filed with the designated infection control officer (ICO), resulting in an overall exposure rate of 1.2 per 1,000 EMS incidents. The most common exposure was to possible meningitis (n = 131, 32.9%), followed by tuberculosis (TB) (n = 68, 17.1%), viral respiratory infections (VRIs) such as influenza or H1N1 (n = 61, 15.4%), and body fluid splashes to skin or mucous membranes (n = 56, 14.1%). Body fluid splashes involving the eyes accounted for 41 cases (10.3%). Only six cases (1.5%) of needlestick injuries were reported. Three hundred thirty-two of all cases (83.6%) were considered true exposures to an infectious hazard, of which 177 (53.3%) were actually confirmed. Half of all exposures required only follow-up with the ICO (52.6%). One hundred twenty-seven cases (31.9%) required follow-up at a designated occupational health services or emergency department. Of these, only 23 cases (18.1%) required treatment. There was a significant trend of increasing incidence of VRI exposures from 2008 to 2009 (6.3% vs. 26.8%, p < 0.001), while a significant decrease in TB exposures was experienced during the same year (22.9% vs. 8.2%, p = 0.002). CONCLUSIONS: Trends in our data suggest increasing exposures to viral respiratory illnesses, whereas exposures to needlestick injuries were relatively infrequent. Efforts should continue to focus on proper respiratory protection to include eye protection in order to mitigate these exposure risks.

Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol.

INTRODUCTION: There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol. METHODS: This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017-December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients' clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia. RESULTS: Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69-0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96-2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use non-opiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns. CONCLUSION: The introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization.

Evaluation of an emergency medical services-based social services referral program for elderly patients.

OBJECTIVE: To describe the preliminary experience of an emergency medical services (EMS)-based follow-up program providing elderly patients access to community-based social services. METHODS: This was a retrospective, case series report. Inclusion criteria were adults aged 60 years and older requesting EMS for fall or lift assist; against medical advice (AMA) refusal of transport for a medical complaint; any social service or home care needs; request for nonmedical transportation; multiple prior EMS visits; or cases of elder abuse or neglect. Patients were identified either by paramedics at the time of the call or an EMS physician during routine chart review of "no-transport" calls. Patients were then contacted and offered referral follow-up with a social services worker. Data were collected for age, gender, presence of established social services, referral strategy, complaint type, referral acceptance rate, and follow-up plan. RESULTS: Seventy patients were referred over eight months. Paramedics provided 33% of referrals (23/70) as well as a significantly higher number of social service-related complaints (48% vs. 15%, p = 0.005). Follow-up from a fall occurred more often after EMS physician chart review (53% vs. 30%, p = 0.07). Rates of established social services were similar for patients who accepted and those who declined follow-up (89% vs. 90%, p = 0.95) and between patients who were referred by paramedics and those who were referred by EMS physicians (93% vs. 90%, p = 0.72). Paramedic referral was associated with a significantly higher rate of acceptance (94% vs. 28%, p < 0.001). CONCLUSION: EMS provides an invaluable opportunity to connect the elderly with social services at the time of contact. In this study, paramedics appeared to refer more social service-related complaints compared with other categories such as fall assistance. This highlights a difference in perception of social service needs among paramedics and represents an area for further training and education.

Providing student health services at sea: a survey of chief complaints onboard a maritime academy training ship.

OBJECTIVE: The authors describe the epidemiology of infirmary chief complaints aboard a collegiate maritime training ship. PARTICIPANTS: They assessed patients (N = 646 visits) evaluated by the USTS Enterprise medical department during a 44-day sea term from January to February 2007. METHODS: The authors conducted a retrospective chart review of infirmary use and extracted information on age, sex, rank, chief complaints, and frequency of visits. RESULTS: Overall, 646 visits were made. The most common complaints were dermatologic (30.1%): rash, skin infection, laceration, and sunburn. Together, ear, nose, and throat and dermatologic complaints accounted for 57.6% of all visits. Work-related complaints accounted for 12.5% of recorded visits. Compared with the ship population, senior and female cadets had more visits than the average. Port departure days were typically the busiest. CONCLUSIONS: Among healthy, college-aged cadets at sea, typical primary care constitute comprise the majority of visits.

Integrating Prolonged Field Care Into Rough Terrain and Mountain Warfare Training: The Mountain Critical Care Course.

