Defibrillation Strategies for Refractory Ventricular Fibrillation.

BACKGROUND: Despite advances in defibrillation technology, shock-refractory ventricular fibrillation remains common during out-of-hospital cardiac arrest. Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and vector-change (VC) defibrillation (switching defibrillation pads to an anterior-posterior position) have been proposed as defibrillation strategies to improve outcomes in patients with refractory ventricular fibrillation. METHODS: We conducted a cluster-randomized trial with crossover among six Canadian paramedic services to evaluate DSED and VC defibrillation as compared with standard defibrillation in adult patients with refractory ventricular fibrillation during out-of-hospital cardiac arrest. Patients were treated with one of these three techniques according to the strategy that was randomly assigned to the paramedic service. The primary outcome was survival to hospital discharge. Secondary outcomes included termination of ventricular fibrillation, return of spontaneous circulation, and a good neurologic outcome, defined as a modified Rankin scale score of 2 or lower (indicating no symptoms to slight disability) at hospital discharge. RESULTS: A total of 405 patients were enrolled before the data and safety monitoring board stopped the trial because of the coronavirus disease 2019 pandemic. A total of 136 patients (33.6%) were assigned to receive standard defibrillation, 144 (35.6%) to receive VC defibrillation, and 125 (30.9%) to receive DSED. Survival to hospital discharge was more common in the DSED group than in the standard group (30.4% vs. 13.3%; relative risk, 2.21; 95% confidence interval [CI], 1.33 to 3.67) and more common in the VC group than in the standard group (21.7% vs. 13.3%; relative risk, 1.71; 95% CI, 1.01 to 2.88). DSED but not VC defibrillation was associated with a higher percentage of patients having a good neurologic outcome than standard defibrillation (relative risk, 2.21 [95% CI, 1.26 to 3.88] and 1.48 [95% CI, 0.81 to 2.71], respectively). CONCLUSIONS: Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. (Funded by the Heart and Stroke Foundation of Canada; DOSE VF ClinicalTrials.gov number, NCT04080986.).

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, ß-adrenergic receptor antagonists (also known as ß-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Bendamustine and rituximab is well-tolerated and efficient in the treatment of indolent non-Hodgkin's lymphoma and mantle cell lymphoma in elderly: A single center observational study.

Bendamustine and rituximab (BR) is a preferred first-line therapy for indolent non-Hodgkin's lymphoma (iNHL) and mantle cell lymphoma (MCL); however, few reports on BR performance in elderly patients are available to date. We compared safety and efficacy of BR in patients ≥70 years (elderly) vs <70 years (younger) treated at our institution. Among 201 patients, 113 were elderly (median age: 77 years), including 38 patients ≥80 years, and 88 were younger (median age: 62 years). Elderly patients had more bone marrow involvement by lymphoma, anemia, ECOG status 3 and high-risk disease follicular lymphoma (P < .05 for all). Fifty-four percent of elderly received full dose of bendamustine vs 79.5% of younger patients. More elderly patients (54%) vs younger (43.2%) experienced treatment delay. Less elderly proceeded to rituximab maintenance. Overall, the number of adverse events per patient and transformed B-Cell lymphoma/secondary malignancies were similar between groups. Elderly patients had less febrile neutropenia, rituximab-associated infusion reactions, but more herpes zoster reactivation. There were more deaths in the elderly (37.2%) vs younger (10.2%) groups (P < .001), mainly due to non-lymphoma-related causes. With median follow-up of 42 months [4.0-97.0] disease-free survival for the elderly was similar to younger patients. There was no difference between patients <80 and ≥80 years (P = .274). In conclusion, the real-world elderly patients have more advanced disease and higher ECOG status. BR is well-tolerated; elderly patients had lower incidence of febrile neutropenia. Dose reduction and treatment delays are common, but BR efficacy was not affected even in very old patients (≥80 years).

Ventricular Fibrillation Simulated Electrocardiogram Artifact by a Deep Brain Stimulator.

Deep brain stimulation devices can disrupt cardiac rhythm interpretation by causing electrocardiogram artifact. We report the case of a deep brain stimulating device initiating ventricular fibrillation simulated electrocardiogram artifact in the prehospital setting. Mimicked ventricular fibrillation due to a deep brain stimulator has not been documented, and if unrecognized could influence unwarranted or potentially harmful clinical decisions.

