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

Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. NAEMSP recommends:Based on the skill of the clinician and available resources, BVM, SGA, or ETI may be considered as airway management strategies in OHCA.Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest.EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation.Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.

Multimedia Evaluation of EMT-Paramedic Assessment and Management of Pediatric Respiratory Distress.

BACKGROUND: The prehospital care of asthma, bronchiolitis and croup is directed by evidence-based Emergency Medical Services (EMS) protocols. Determining the appropriate intervention for these conditions requires Emergency Medical Technicians-Paramedics (EMT-Ps) to correctly differentiate asthma/bronchospasm, bronchiolitis, and croup. The diagnostic accuracy of EMT-Ps for these pediatric respiratory distress conditions is unknown. OBJECTIVE: We hypothesized increasing provider age, years of provider experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of one's own would be associated with increased accuracy in diagnosis on a validated multimedia questionnaire. METHODS: This is a cross-sectional study of paramedics from a single EMS agency who completed a validated, case-based questionnaire between July and September 2018. The multimedia questionnaire consisted of four cases, each of which included patient videos and lung sound recordings. Paramedics were asked to assess the severity of distress and ascribe the correct diagnosis and prehospital intervention for each case. Each paramedic completed the questionnaire independently. We defined high questionnaire performance a priori as correctly identifying the diagnosis for ≥75% of cases and used multivariate regression to assess factors associated with high questionnaire performance. Provider age and EMS experience were reported in years and analyzed as continuous variables. Volume of pediatric cases was dichotomized to <1 and ≥1 case per shift and having children was dichotomized to either having children or not having children. RESULTS: Of 514 paramedics, 420 (82%) completed the questionnaire. Overall, paramedics correctly assessed the severity of respiratory distress 92% of the time. However, they only ascribed the correct diagnosis 50% and selected the correct intervention(s) 38% of the time. Increasing age, years of experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance. CONCLUSION: Paramedics accurately assessed severity of distress in multimedia cases of asthma/bronchospasm, bronchiolitis and croup in children, but showed significant room for improvement in correctly identifying the diagnosis and in selecting appropriate intervention(s). Age, years of EMS experience, higher volume of clinical pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance.

Challenges and opportunities for more efficient water use and circular wastewater management. The case of Campania Region, Italy.

By 2050, global demand for water is expected to increase by some 55% due to population growth and urbanization. The utilization of large amounts of freshwater in the world, generate huge volumes of wastewater of which, globally, more than 80% is discharged without treatment, thus causing impacts on aquatic ecosystems, human health and economic productivity. More sustainable practices of wastewater management are expected as a way towards circular bioeconomy (CBE) processes, whose goal is to implement closed systems promoting the systematic use of recycling, reuse and recovery of bioproducts and by-products and the reduction of waste generation. This approach, if adopted in the water and wastewater sector, can ensure environmental, economic and social benefits. The reuse of wastewater, on the one hand, reduces the volume of wastewater and the pressure on water bodies; on the other hand, the recovery of nutrients (P or N) and/or other high value bioproducts (biogas, cellulose, biopolymers) from wastewater offers numerous advantages in terms of supplying new raw bio-based materials that can be refed back to supply chains (thus substituting fossil resources) and, at the same time, producing cleaner water to be reused. Nevertheless, while in Europe many industries have demonstrated the ability to recycle and reuse water, in many regions of Italy the sustainable management of water and wastewater is not yet consolidated. In this study we explore the available technological, economic and environmental options concerning water use and wastewater treatment and we apply them to design appropriate scenarios for improved use efficiency and circular management. A comprehensive literature review of the most promising wastewater treatment processes for resources and energy valorization was conducted. The recovery of PHAs, struvite, nitrogen and algal biomass, as potential substitutes for conventional PET, phosphate and nitrogen chemical fertilizers and electricity, respectively, in addition to reusable treated water, were hypothesized and carefully discussed. Resulting scenarios are tested against the present situation of Campania Region (situated in Southern Italy) based on population and demand statistics, in order to develop strategies and policies potentially applicable locally and elsewhere.

Relationship Between Duration of Targeted Temperature Management, Ischemic Interval, and Good Functional Outcome From Out-of-Hospital Cardiac Arrest.

