Utilization and extravasation of peripheral norepinephrine in the emergency department.

OBJECTIVE: Vasopressors are typically administered through central venous catheters (CVC) due to a historical risk of extravasation with peripheral administration. However, CVC insertion is a time-consuming process that may delay vasopressor administration and is associated with complications. The Virginia Commonwealth University Health System (VCUHS) Emergency Department (ED) implemented a protocol that recommends peripheral norepinephrine (pNE) be administered through an 18 gauge or larger at or above the antecubital fossa or the external jugular vein with a maximum dose of 20 µg/min. This study characterizes the use and incidence of extravasation in all adult patients who received pNE initiated in the VCUHS ED. METHODS: This was an observational, retrospective cohort study in adult patients from March 2016 to March 2019. Of the 331 patients that were screened, 177 met inclusion criteria. Data were analyzed using descriptive statistics. RESULTS: Patients had a median age of 60 years and 59% were male. The median APACHE II score was 25 with an overall hospital mortality of 27%. A majority of patients received pNE for distributive shock (63%). Approximately 69% received pNE through an antecubital infusion site. The median total pNE duration was 62 min (IQR 32, 142). Eighty-four percent of patients received a central line. Only 2.3% of patients had confirmed extravasation in addition to another 2.3% where extravasation could not be excluded, for a total rate of 4.5%. None had subsequent extremity injury. CONCLUSIONS: Administration of pNE according to the VCUHS ED protocol resulted in a low extravasation rate.

When Safety Event Reporting Is Seen as Punitive: "I've Been PSN-ed!"

STUDY OBJECTIVE: Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs. METHODS: Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described. RESULTS: A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%). CONCLUSION: Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.

Patient Safety Event Reporting and Opportunities for Emergency Medicine Resident Education.

INTRODUCTION: Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education. METHODS: Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories. RESULTS: After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and <1% requiring simulation. CONCLUSION: Twenty years after the publication of To Err is Human, gains have been made integrating quality assurance and patient safety within medical education and hospital systems, but there remains extensive work to be done. Through a review and analysis of our patient safety event reporting system, we were able to gain a better understanding of the events that are submitted, including the types of events and their severity, and how these relate to the types of educational interventions provided (eg, feedback, simulation). We also determined that these events can help inform resident education and learning using various types of education. Additionally, incorporating residents in the review process, such as through root cause analyses, can provide residents with high-quality, engaging learning opportunities and useful, lifelong skills, which is invaluable to our learners and future physicians.

Incomplete Spinal Cord Injury With Concurrent Hypertrophic Obstructive Cardiomyopathy.

Traumatic spinal cord injuries are significant contributors to the morbidity and mortality burden of trauma patients worldwide, and consume significant resources in both their acute and rehabilitative care. Another cause of mortality and morbidity is hypertrophic obstructive cardiomyopathy, which can cause syncope or sudden cardiac death in patients with no known prior cardiac disease. This case report describes a unique combination of these two high-risk pathologies in a scene trauma patient, and provides an overview of the pathophysiology and treatment of these high-risk disease processes.

Pediatric Blunt Neck Trauma Causing Esophageal and Complete Tracheal Transection.

BACKGROUND: Blunt injuries to the cervical trachea remain rare but present unique and challenging clinical scenarios for prehospital providers. These injuries depend on prehospital providers either definitively securing the injured airway or bridging the patient to a treatment facility that can mobilize the necessary resources. CASE SUMMARY: The case presented here involves a clothesline injury to a pediatric patient that resulted in complete tracheal transection and partial esophageal transection. Ground and air prehospital providers utilized a stepwise approach to this airway injury and achieved a favorable outcome. The patient was serendipitously intubated through a blind nasal approach that entered the proximal esophagus, exited through the tear and entered the distal trachea. DISCUSSION: There is a paucity of literature describing the successful management of these devastating injuries. While some authors have advocated for early flexible fiberoptic intubation or proceeding directly to tracheostomy, these techniques are not available in the prehospital environment. This case also highlights the inherent issues with proceeding to cricothyroidotomy in patients with tracheal trauma and should give all providers pause before considering this management technique. CONCLUSION: Ultimately, a systematic approach to all airways will ensure that prehospital providers are best prepared for even the most challenging scenarios.