Predefibrillation end-tidal CO2 and defibrillation success in out-of-hospital cardiac arrest: an observational cohort study.

BACKGROUND: Predefibrillation end-tidal CO2 (ETCO2) may predict defibrillation success and could guide defibrillation timing in ventricular fibrillation (VF) cardiac arrest. This relationship has only been studied using advanced airways. Our aim was to evaluate this relationship using both basic (bag-valve-mask (BVM)) and advanced airways (supraglottic airways and endotracheal tubes). METHODS: Prehospital patient records and defibrillator files were abstracted for patients with out-of-hospital cardiac arrest in Ontario, Canada, with initial VF cardiac rhythms between 1 January 2018, and 31 December 2019. Analyses assessed the relationship between each predefibrillation ETCO2 reading and defibrillation outcomes at the subsequent 2 min pulse check (ie, VF, asystole, pulseless electrical activity (PEA) or return of spontaneous circulation (ROSC)), accounting for airway types used during resuscitation. Multivariable logistic regression evaluated the association between the first documented predefibrillation ETCO2 and postshock VF termination or ROSC. RESULTS: Of 269 cases abstracted, 153 had predefibrillation ETCO2 measurements and were included in the study. Among these cases, 904 shocks were delivered and 44.4% (n=401) had predefibrillation ETCO2 measured. The first ETCO2 reading was more often from BVM (n=134) than advanced airways (n=19). ETCO2 readings were lower when measured through BVM versus advanced airways (30.5 mm Hg (4.06 kPa) (±14.4 mm Hg (1.92 kPa)) vs 42.1 mm Hg (5.61 kPa) (±22.5 mm Hg (3.00 kPa)), adjANOVA p<0.01). Of all shocks with ETCO2 reading (n=401), no difference in preshock ETCO2 was found for subsequent shocks that resulted in persistent VF (32.2 mm Hg (4.29 kPa) (±15.8 mm Hg (2.11 kPa))), PEA (32.8 mm Hg (4.37 kPa) (±17.1 mm Hg (2.30 kPa))), asystole (32.4 mm Hg (4.32 kPa) (±20.6 mm Hg (2.75 kPa))) or ROSC (32.5 mm Hg (4.33 kPa) (±15.3 mm Hg (2.04 kPa))), analysis of variance p=0.99. In the multivariate analysis using the initial predefibrillation ETCO2, there was no association with VF termination on the subsequent shock (adjusted OR (adjOR) 0.99, 95% CI 0.97 to 1.02, p=0.57) or ROSC (adjOR 1.00, 95% CI 0.97 to 1.03, p=0.94) when evaluated as a continuous or categorical variable. CONCLUSION: Predefibrillation ETCO2 measurement is not associated with VF termination or ROSC when basic and advanced airways are included in the analysis. The role of predefibrillation ETCO2 requires careful consideration of the type of airway used during resuscitation.

A Prospective Observational Cohort Comparison of SARS-CoV-2 Seroprevalence Between Paramedics and Matched Blood Donors in Canada During the COVID-19 Pandemic.

STUDY OBJECTIVE: SARS-CoV-2 represents an occupational risk to paramedics, who work in uncontrolled environments. We sought to identify the occupation-specific risk to paramedics by comparing their seroprevalence of SARS-CoV-2 infection-specific antibodies to that of blood donors in Canada. METHODS: In this prospective cohort study, we performed serology testing (Elecsys Anti-SARS-CoV-2 nucleocapsid assay) on samples from paramedics and blood donors (January to July 2021) in Canada. Paramedic samples were compared to blood donor samples through 1:1-matched (based on age, sex, location, date of blood collection, and vaccination status) and raking weighted comparisons. We compared the seroprevalence with a risk difference (and 95% confidence interval [CI]) and performed secondary analyses within subgroups defined by vaccination status. RESULTS: The 1:1 match included 1,627 cases per group; in both groups, 723 (44%) were women, with a median age of 38. The raking weighted comparison included 1,713 paramedic samples and 19,515 blood donor samples, with similar characteristics. In the 1:1 match, the seroprevalence was similar (difference 1.2; 95% CI -0.20 to 2.7) between paramedics (5.2%) and blood donors (3.9%). The raking weighted comparison was consistent (difference 0.97; 95% CI -0.10 to 2.0). The unvaccinated paramedic samples, in comparison to the blood donor samples, demonstrated a higher seroprevalence in the 1:1 (difference 5.9; 95% CI 1.8 to 10) and weighted (difference 6.5; 95% CI 1.8 to 10) comparisons. Among vaccinated cases, the between-group seroprevalence was similar. CONCLUSION: Overall, paramedics demonstrated similar evidence of prior SARS-CoV-2 infection to that of blood donors. However, among unvaccinated individuals, evidence of prior infection was higher among paramedics compared to blood donors.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Emergency care with lay responders in underserved populations: a systematic review.