OBJECTIVES: Tailoring hypothermia duration to ischemia duration may improve outcome from out-of-hospital cardiac arrest. We investigated the association between the hypothermia/ischemia ratio and functional outcome in a secondary analysis of data from the Resuscitation Outcomes Consortium Amiodarone, Lidocaine, or Placebo Study trial. DESIGN: Cohort study of out-of-hospital cardiac arrest patients screened for Resuscitation Outcomes Consortium-Amiodarone, Lidocaine, or Placebo Study. SETTING: Multicenter study across North America. PATIENTS: Adult, nontraumatic, out-of-hospital cardiac arrest patients screened for Resuscitation Outcomes Consortium-Amiodarone, Lidocaine, or Placebo Study who survived to hospital admission and received targeted temperature management between May 2012 and October 2015. INTERVENTIONS: Targeted temperature management in comatose survivors of out-of-hospital cardiac arrest. We defined hypothermia/ischemia ratio as total targeted temperature management time (initiation through rewarming) divided by calculated total ischemia time (approximate time of arrest [9-1-1 call or emergency medical services-witnessed] to return of spontaneous circulation). MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital survival with good functional status (modified Rankin Score, 0-3) at hospital discharge. We fitted logistic regression models to estimate the association between hypothermia/ischemia ratio and the primary outcome, adjusting for demographics, arrest characteristics, and Resuscitation Outcomes Consortium enrolling site. A total of 3,429 patients were eligible for inclusion, of whom 36.2% were discharged with good functional outcome. Patients had a mean age of 62.0 years (SD, 15.8), with 69.7% male, and 58.0% receiving lay-rescuer cardiopulmonary resuscitation. Median time to return of spontaneous circulation was 21.1 minutes (interquartile range, 16.1-26.9), and median duration of targeted temperature management was 32.9 hours (interquartile range, 23.7-37.8). A total of 2,579 had complete data and were included in adjusted regression analyses. After adjustment for patient characteristics and Resuscitation Outcomes Consortium site, a greater hypothermia/ischemia ratio was associated with increased survival with good functional outcome (odds ratio, 2.01; 95% CI, 1.82-2.23). This relationship, however, appears to be primarily driven by time to return of spontaneous circulation in this patient cohort. CONCLUSIONS: Although a larger hypothermia/ischemia ratio was associated with good functional outcome after out-of-hospital cardiac arrest in this cohort, this association is primarily driven by duration of time to return of spontaneous circulation. Tailoring duration of targeted temperature management based on duration of time to return of spontaneous circulation or patient characteristics requires prospective study.

Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population.

Objective: To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population. Methods: We performed a prospective, observational study of a convenience sample of adults aged 18 years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject's initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects' medical records were reviewed after their discharge from the hospital to assign the "correct" triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the "correct" assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system. Results: A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43-60) compared to START (36%; 95% CI 28-44), CareFlight (36%; 95% CI 28-44), and TriageSieve (37%; 95% CI 28-45). SALT also had the lowest under-triage rate (26%; 95% CI 19-34) compared to START (57%; 95% CI 48-66), CareFlight (58%; 95% CI 49-66), and TriageSieve (58%; 95% CI 49-66). SALT had the highest over-triage rate (22%; 95% CI 14-29) compared to START (7%; 95% CI 3-12), CareFlight (6%; 95% CI 2-11) and TriageSieve (6%; 95% CI 2-11). Conclusion: We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest.

BACKGROUND: Antiarrhythmic drugs are used commonly in out-of-hospital cardiac arrest for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, but without proven survival benefit. METHODS: In this randomized, double-blind trial, we compared parenteral amiodarone, lidocaine, and saline placebo, along with standard care, in adults who had nontraumatic out-of-hospital cardiac arrest, shock-refractory ventricular fibrillation or pulseless ventricular tachycardia after at least one shock, and vascular access. Paramedics enrolled patients at 10 North American sites. The primary outcome was survival to hospital discharge; the secondary outcome was favorable neurologic function at discharge. The per-protocol (primary analysis) population included all randomly assigned participants who met eligibility criteria and received any dose of a trial drug and whose initial cardiac-arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia was refractory to shock. RESULTS: In the per-protocol population, 3026 patients were randomly assigned to amiodarone (974), lidocaine (993), or placebo (1059); of those, 24.4%, 23.7%, and 21.0%, respectively, survived to hospital discharge. The difference in survival rate for amiodarone versus placebo was 3.2 percentage points (95% confidence interval [CI], -0.4 to 7.0; P=0.08); for lidocaine versus placebo, 2.6 percentage points (95% CI, -1.0 to 6.3; P=0.16); and for amiodarone versus lidocaine, 0.7 percentage points (95% CI, -3.2 to 4.7; P=0.70). Neurologic outcome at discharge was similar in the three groups. There was heterogeneity of treatment effect with respect to whether the arrest was witnessed (P=0.05); active drugs were associated with a survival rate that was significantly higher than the rate with placebo among patients with bystander-witnessed arrest but not among those with unwitnessed arrest. More amiodarone recipients required temporary cardiac pacing than did recipients of lidocaine or placebo. CONCLUSIONS: Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT01401647.).