Helicopter Transport in Regionalized Burn Care: One Program's Perspective.

BACKGROUND: The decision to use helicopter EMS (HEMS) for the transport of burn patients is a complex decision. This analysis sought to evaluate burn patients flown to burn centers who met predetermined criteria for patients who likely benefit from HEMS care. METHODS: A retrospective transport chart review of all burn transports covering the preceding nine and a half years was conducted to evaluate for HEMS appropriate criteria defined as patients requiring advanced airway management, ventilator support, facial burns, inhalation injury, circumferential burns, electrical or chemical burn, or major burns. All ages were included. RESULTS: A total of 171 cases were identified. Thirty-one (18.1%) were pediatric. Facial burns constituted the most frequent criteria met with 112 (65.5%) patients identified. Sixty-nine (40.4%) had suspected inhalation injuries. Fifty-five (32.2%) patients were intubated. Forty (28.6%) adults and twelve (38.7%) children had major burns. CONCLUSION: Of the 171 burn patient transported, twenty-one (12.3%) patients did not meet any HEMS criteria. Excluding those who did not meet any criteria, 98 (57.3%) patients were flown with non-major burns. Efforts are needed to determine the risks burn patients face if slower, non-critical care transport is utilized and which patients are appropriate for HEMS.

Does the Implementation of an Advanced Life Support Quick Response Vehicle (QRV) in an Integrated Fire/EMS System Improve Patient Contact Response Time?

BACKGROUND: The current Fire/Emergency Medical Services (EMS) model throughout the United States involves emergency vehicles which respond from a primary location (ie, firehouse or municipal facility) to emergency calls. Quick response vehicles (QRVs) have been used in various Fire/EMS systems; however, their effectiveness has never been studied. OBJECTIVES: The goal of this study was to determine if patient response times would decrease by placing an Advanced Life Support (ALS) QRV in an integrated Fire/EMS system. METHODS: Response times from an integrated Fire/EMS system with an annual EMS call volume of 3,261 were evaluated over the three years prior to the implementation of this study. For a 2-month period, an ALS QRV staffed by a firefighter/paramedic responded to emergency calls during peak call volume hours of 8:00 am to 5:00 pm. The staging of this vehicle was based on historical call volume percentages using respective geocodes as well as system requirements during multiple emergency dispatches. RESULTS: Prior to the study, the citywide average response time for the twelve months preceding was 5.44 minutes. During the study, the citywide average response time decreased to 4.09 minutes, resulting in a 27.62% reduction in patient response time. CONCLUSION: The implementation of an ALS QRV in an integrated Fire/EMS system reduces patient response time. Having a QRV that is not staged continuously in a traditional fire station or municipal location reduces the time needed to reach patients. Also, using predictive models of historic call volume can aid Fire and EMS administrators in reduction of call response times.

Relationship of the distance between non-PCI hospitals and primary PCI centers, mode of transport, and reperfusion time among ground and air interhospital transfers using NCDR's ACTION Registry-GWTG: a report from the American Heart Association Mission: Lifeline Program.

