Glasgow Coma Scale Scoring is Often Inaccurate.

INTRODUCTION: The Glasgow Coma Scale (GCS) is widely applied in the emergency setting; it is used to guide trauma triage and for the application of essential interventions such as endotracheal intubation. However, inter-rater reliability of GCS scoring has been shown to be low for inexperienced users, especially for the motor component. Concerns regarding the accuracy and validity of GCS scoring between various types of emergency care providers have been expressed. Hypothesis/Problem The objective of this study was to determine the degree of accuracy of GCS scoring between various emergency care providers within a modern Emergency Medical Services (EMS) system. METHODS: This was a prospective observational study of the accuracy of GCS scoring using a convenience sample of various types of emergency medical providers using standardized video vignettes. Ten video vignettes using adults were prepared and scored by two board-certified neurologists. Inter-rater reliability was excellent (Cohen's κ = 1). Subjects viewed the video and then scored each scenario. The scoring of subjects was compared to expert scoring of the two board-certified neurologists. RESULTS: A total of 217 emergency providers watched 10 video vignettes and provided 2,084 observations of GCS scoring. Overall total GCS scoring accuracy was 33.1% (95% CI, 30.2-36.0). The highest accuracy was observed on the verbal component of the GCS (69.2%; 95% CI, 67.8-70.4). The eye-opening component was the second most accurate (61.2%; 95% CI, 59.5-62.9). The least accurate component was the motor component (59.8%; 95% CI, 58.1-61.5). A small number of subjects (9.2%) assigned GCS scores that do not exist in the GCS scoring system. CONCLUSIONS: Glasgow Coma Scale scoring should not be considered accurate. A more simplified scoring system should be developed and validated.

EMS provider compliance with infection control recommendations is suboptimal.

INTRODUCTION: Standard precautions are disease transmission prevention strategies recommended by both the World Health Organization (WHO) and by the Centers for Disease Control and Prevention (CDC). Emergency medical services (EMS) personnel are expected to utilize standard precautions. METHODS: This was a prospective observational study of the use of standard precautions by EMS providers arriving at a large urban emergency department (ED). Research assistants (RAs) observed EMS crews throughout their arrival and delivery of patients and recorded data related to the use of gloves, hand hygiene, and equipment disinfection. RESULTS: A total of 423 EMS deliveries were observed, allowing for observation of 899 EMS providers. Only 512 (56.9%) EMS providers arrived wearing gloves. Hand washing was observed in 250 (27.8%) of providers. Reusable equipment disinfection was noted in only 31.6% of opportunities. The most commonly disinfected item was the stretcher (55%). CONCLUSION: EMS provider compliance with standard precautions and equipment disinfection recommendations is suboptimal. Strategies must be developed to improve EMS provider compliance with internationally recognized infection control guidelines. Key words: Emergency medical services, hand washing, hygiene, disinfection, disease prevention.

The swelling airway. Angioedema is not always caused by allergic reaction.

The case detailed here is relatively rare but can be life-threatening. EMS personnel identified the case, provided the appropriate treatment presuming it to be an allergic reaction. Later, it was determined to have been caused by angioedema, but the staff believed that the prehospital care led to a more rapid diagnosis and subsequent care.

Thin blood. Risk of internal bleeding heightened with anticoagulant therapy.

The case detailed here is not uncommon. A day rarely passes at UMC where we don't evaluate and subsequently admit a patient from the Las Vegas valley and surrounding regions that has sustained an intracranial hemorrhage secondary to oral anticoagulants. Because of this, EMS and emergency department personnel should have an increased incidence of suspicion for the possibility of a bleeding complication in patients taking oral anticoagulants. You should always question patients who have atrial fibrillation in regard to oral anticoagulant usage. In the case discussed here, probing questions by paramedics were able to elucidate a history of atrial fibrillation and the use of an oral anticoagulant. This allowed the paramedics to stratify the patient's risk for hemorrhage and need for further medical care. Ultimately, the patient was assessed and transported to a hospital that could care for any possible complications related to the injury.

Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting.

OBJECTIVE: The objective of this study was to determine the effects of low-fractional concentration of inspired oxygen (FiO(2)) continuous positive airway pressure (CPAP) in prehospital noninvasive ventilation (NIV). With increasing concerns about the detrimental effects of hyperoxia, we sought to determine whether CPAP using a low FiO(2) (28%-30%) was effective in the prehospital setting. METHODS: The study was a six-month prospective, nonblinded observational study conducted in a large, busy urban emergency medical services (EMS) system (Las Vegas, NV). RESULTS: A total of 340 patients participated in the study. Most patients presented with symptoms consistent with a diagnosis of congestive heart failure/acute pulmonary edema (47.4%), followed by chronic obstructive pulmonary disease (COPD) (40.9%), asthma (22.7%), and pneumonia (15.9%). Improvements were seen in respiratory rate (p = 0.00) and oxygen saturation (p = 0.00). The overall CPAP discontinuation rate was 16.5%. The most common reason for CPAP discontinuation was anxiety/claustrophobia. The total number of patients requiring prehospital intubation was 5.6%. Subjective paramedic assessment of patient status at hospital delivery found that 71.5% of patients' conditions were improved, 15.1% remained unchanged, and 13.4% were worse. CONCLUSIONS: CPAP using a low FiO(2) (28%-30%) was highly effective in the treatment of commonly encountered prehospital respiratory emergencies.

Enigmatic rhythm: swift action is key in complex cardiac case.