Self-Assessment Feedback Form Improves Quality of Out-of-Hospital CPR.

Objective: Various continuous quality improvement (CQI) approaches have been used to improve quality of cardiopulmonary resuscitation (CPR) delivered at the scene of out-of-hospital cardiac arrest. We evaluated a post-event, self-assessment, CQI feedback form to determine its impact on delivery of CPR quality metrics. Methods: This before/after retrospective review evaluated data from a CQI program in a midsized urban emergency medical services (EMS) system using CPR quality metrics captured by Zoll Medical Inc. X-series defibrillator ECG files in adult patients (≥18 years old) with non-traumatic out-of-hospital cardiac arrest. Two 9-month periods, one before and one after implementation of the feedback form on December 31, 2013 were evaluated. Metrics included the mean and percentage of goal achievement for chest compression depth (goal: >5 centimeters [cm]; >90%/episode), rate (goal: 100-120 compressions/minute [min]), chest compression fraction (goal: ≥75%), and preshock pause (goal: <10 seconds [sec]). The feedback form was distributed to all EMS providers involved in the resuscitation within 72 hours for self-review. Results: A total of 439 encounters before and 621 encounters after were evaluated including basic life support (BLS) and advanced life support (ALS) providers. The Before Group consisted of 408 patients with an average age of 61 ± 17 years, 61.8% male. The After Group consisted of 556 patients with an average age of 61 ± 17 years, 58.3% male. Overall, combining BLS and ALS encounters, the mean CPR metric values before and after were: chest compression depth (5.0 cm vs. 5.5 cm; p < 0.001), rate (109.6/min vs 114.8/min; p < 0.001), fraction (79.2% vs. 86.4%; p < 0.001), and preshock pause (18.8 sec vs. 11.8 sec; p < 0.001), respectively. Overall, the percent goal achievement before and after were: chest compression depth (48.5% vs. 66.6%; p < 0.001), rate (71.8% vs. 71.7%, p = 0.78), fraction (68.1% vs. 91.0%; p < 0.001), and preshock pause (24.1% vs. 59.5%; p < 0.001), respectively. The BLS encounters and ALS encounters had similar statistically significant improvements seen in all metrics. Conclusion: This post-event, self-assessment CQI feedback form was associated with significant improvement in delivery of out-of-hospital CPR depth, fraction and preshock pause time.

Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population.

INTRODUCTION: It was previously difficult to compare the accuracy of different mass casualty triage systems to one another. This pilot study is one of the first attempts to operationalize an expert panel's criterion standard definitions of triage categories in a pediatric population in order to compare accuracy between different systems. OBJECTIVE: To compare the accuracy of 4 different mass casualty triage systems (SALT, JumpSTART, Triage Sieve, and CareFlight) when used for children. METHODS: We observed the emergency department triage of patients less than 18 years old presenting to the only pediatric specialty hospital/Level 1 trauma center in Milwaukee County, Wisconsin. A single, certified EMS provider observed each patient's initial triage in the emergency department and recorded all findings that were necessary to categorize the patient using each of the 4 mass casualty triage systems being studied. Hospital medical records were then reviewed for each patient and assigned a criterion standard triage category based on the treatments received and final disposition. Descriptive statistics were used to compare accuracy, over-, and under-triage rates for each of the triage systems. RESULTS: A total of 115 subjects were enrolled. Of those, 51% were male and 57% were transported by ambulance. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (59%; 95% CI 50-68) compared to JumpSTART (57%; 95% CI 48-66), CareFlight (56%; 95% CI 47-65), and TriageSieve (56%; 95% CI 46-65). SALT also had the lowest under-triage rate (33%; 95% CI 24-42) compared to JumpSTART (39%; 95% CI 30-48), CareFlight (39%; 95% CI 30-48), and TriageSieve (39%; 95% CI 30-48). SALT had the highest over-triage rate (6%; 95% CI 2-11) compared to JumpSTART (4%; 95% CI 1-8), CareFlight (5%; 95% CI 1-9), and TriageSieve (5%; 95% CI 1-9). However, the confidence intervals for both the accuracy and under-triage rates overlapped between all triage systems. For each triage system, the most common error was designating a patient as "minimal" that, according to the criterion standard, should have been triaged as "delayed." CONCLUSION: We found that the 4 most popular mass casualty triage systems preformed similarly in an emergency department-based pediatric population. None of the systems were extremely accurate, and each demonstrated an unacceptable amount of under-triage. Better differentiating between patients categorized as "minimal" and "delayed" may improve the accuracy of mass casualty triage systems.