BACKGROUND: ST-segment myocardial infarction patients frequently present to non-percutaneous coronary intervention (PCI) hospitals and require interhospital transfer for primary PCI. The effect of distance and mode of transport to the PCI center and the frequency that recommended primary PCI times are met are not clear. METHODS AND RESULTS: Data from the ACTION Registry(®)-GWTG™ were used to determine the distance between the Non-PCI and PCI center and first door time to balloon time based on transfer mode (ground and air) for patients having interhospital transfer for primary PCI. From July 1, 2008, to December 31, 2012, 17 052 ST-segment myocardial infarction patients were transferred to 413 PCI hospitals. The median distance from the non-PCI hospital to the primary PCI center was 31.9 miles (Q1, Q3: 19.1, 47.9; ground 25.2 miles; air 43.9 miles; P<0.001). At distances <40 miles, ground transport was the primary transport method, whereas at distances >40 miles air transport predominanted. Median first door time to balloon time time for patients transferred for primary PCI was 118 minutes (Q1, Q3: 95 152), with time for patients transported by air significantly longer (median 124 versus 113 minutes; respectively, P<0.001) than for patients transported by ground. Fifty-three percent of patients had a first door time to balloon time ≤120 minutes, with only 20% ≤90 minutes. A first door time to balloon time ≤120 minutes was more likely in ground than in air transport patients (57.0% versus 45.6%; P<0.001). CONCLUSIONS: Interhospital transfer for primary PCI is associated with prolonged reperfusion times. These delays should prompt increased consideration of fibrinolytic therapy, emergency medical services hospital bypass protocols, and improved systems of care for ST-segment myocardial infarction patients requiring transfer.

A patient with altered mental status and possible seizure reveals an atypical aortic dissection upon workup.

Aortic dissection occurs when a tear occurs in the inner muscle wall lining of the aorta, allowing blood to split the muscle layers of the aortic wall apart. It is classically characterized by pain that starts in the upper chest, which then radiates to the upper back and is tearing or ripping in quality. Our objective is to present a case followed by a brief literature review of aortic dissection and uncommon but important features that may be demonstrated. In this report, we present the case of a 57-year-old woman who was transported to the emergency department with an acute episode of altered mental status, presenting as a possible stroke with possible seizures. The patient's only complaint was mild low back pain. Physical examination revealed disorientation to time with no other neurologic deficits or abnormal findings. Results from initial noncontrast head computed tomography, chest radiograph, and laboratory studies were all normal, except for an elevated D-dimer and serum creatinine. Chest computed tomography with contrast demonstrated a type A aortic dissection. The patient was taken emergently to the operating room where the aortic valve and a portion of the ascending aorta were replaced. The patient did well and was discharged from the hospital 5 days later without any permanent sequalae. Aortic dissection is both rare and life threatening and may present with atypical signs. It is important to note that patients may show no signs of typical features or may even display other symptoms based on other branches from the aorta that have been occluded.

Appropriate and safe utilization of helicopter emergency medical services: a joint position statement with resource document.

This position statement with accompanying resource document is the result of a collaborative effort of a writing group comprised of members of the Air Medical Physician Association (AMPA), the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), and the American Academy of Emergency Medicine (AAEM). This document has been jointly approved by the boards of all four organizations. Patients benefit from the appropriate utilization of helicopter emergency medical services (HEMS). EMS and regional health care systems must have and follow guidelines for HEMS utilization to facilitate proper patient selection and ensure clinical benefit. Clinical benefit can be provided by Meaningfully shortening the time to delivery of definitive care to patients with time-sensitive medical conditions Providing necessary specialized medical expertise or equipment to patients before and/or during transport Providing transport to patients inaccessible by other means of transport The decision to use HEMS is a medical decision, separate from the aviation determination whether a transport can be completed safely. Physicians with specialized training and experience in EMS and air medical transport must be integral to HEMS utilization decisions, including guideline development and quality improvement activities. Safety management systems must be developed, adopted, and adhered to by air medical operators when making decisions to accept and continue every HEMS transport. HEMS must be fully integrated within the local, regional, and state emergency health care systems. HEMS programs cannot operate independently of the surrounding health care environment. The EMS and health care systems must be involved in the determination of the number of HEMS assets necessary to provide appropriate coverage for their region. Excessive resources may lead to competitive practices that can affect utilization and negatively impact safety. Inadequate resources will delay receipt of definitive care. National guidelines for appropriate utilization of HEMS must be developed. These guidelines should be national in scope yet allow local, regional, and state implementation. A National HEMS Agenda for the Future should be developed to address HEMS utilization and availability and to identify and support a research strategy for ongoing, evidence-based refinement of utilization guidelines.