OBJECTIVE: To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide. METHODS: We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format. FINDINGS: Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies). CONCLUSION: First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Successful Resuscitation from Refractory Ventricular Fibrillation by BLS Providers Employing Double Sequential External Defibrillation: A Case Report.

Double sequential external defibrillation (DSED) is a novel treatment option for cardiac arrest patients in refractory ventricular fibrillation (VF). There is limited research, however, examining the efficacy of this treatment in clinical practice. Previous research is further confounded by the use of other treatments such as advanced cardiac life support medications. We present the case of the successful use of DSED for refractory out-of-hospital cardiac arrest without the use of advanced life support care.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival.

BACKGROUND: The increasing number of people living in high-rise buildings presents unique challenges to care and may cause delays for 911-initiated first responders (including paramedics and fire department personnel) responding to calls for out-of-hospital cardiac arrest. We examined the relation between floor of patient contact and survival after cardiac arrest in residential buildings. METHODS: We conducted a retrospective observational study using data from the Toronto Regional RescuNet Epistry database for the period January 2007 to December 2012. We included all adult patients (≥ 18 yr) with out-of-hospital cardiac arrest of no obvious cause who were treated in private residences. We excluded cardiac arrests witnessed by 911-initiated first responders and those with an obvious cause. We used multivariable logistic regression to determine the effect on survival of the floor of patient contact, with adjustment for standard Utstein variables. RESULTS: During the study period, 7842 cases of out-of-hospital cardiac arrest met the inclusion criteria, of which 5998 (76.5%) occurred below the third floor and 1844 (23.5%) occurred on the third floor or higher. Survival was greater on the lower floors (4.2% v. 2.6%, p = 0.002). Lower adjusted survival to hospital discharge was independently associated with higher floor of patient contact, older age, male sex and longer 911 response time. In an analysis by floor, survival was 0.9% above floor 16 (i.e., below the 1% threshold for futility), and there were no survivors above the 25th floor. INTERPRETATION: In high-rise buildings, the survival rate after out-of-hospital cardiac arrest was lower for patients residing on higher floors. Interventions aimed at shortening response times to treatment of cardiac arrest in high-rise buildings may increase survival.

A Novel Approach to Improve Time to First Shock in Prehospital STEMI Complicated by Ventricular Fibrillation.

Lethal cardiac arrhythmias such as ventricular fibrillation and pulseless ventricular tachycardia (VF/pVT) complicate up to 6% of all out-of-hospital STEMIs. Typically, paramedics respond to this by applying defibrillation pads and delivering a shock as soon as possible. A recently introduced "pads-on" protocol directed paramedics to apply defibrillation pads to all STEMI patients (regardless of clinical stability) with the aim of decreasing time to first shock. In this article we present two cases of prehospital STEMI complicated by VF to illustrate times to first shock for the two different protocols. One case each of a STEMI complicated by VF before implementation of the pads-on protocol and after the implementation of the protocol is presented. An important difference in the time to first shock is noted between the two patients with STEMI complicated by VF. While it took 2 min 43 s for the pads-off patient to be defibrillated, only 27 s elapsed before the pads-on patient was defibrillated. These two cases demonstrate that the application of defibrillation pads immediately following the diagnosis of prehospital STEMI has the potential to decrease the time to shock in patients suffering VF/pVT.