Helicopter Emergency Medical Services Utilization.

BACKGROUND: The decision to utilize HEMS is a complex process that involves many considerations. Professional associations and agencies have published guidelines to assist providers with decision making for the utilization of helicopter transport. STUDY OBJECTIVE: Determine if requests for HEMS align with recently published utilization guidelines. STUDY DESIGN: A retrospective chart review was performed during a six-month period. Reviewers versed in Wisconsin HEMS Utilization, NAEMSP, and CAMTS guidelines determined if transport criteria were met. Charts were categorized according to whether or not criteria for each set of recommendations were followed. RESULTS: 514 charts were reviewed; 439 consisted of completed patient transports. CAMTS, NAEMSP, and WI HEMS guidelines satisfied 85.4%, 83.4%, and 53.1% of requests, respectively. Statistically significant differences existed when comparing rates meeting criteria between WI HEMS and CAMTS and between WI HEMS and NAEMSP guidelines (p-value <0.0001). This was true in all subgroups except STEMI, which did not show significant difference. No difference existed between rates for CAMTS and NAEMSP guidelines in any group. CONCLUSION: Significant difference between Wisconsin HEMS utilization versus NAEMSP guidelines, and between Wisconsin HEMS utilization and CAMTS guidelines in all subgroups except STEMI patients exist. No statistically significant difference existed between NAEMSP and CAMTS guidelines.

Antiarrhythmic Drugs for Nonshockable-Turned-Shockable Out-of-Hospital Cardiac Arrest: The ALPS Study (Amiodarone, Lidocaine, or Placebo).

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) commonly presents with nonshockable rhythms (asystole and pulseless electric activity). It is unknown whether antiarrhythmic drugs are safe and effective when nonshockable rhythms evolve to shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia [VF/VT]) during resuscitation. METHODS: Adults with nontraumatic OHCA, vascular access, and VF/VT anytime after ≥1 shock(s) were prospectively randomized, double-blind, to receive amiodarone, lidocaine, or placebo by paramedics. Patients presenting with initial shock-refractory VF/VT were previously reported. The current study was a prespecified analysis in a separate cohort that initially presented with nonshockable OHCA and was randomized on subsequently developing shock-refractory VF/VT. The primary outcome was survival to hospital discharge. Secondary outcomes included discharge functional status and adverse drug-related effects. RESULTS: Of 37 889 patients with OHCA, 3026 with initial VF/VT and 1063 with initial nonshockable-turned-shockable rhythms were treatment-eligible, were randomized, and received their assigned drug. Baseline characteristics among patients with nonshockable-turned-shockable rhythms were balanced across treatment arms, except that recipients of a placebo included fewer men and were less likely to receive bystander cardiopulmonary resuscitation. Active-drug recipients in this cohort required fewer shocks, supplemental doses of their assigned drug, and ancillary antiarrhythmic drugs than recipients of a placebo (P<0.05). In all, 16 (4.1%) amiodarone, 11 (3.1%) lidocaine, and 6 (1.9%) placebo-treated patients survived to hospital discharge (P=0.24). No significant interaction between treatment assignment and discharge survival occurred with the initiating OHCA rhythm (asystole, pulseless electric activity, or VF/VT). Survival in each of these categories was consistently higher with active drugs, although the trends were not statistically significant. Adjusted absolute differences (95% confidence interval) in survival from nonshockable-turned-shockable arrhythmias with amiodarone versus placebo were 2.3% (-0.3, 4.8), P=0.08, and for lidocaine versus placebo 1.2% (-1.1, 3.6), P=0.30. More than 50% of these survivors were functionally independent or required minimal assistance. Drug-related adverse effects were infrequent. CONCLUSIONS: Outcome from nonshockable-turned-shockable OHCA is poor but not invariably fatal. Although not statistically significant, point estimates for survival were greater after amiodarone or lidocaine than placebo, without increased risk of adverse effects or disability and consistent with previously observed favorable trends from treatment of initial shock-refractory VF/VT with these drugs. Together the findings may signal a clinical benefit that invites further investigation. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01401647.

