Common Iliac Artery Mycotic Pseudoaneurysm Associated with a Prevertebral Infection: A Case Report.

Introduction: Mycotic pseudoaneurysms are rare but severe sequelae of an arterial wall infection. If undiagnosed and untreated they can lead to significant morbidity and mortality through complications such as arterial rupture or dissection. Case report: This report details the case of a 64-year-old-male who developed a left common iliac artery mycotic pseudoaneurysm from Proteus mirabilis, which was associated with a prevertebral abscess. The patient presented with isolated, left lower extremity edema and intermittent fevers. The case is unique in both the pathogen (P mirabilis) and in its association with presumed direct arterial wall infection from an adjacent prevertebral abscess. Conclusion: The obscure presentation highlights the need for a high clinical suspicion of such a diagnosis when a patient presents with a certain constellation of symptoms and the right predisposing risk factors in their history.

Prehospital Surgical Airway Management: An NAEMSP Position Statement and Resource Document.

Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. However, there exists a small portion of patients who are unable to be intubated and cannot be adequately ventilated with either a facemask or a supraglottic airway. These patients require an emergent surgical airway. A surgical airway is an important component of all airway algorithms, and in some cases may be the only viable approach; therefore, it is imperative that EMS agencies that are credentialed to manage airways have the capability to perform surgical airways when appropriate. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends the following for emergency medical services (EMS) agencies that provide advanced airway management.A surgical airway is reasonable in the prehospital setting when the airway cannot be secured by less invasive means.When indicated, a surgical airway should be performed without delay.A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available.Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.

COVID-19: A review of therapeutics under investigation.

The COVID-19 outbreak has disrupted global health care networks and caused thousands of deaths and an international economic downturn. Multiple drugs are being used on patients with COVID-19 based on theoretical and in vitro therapeutic targets. Several of these therapies have been studied, but many have limited evidence behind their use, and clinical trials to evaluate their efficacy are either ongoing or have not yet begun. This review summarizes the existing evidence for medications currently under investigation for treatment of COVID-19, including remdesivir, chloroquine/hydroxychlorquine, convalescent plasma, lopinavir/ritonavir, IL-6 inhibitors, corticosteroids, and angiotensin-converting enzyme inhibitors.

Evaluation of an Integrated Rescue Task Force Model for Active Threat Response.

OBJECTIVE: An integrated response to active threat events is essential to saving lives. Coordination of law enforcement officer (LEO) and emergency medical services (EMS) roles requires joint training, as maximizing survival is a shared responsibility. We sought to evaluate the performance of an integrated LEO-EMS Rescue Task Force (RTF) response to a simulated active shooter incident utilizing objective performance measures. METHODS: Following prior didactic training, we conducted a series of evaluation scenarios for EMS providers and patrol officers in our urban/suburban advanced life support EMS system (pop. 1,000,000). The scenario-tested command staff, LEOs tasked with neutralizing an active shooter threat, and two RTFs of LEOs and EMS providers each tasked with triage and treatment of 11 simulated casualties scattered over 2 office building floors totaling 13,000 square feet. Trained evaluators recorded performance on 30 objective data elements related to LEO-EMS operations/communication, time intervals, and trauma care. Data were analyzed using descriptive statistics and t-tests for between group comparisons. RESULTS: Over 18 days, 69 scenario events evaluated 388 EMS providers and 468 LEOs. Overall median (90th percentile) times in minutes from dispatch were: unified command established 4.1 (5.5), RTF assembled 9.4 (13.5), first victim contact 11.9 (16.5), first victim to internal casualty collection point (CCP) 16.6 (20.8), all victims ready for evacuation 21.6 (26.0). Life-saving interventions included tourniquet placed: 96% (95% CI 92-99) and LEO placed tourniquet: 88% (79-94). Clinical delays included inappropriate chest decompression: 4% (2-9) and unnecessary initial treatment: 17% (12-25). Correct operational actions included communication with LEO to ensure EMS was safe to treat: 70% (61-77) and appropriate CCP selection: 84% (74-91). Incorrect operational actions included failure to maintain protective LEO-EMS formation: 49% (45-62) and inappropriate single patient evacuation: 20% (14-28). Limitations included the lack of a pre-training control group for this novel program. CONCLUSIONS: We described the performance of an integrated LEO-EMS Rescue Task Force response to a simulated active shooter event in a large city. In general, clinical care was appropriate while operational targets can be improved. Objective measurement of response goals may be used for benchmarking and performance improvement for active threat events.

Lack of early defibrillation capability and automated external defibrillators in nursing homes.

OBJECTIVE: To determine the availability of early defibrillation and automated external defibrillators in nursing homes in selected cities. DESIGN: A standardized telephone survey was conducted of all skilled nursing facilities to characterize early defibrillation capabilities. SETTING: The study involved nursing homes in Philadelphia, Omaha, Seattle, and Boston. PARTICIPANTS: All skilled nursing facilities not physically attached to hospitals in the selected cities based on listings from the Centers for Medicare and Medicaid Services as of January 2004. MEASUREMENTS: Each site was queried as to whether or not they had an automated external defibrillator (AED), if they were physically freestanding facilities, if a manual defibrillator was present, and if staff were present 24 hours a day to use the defibrillator. Early defibrillation was defined as the presence of either a manual defibrillator or AED in addition to 24-hour trained staff availability. RESULTS: There were 126 nursing homes identified from the Medicare listing and 81% (102) responded to our phone survey. After exclusion of non-freestanding facilities, 90 nursing homes (71.4%) were available for analysis. Overall, 16.7% (95% CI 8.8-24.5) of nursing homes reported early defibrillation capabilities via manual defibrillator or AEDs; 6.7% (95% CI 1.4-11.9) of nursing homes reported AEDs; 10.0% (95% CI 3.7-16.3) of nursing homes reported manual defibrillators. Nursing homes in Seattle had a higher rate of early defibrillation capability than the other 3 cities. CONCLUSION: Despite the fact that nursing homes have been identified as locations with multiple cardiac arrests, the early defibrillation capabilities and prevalence of AEDs in this setting remains low. AEDs may play a role in improving survival from cardiac arrest in nursing homes. The placement of AEDs in nursing homes needs further consideration and study.

If the bubble bursts.... EMS response to aortic aneurysms & dissections.

An aortic disease patient is typically an older male with a history of atherosclerosis and hypertension. He might have Marfanoid characteristics, a history of cocaine or methamphetamine abuse or history of syphilis. Alternatively, suspect dissection in a pregnant female with complaints consistent with possible aortic problems. During your assessment, zero in on the patient's anatomy. Include aortic phenomena in your differential for chest and back pain. Take blood pressures in both arms. Search the abdomen for pulsatile masses, and be wary of hoarseness and Horner's syndrome.