Prevalence of troponin elevations in patients with cardiac arrest and implications for assessing quality of care in hypothermia centers.

The prevalence of troponin elevations in patients with cardiac arrest (CA) using newer generation troponin assays when the ninety-ninth percentile is used has not been well described. We studied patients admitted with CA without ST elevation myocardial infarction (MI). Treatment included a multidisciplinary protocol that included routine use of hypothermia for appropriate patients. Serial assessment of cardiac biomarkers, including troponin I was obtained over the initial 24 to 36 hours. Patients were classified into 1 of 5 groups on the basis of multiples of the ninety-ninth percentile (upper reference limit [URL]), using the peak troponin I value: <1×, 1 to 3×, 3 to 5×, 5 to 10×, and >10×. Serial changes between the initial and second troponin I values were also assessed. A total of 165 patients with CA (mean age 58 ± 16, 67% men) were included. Troponin I was detectable in all but 2 patients (99%); all others had peak troponin I values that were greater than or equal to the URL. Most patients had peak troponin I values >10× URL, including patients with ventricular fibrillation or ventricular tachycardia (85%), asystole (50%), and pulseless electrical activity (59%). Serial changes in troponin I were present in almost all patients: ≥20% change in 162 (98%), ≥30% change in 159 (96%), and an absolute increase of ≥0.02 ng/ml in 85% of patients. In conclusion, almost all patients with CA who survived to admission had detectable troponin I, most of whom met biomarker guideline criteria for MI. Given the high mortality of these patients, these data have important implications for MI mortality reporting at CA treatment centers.

Evaluation of appropriateness of patient transfers for hand and microsurgery to a level I trauma center.

BACKGROUND: The transfer of patients for hand and microsurgical emergencies to level I trauma centers is a common practice. Many of these transfers do not actually require a hand specialist and could be taken care of at most regional hospitals. In this study, we will evaluate the appropriateness of patient transfers for hand trauma and determine if there is a correlation between inappropriate transfers and undesirable factors, such as insurance status and off-hour's presentation. METHODS: A retrospective chart review was performed in all patients transferred to a level I trauma center for hand and microsurgical trauma over a 22-month period. Collected data included indication for transfer, mode of transfer, time and day of the week, patient demographics, insurance status, and whether the transferring facilities had surgical coverage available. A synopsis, including treatment details, of each transfer was created, and a survey was sent to a review committee who rated the appropriateness of the transfers. Statistical analysis was performed to determine whether appropriateness of transfers was influenced by nonmedical variables. RESULTS: Over a 22-month period, a total of 95 hand or microsurgical patients were transferred to a single tertiary referral center. Of these, 66 % of the transfers were considered inappropriate by the surveyed physicians. Inappropriate transfers were statistically more likely to be under insured or transferred during nonbusiness hours. CONCLUSION: A large percentage of patients are being transferred to tertiary care centers for reasons other than medical necessity, generating a large burden on already strained medical resources.

Impact of resuscitation system errors on survival from in-hospital cardiac arrest.

BACKGROUND: An estimated 350,000-750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA. METHODS AND RESULTS: We evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5 min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT. CONCLUSIONS: The presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols.

Traumatic tension pneumocephalus after blunt head trauma and positive pressure ventilation.