Current prolonged field care (PFC) training routinely occurs in simulated physical locations that force providers to continue care until evacuation to definitive care, as based on the staged Ruck-Truck-House-Plane model. As PFC-capable teams move further forward into austere environments in support of the fight, they are in physical locations that do not fit this staged model and may require teams to execute their own casualty evacuation through rough terrain. The physical constraints that come specifically with austere, mountainous terrain can challenge PFC providers to initiate resuscitative interventions and challenge their ability to sustain these interventions during lengthy, dismounted movement over unimproved terrain. In this brief report, we describe our experience with a novel training course designed for PFC-capable medical teams to integrate their level of advanced resuscitative care within a mountainous, rough terrain evacuation-training program. Our goals were to identify training gaps for Special Operations Forces medical units tasked to operate in a cold-weather, mountain environment with limited evacuation resources and the challenges related to maintaining PFC interventions during dismounted casualty movement.

The Use of Emergency Lights and Sirens by Ambulances and Their Effect on Patient Outcomes and Public Safety: A Comprehensive Review of the Literature.

The benefits of emergency lights and sirens (L&S) use as warning devices by ambulances continue to be a debated topic in Emergency Medical Services (EMS). While the most widely studied aspect of L&S use has been related to their effect on ambulance response and transport times, the literature suggests minimal time savings with more questionable impact on actual patient outcomes. As L&S use has been shown to increase the risk for vehicle crashes, the secondary concern of ambulance design and safety also becomes an important aspect on potential design recommendations that could mitigate the effects of a crash on patients, EMS providers, and the general public. The least studied aspect of L&S use (and probably the most important) is their effect on patient outcomes and quality of medical care during transport. The current evidence suggests no significant improvement on patient outcomes and potential worsening to certain aspects of patient care during transport. The purpose of this review was to examine the current literature regarding ambulance L&S use and the risks they pose to EMS providers, patients, and the general public. In doing so, it will provide sound background for EMS leaders to better develop policies governing the use of L&S by ambulances and promote better research in the patient outcomes effect associated with their use. This review offers some strategies in mitigating the risks associated with L&S use, such as ways to reduce their overall use and modifying other related factors to emergency medical vehicle collisions (EMVCs). Murray B , Kue R . The use of emergency lights and sirens by ambulances and their effect on patient outcomes and public safety: a comprehensive review of the literature. Prehosp Disaster Med. 2017;32(2):209-216.

Prehospital diagnosis and management of patients with acute stroke.

Significant advances in the early management of ischemic stroke have been made since the 1995 National Institute of Neurologic Disorders and Stroke data demonstrated the benefit of early intravenous administration of tissue plasminogen activator to select patients with acute ischemic stroke within a 3-hour onset window of suspected stroke symptoms. One concept in stroke care that has become better understood is the importance of time management and the ability to deliver patients with acute stroke to appropriate care as soon as possible. Minimizing delay to definitive therapy remains the current focus in the prehospital phase of stroke care.

Adverse clinical events during intrahospital transport by a specialized team: a preliminary report.

BACKGROUND: Caring for patients during intrahospital transport is a high-risk activity. Few data exist on the use of specialized transport teams similar to the teams used for out-of-hospital transport. OBJECTIVE: To describe the experience with a dedicated, intra-hospital transport program, to report the rate of clinically significant adverse events, and to examine types of adverse events, interventions provided, and outcomes. METHODS: Patient transports within an academic quaternary-care hospital from November 2007 through April 2008 were retrospectively reviewed. Adverse events were defined as extubation, code team activation, death, sustained arrhythmia, hypoxia exceeding 5 minutes, hypotension exceeding 20% of baseline systolic or diastolic blood pressure and requiring intervention, use of physical restraints, or acute change in mental status. RESULTS: A total of 3383 charts were reviewed (91.8% of all completed transports).The overall rate of adverse events was 1.7% (59 events). Most events were related to hypoxia (25/59) and blood pressure changes (25/59). One extubation and one code team activation occurred. Most interventions involved adjustments to oxygen therapy (22/59) and vasopressor management (18/59). Only 12 (20.3%) of the transports with adverse events were aborted, more often during magnetic resonance imaging (χ(2) = 6.86, df = 1, P = .01) and in older patients (mean [SD], 70.8 [14.2] vs 58.7 [14.9] years; P = .02). CONCLUSIONS: The rate of clinically significant adverse events during patient transport by a specialized team is relatively low. Further studies are needed to compare effectiveness and mortality benefits between intrahospital transport teams and traditional transport teams.