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Importance: Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. Objective: To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. Design, Setting, and Participants: Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. Interventions: Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. Main Outcomes and Measures: The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events. Results: Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). Conclusions and Relevance: Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT02419573.

Prehospital Dextrose Extravasation Causing Forearm Compartment Syndrome: A Case Report.

CASE: A 57-year-old woman was found at home by paramedics to be hypoglycemic with altered mental status. She had multiple attempts at IV access and eventually a 22G IV was established and D50 was infused into her right forearm. Extravasation of the dextrose was noted after approximately 12 g of the medication was infused. She was given a dose of glucagon intramuscularly and her mental status improved. Shortly after her arrival to the emergency department, she was noted to have findings of compartment syndrome of her forearm at the site of the dextrose extravasation. She was evaluated by plastic surgery and taken to the operating room for emergent fasciotomy. She recovered well from the operation. DISCUSSION: D50 is well known to cause phlebitis and local skin necrosis as a complication. This case illustrates the danger of compartment syndrome after D50 extravasation. It is the first documented case of prehospital dextrose extravasation leading to compartment syndrome. There may be safer alternatives to D50 administration and providers must be acutely aware to monitor for D50 infusion complications.

A randomized trial of continuous versus interrupted chest compressions in out-of-hospital cardiac arrest: rationale for and design of the Resuscitation Outcomes Consortium Continuous Chest Compressions Trial.

The Resuscitation Outcomes Consortium is conducting a randomized trial comparing survival with hospital discharge after continuous chest compressions without interruption for ventilation versus currently recommended American Heart Association cardiopulmonary resuscitation with interrupted chest compressions in adult patients with out-of-hospital cardiac arrest without obvious trauma or respiratory cause. Emergency medical services perform study cardiopulmonary resuscitation for 3 intervals of manual chest compressions (each ~2 minutes) or until restoration of spontaneous circulation. Patients randomized to the continuous chest compression intervention receive 200 chest compressions with positive pressure ventilations at a rate of 10/min without interruption in compressions. Those randomized to the interrupted chest compression study arm receive chest compressions interrupted for positive pressure ventilations at a compression:ventilation ratio of 30:2. In either group, each interval of compressions is followed by rhythm analysis and defibrillation as required. Insertion of an advanced airway is deferred for the first ≥6 minutes to reduce interruptions in either study arm. The study uses a cluster randomized design with every-6-month crossovers. The primary outcome is survival to hospital discharge. Secondary outcomes are neurologically intact survival and adverse events. A maximum of 23,600 patients (11,800 per group) enrolled during the post-run-in phase of the study will provide ≥90% power to detect a relative change of 16% in the rate of survival to discharge, 8.1% to 9.4% with overall significance level of 0.05. If this trial demonstrates improved survival with either strategy, >3,000 premature deaths from cardiac arrest would be averted annually.

A consensus-based gold standard for the evaluation of mass casualty triage systems.

INTRODUCTION: Accuracy and effectiveness analyses of mass casualty triage systems are limited because there are no gold standard definitions for each of the triage categories. Until there is agreement on which patients should be identified by each triage category, it will be impossible to calculate sensitivity and specificity or to compare accuracy between triage systems. OBJECTIVE: To develop a consensus-based, functional gold standard definition for each mass casualty triage category. METHODS: National experts were recruited through the lead investigators' contacts and their suggested contacts. Key informant interviews were conducted to develop a list of potential criteria for defining each triage category. Panelists were interviewed in order of their availability until redundancy of themes was achieved. Panelists were blinded to each other's responses during the interviews. A modified Delphi survey was developed with the potential criteria identified during the interview and delivered to all recruited experts. In the early rounds, panelists could add, remove, or modify criteria. In the final rounds edits were made to the criteria until at least 80% agreement was achieved. RESULTS: Thirteen national and local experts were recruited to participate in the project. Six interviews were conducted. Three rounds of voting were performed, with 12 panelists participating in the first round, 12 in the second round, and 13 in the third round. After the first two rounds, the criteria were modified according to respondent suggestions. In the final round, over 90% agreement was achieved for all but one criterion. A single e-mail vote was conducted on edits to the final criterion and consensus was achieved. CONCLUSION: A consensus-based, functional gold standard definition for each mass casualty triage category was developed. These gold standard definitions can be used to evaluate the accuracy of mass casualty triage systems after an actual incident, during training, or for research.