Pneumocephalus following head trauma is relatively rare, with tension pneumocephalus occurring in an even smaller group of patients. This review presents a recent case of tension pneumocephalus following the use of a manually operated bag-valve-mask to assist ventilations prior to rapid-sequence intubation. A discussion of this case in terms of other reported cases of pneumocephalus after oxygen therapy follows. A limited number of current case reports identified in the literature indicate a connection between pneumocephalus and positive pressure ventilation following blunt trauma. Continuous positive airway pressure (CPAP) ventilation use in patients with an undiagnosed skull fracture is the most common reported cause of ventilation-related pneumocephalus. The case review presented here identifies the use of a bag-valve-mask prior to intubation as a possible contributory cause of the tension pneumocephalus. With only one prior case reported in the literature of pneumocephalus following the use of a bag-valve-mask, this case is unique and may indicate the need for additional awareness for this rare complication. The prehospital diagnosis of pneumocephalus is difficult, as the symptoms and mechanism of injury mimic those associated with intracranial hemorrhage. The use of mannitol in the prehospital treatment of this patient and subsequent improvement in pupillary response may indicate that mannitol has a role in the treatment of tension pneumocephalus when neurosurgical services are not readily available. Additional research is needed to better understand the benefits and risks associated with this treatment modality.

Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation.

CONTEXT: Only 1% to 8% of adults with out-of-hospital cardiac arrest survive to hospital discharge. OBJECTIVE: To compare resuscitation outcomes before and after an urban emergency medical services (EMS) system switched from manual cardiopulmonary resuscitation (CPR) to load-distributing band (LDB) CPR. DESIGN, SETTING, AND PATIENTS: A phased, observational cohort evaluation with intention-to-treat analysis of 783 adults with out-of-hospital, nontraumatic cardiac arrest. A total of 499 patients were included in the manual CPR phase (January 1, 2001, to March 31, 2003) and 284 patients in the LDB-CPR phase (December 20, 2003, to March 31, 2005); of these patients, the LDB device was applied in 210 patients. INTERVENTION: Urban EMS system change from manual CPR to LDB-CPR. MAIN OUTCOME MEASURES: Return of spontaneous circulation (ROSC), with secondary outcome measures of survival to hospital admission and hospital discharge, and neurological outcome at discharge. RESULTS: Patients in the manual CPR and LDB-CPR phases were comparable except for a faster response time interval (mean difference, 26 seconds) and more EMS-witnessed arrests (18.7% vs 12.6%) with LDB. Rates for ROSC and survival were increased with LDB-CPR compared with manual CPR (for ROSC, 34.5%; 95% confidence interval [CI], 29.2%-40.3% vs 20.2%; 95% CI, 16.9%-24.0%; adjusted odds ratio [OR], 1.94; 95% CI, 1.38-2.72; for survival to hospital admission, 20.9%; 95% CI, 16.6%-26.1% vs 11.1%; 95% CI, 8.6%-14.2%; adjusted OR, 1.88; 95% CI, 1.23-2.86; and for survival to hospital discharge, 9.7%; 95% CI, 6.7%-13.8% vs 2.9%; 95% CI, 1.7%-4.8%; adjusted OR, 2.27; 95% CI, 1.11-4.77). In secondary analysis of the 210 patients in whom the LDB device was applied, 38 patients (18.1%) survived to hospital admission (95% CI, 13.4%-23.9%) and 12 patients (5.7%) survived to hospital discharge (95% CI, 3.0%-9.3%). Among patients in the manual CPR and LDB-CPR groups who survived to hospital discharge, there was no significant difference between groups in Cerebral Performance Category (P = .36) or Overall Performance Category (P = .40). The number needed to treat for the adjusted outcome survival to discharge was 15 (95% CI, 9-33). CONCLUSION: Compared with resuscitation using manual CPR, a resuscitation strategy using LDB-CPR on EMS ambulances is associated with improved survival to hospital discharge in adults with out-of-hospital nontraumatic cardiac arrest.

A vital and growing organization, the National EMS Memorial Service Honors EMS professionals during annual ceremony.

This submission is a descriptive account of the 2005 National EMS Memorial Service held in Roanoke Virginia to honor EMS personnel who have recently experienced line of duty deaths. Included is a brief history of the National EMS Memorial, a description of the service, and a list of the honorees, including two from the authors EMS agency. In addition the impact of the service on the survivors of the honorees and the commitment of those who operate and support the memorial is briefly described.