Prehospital management and identification of sepsis by emergency medical services: a systematic review.

OBJECTIVE: To identify studies describing the accuracy of prehospital sepsis identification and to summarise results of studies of prehospital management of patients with sepsis, severe sepsis or septic shock. METHODS: We conducted a systematic review to retrieve studies that evaluated the prehospital identification or treatment of patients with sepsis by emergency medical services (EMS). Two authors extracted data describing the study characteristics, incidence of sepsis among EMS-transported patients, criteria used to identify sepsis and specific treatments provided to patients with sepsis. When possible, we calculated the sensitivity and specificity of EMS provider diagnosis of sepsis. RESULTS: Our search identified no randomised controlled trials and 16 cohort studies. Eight studies described the identification of sepsis, seven described prehospital management or treatment of sepsis and one described both. The most common approach to the identification of sepsis involved applying systemic inflammatory response syndrome criteria or a combination of vital signs, which had sensitivity ranging from 0.43 to 0.86 when used alone or combined with provider impression. Only four studies collected information required to calculate specificity (0.47-0.87). Meta-analysis was not performed owing to significant heterogeneity and an overall low quality of evidence. A few studies described prehospital sepsis treatment-most commonly intravenous fluid resuscitation. CONCLUSIONS: The evidence suggests that identification of sepsis in the prehospital setting by EMS providers is carried out with varied success, depending on the strategy used; however, high-quality studies are lacking. Relying on provider impression alone had poor sensitivity, but some moderate-quality evidence supporting structured screening for sepsis with vital signs criteria demonstrated modest sensitivity and specificity. Additional research to improve diagnostic accuracy and explore improvements in EMS management is needed.

Prehospital Identification of Underlying Coronary Artery Disease by Community Paramedics.

There is a lack of definitive evidence that preventative, in-home medical care provided by highly trained community paramedics reduces acute health care utilization and improves the overall well-being of patients suffering from chronic diseases. The Expanding Paramedicine in the Community (EPIC) trial is a randomized controlled trial designed to investigate the use of community paramedics in chronic disease management (ClinicalTrials.gov ID: NCT02034045). This case of a patient randomized to the intervention arm of the EPIC study demonstrates how the added layer of frequent patient contact by community paramedics and real-time electronic medical record (EMR) correspondence between the paramedics, physicians and other involved practitioners prevented possible life-threatening complications. The visiting community paramedic deduced the need for an electrocardiogram, which prompted the primary care physician to order a stress test revealing abnormalities and thus a coronary artery bypass graft was performed without emergency procedures, unnecessary financial expenditure or further health degradation such as a myocardial infarction.

Paramedic self-reported exposure to violence in the emergency medical services (EMS) workplace: a mixed-methods cross-sectional survey.

INTRODUCTION: Studies from Australia, Sweden, the United States, and elsewhere have found that paramedics experience violence in the emergency medical services (EMS) workplace. The objective of this study was to describe and explore violence experienced by paramedics in the ground ambulance setting, including types of violence experienced, by whom the violence was perpetrated, actions taken by paramedics, and effects of these episodes. METHOD: A cross-sectional study utilizing a mixed-methods paper survey was provided to a convenience sample of rural, suburban, and urban-based ground ambulance paramedics in two Canadian provinces. Paramedics were asked to describe episodes of verbal assault, intimidation, physical assault, sexual harassment, and sexual assault they were exposed to during the past 12 months. Qualitative questions inquired about the impact of these experiences. Response selections were analyzed using descriptive statistics and regression analysis, and qualitative data was analyzed using descriptive content analysis. RESULTS: A total of 1,884 paramedics were invited to participate and 1,676 responded (89.0%). Most participants (75%) reported experiencing violence in the past 12 months. The most common form of violence reported was verbal assault (67%), followed by intimidation (41%), physical assault (26%), sexual harassment (14%), and sexual assault (3%). Patients were identified as the most common perpetrators of violence. Serious sequellae were qualitatively reported. CONCLUSION: The majority of Canadian paramedics surveyed experience violence in the workplace, which can lead to serious personal and professional sequellae. Strategies should be devised and studied to reduce violent events toward paramedics and to mitigate the impact such events have on the wellbeing of paramedics.