Resuscitation Outcomes Consortium-Amiodarone, Lidocaine or Placebo Study (ROC-ALPS): Rationale and methodology behind an out-of-hospital cardiac arrest antiarrhythmic drug trial.

BACKGROUND: Despite their wide use, whether antiarrhythmic drugs improve survival after out-of-hospital cardiac arrest (OHCA) is not known. The ROC-ALPS is evaluating the effectiveness of these drugs for OHCA due to shock-refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/VT). METHODS: ALPS will randomize 3,000 adults across North America with nontraumatic OHCA, persistent or recurring VF/VT after ≥1 shock, and established vascular access to receive up to 450 mg amiodarone, 180 mg lidocaine, or placebo in the field using a double-blind protocol, along with standard resuscitation measures. The designated target population is all eligible randomized recipients of any dose of ALPS drug whose initial OHCA rhythm was VF/VT. A safety analysis includes all randomized patients regardless of their eligibility, initial arrhythmia, or actual receipt of ALPS drug. The primary outcome of ALPS is survival to hospital discharge; a secondary outcome is functional survival at discharge assessed as a modified Rankin Scale score ≤3. RESULTS: The principal aim of ALPS is to determine if survival is improved by amiodarone compared with placebo; secondary aim is to determine if survival is improved by lidocaine vs placebo and/or by amiodarone vs lidocaine. Prioritizing comparisons in this manner acknowledges where differences in outcome are most expected based on existing knowledge. Each aim also represents a clinically relevant comparison between treatments that is worth investigating. CONCLUSIONS: Results from ALPS will provide important information about the choice and value of antiarrhythmic therapies for VF/VT arrest with direct implications for resuscitation guidelines and clinical practice.

Topical use of phytotherapic cream (Capilen® cream) to prevent radiodermatitis in breast cancer: a prospective historically controlled clinical study.

AIM: The purpose of this study was to evaluate the ability of a topical phytotherapic product (Capilen® cream) to limit acute radiodermitis and delay the use of corticosteroids in patients with breast cancer (BC). METHODS: From January 2012 to August 2012, 30 consecutive patients, undergoing radiotherapy with adjuvant intent, were invited to use Capilen® cream two times daily two weeks before and during radiotherapy. An historical group was used as an external control. Acute skin toxicity was scored weekly according to RTOG/EORTC criteria. Time of occurrence of acute skin toxicity was taken as endpoint. RESULTS: Compliance was good. Overall, no significative statistical difference was observed in rate of acute radiation dermatitis, 46.7% in experimental arm versus 63.3% in the historical control group, although only 3.3% of Capilen® cream treated patients had a G3 acute radiation dermatitis versus 10% of the control group. A delay in the onset of radition dermatitis in patients treated with Capilen® cream (P=0.04) was showed. CONCLUSION: Our findings suggested that Capilen® cream plays a role in reducing acute radiation dermatitis in breast cancer patients treated with adjuvant radiotherapy. Further evidence is needed to confirm these results.

Covid-19 infection in pregnant women: Auditory evaluation in infants.

 Recent studies showed that COVID-19 infection can affect cochleo-vestibular system. The possibility of a vertical transmission is controversial. Some studies suggested that it is possible but unlikely, others find no evidence of vertical transmission. The objective of this study was to investigate whether exposure to COVID-19 during pregnancy or at birth has an impact on the hearing of the offspring. As part of the national hearing screening program, we performed in all newborns between January 2022 and February 2023, TEOAEs (Transient Evoked Otoacoustic Emissions) at birth and at 3 months. For those "REFER" at the third month test, we performed aABR (Automatic Auditory Brainstem Response) at 6 months. We analysed separately result between infants born to COVID-positive mothers during pregnancy and those born to COVID-negative mothers. To statistical verify differences we performed "Chi-square test". We enrolled a total of 157 infants, of whom 16 were born to mothers who had a molecular PCR test positive for COVID-19. In the latter we tested a total of 32 ears and only 1 ear (3,1%) resulted "REFER". On the other hand, in the control group we tested a total of 282 ears and 22 (7,8%) were found to be "REFER". Our study showed no significant differences in audiological assessment between newborns exposed to COVID-19 infection during pregnancy or at birth compared to the unexposed group. However, further studies with a larger patient's sample will be necessary for a more comprehensive evaluation.