This was an interesting, yet enigmatic, case. An elderly male with a prolonged QT interval developed a third-degree block with a slow ventricular rate. This spontaneously converted to a polymorphic v tach (probably torsades) that worsened his cardiac output causing pulmonary congestion and hypoxia. He ultimately converted back to a third-degree block following treatment with amiodarone and magnesium sulfate. More importantly, paramedics recognized the complexity of the case and, because of the very short transport time, elected to rapidly transport the patient. Complex cases such as this do not fit into any standardized EMS protocol. Because of this, we need paramedics who see and recognize serious conditions that don't fall within the constraints of algorithmic protocols. In this case, they identified the problem, transported promptly and alerted the staffin a busy ED of the patient's complex and deteriorating condition.

Breaking the surface: Arm yourself with knowledge about penetrating trauma.

Penetrating trauma is a serious emergency that requires prompt prehospital identification, transport, and often, immediate surgical intervention. It's easy to miss some penetrating wounds unless you do a detailed secondary assessment. Remember that penetrating injuries to the head, neck and chest have significant morbidity and mortality. Victims of penetrating trauma have the best outcomes when they're treated in a comprehensive trauma center that allows rapid assessment, necessary imaging and quick access to surgical care in the operating room setting. The role of prehospital personnel is to detect these injuries, provide essential emergency care and ensure that the patient is delivered to the closest appropriate facility.

Miracle in the desert. Cardiac case at remote burning man event presents challenges.

This was a miraculous case that illustrates the importance of seamless interaction between field EMS crews and physicians. First, this case occurred in one of the most austere and hostile environments imaginable. Next, it included a patient who was resuscitated from pulseless v tach with a precordial thump performed by a paramedic crew. The patient was subsequently evaluated and diagnosed with a thoracic aorta dissection by medical staff in a tent (with a diagnosis made by plain chest X-ray) and emergently transported 150 miles to a hospital where successful surgery was carried out. It truly was a "perfect storm," or perhaps, it was the general goodwill and spirit of Burning Man. Or maybe those crystals that were everywhere actually worked.

Can emergency medical services personnel effectively place and use the Supraglottic Airway Laryngopharyngeal Tube (SALT) airway?

BACKGROUND: Various alternative airway devices have been developed in the last several years. Among these is the Supraglottic Airway Laryngopharyngeal Tube (SALT), which was designed to function as a basic mechanical airway and as an endotracheal tube (ET) introducer for blind endotracheal intubation (ETI). OBJECTIVE: To determine the rate of successful placement of the SALT and the success rate of subsequent blind ET insertion by a cohort of emergency medical services (EMS) providers of varying levels of EMS certification. METHODS: This study was a two-phase, two-group nonblinded, prospective time trial using a convenience cohort of prehospital providers to determine the success rate for SALT placement (i.e., the basic life support [BLS] phase) and ET placement using the SALT (i.e., the advanced life support [ALS] phase) in an unembalmed human cadaver model. The part 1 cohort (group 1) comprised predominantly basic and intermediate emergency medical technician (EMT)-level providers, whereas the part 2 cohort (group 2) comprised exclusively paramedic-level providers. RESULTS: In group 1, 51 (98%) of the subjects were able to successfully place the SALT and ventilate the cadaver (BLS phase), with 48 (92.3%) subjects successfully placing it on the first attempt. In group 2, 21 (96%) of the subjects were able to successfully place the SALT, with 19 (86%) placing the SALT on the first attempt. Successful blind placement of an ET through the SALT (ALS phase) by group 1 was 48.1% (95% confidence interval [CI]: 34-62), with 37% (95% CI: 24-51) placing the ET on the first attempt. In group 2, 20 subjects (91% [95% CI: 71-99]) were able to successfully place an ET through the SALT, with 13 (59% [95% CI: 36-79]) doing so on the first attempt. CONCLUSIONS: Emergency medical services providers of varying levels can successfully and rapidly place the SALT and ventilate a cadaver specimen. The success rate for blind placement of an ET through the SALT was suboptimal.

Use of pulse co-oximetry as a screening and monitoring tool in mass carbon monoxide poisoning.

Carbon monoxide (CO) poisoning remains a common cause of poisoning in the United States. We describe a case where responding fire department personnel encountered a sick employee with a headache at an automotive brake manufacturing plant. Using both atmospheric CO monitoring and pulse CO-oximetry technology, fire department personnel were able to diagnose the cause of the patient's illness and later identify the source of CO in the plant.

The disappearing endotracheal tube: historic skill threatened by lack of practice & new devices.

When paramedics were first introduced in the 1970s, one of the most controversial aspects of their training program was endotracheal intubation (ETI). Prior to that, the skill of intubating the trachea was purely the domain of physicians and nurse anesthetists. Thus, it was difficult to secure time when paramedic students could practice their intubations skills on live patients. In actuality, many paramedics of that era were graduated without ever having the opportunity to perform an ETI on a living patient.

Is it time to stop chilling? Induced therapeutic hypothermia doesn't appear to have the prehospital effect we thought it did.

The evidence is quite clear that ITH in the prehospital setting is of dubious benefit. But what is the harm in continuing the practice? Well, prehospital ITH most likely takes away from more beneficial therapies such as high-quality CPR, rapid defibrillation, recognition of ST-segment elevation myocardial infarction (STEMI), and similar essential treatments. Several studies have shown prehospital ITH, in many cases, delays hospital transport. When the initial studies of ITH were released, I was immediately on the ITH bandwagon. Interestingly, the American Heart Association (AHA) has never recommended prehospital ITH. Even the position paper on ITH by the National Association of EMS Physicians (NAEMSP) was cautious, saying, "A lack of evidence on induced hypothermia in the prehospital setting currently precludes recommending this treatment modality as standard of care for all emergency medical services (EMS) patients resuscitated from cardiac arrest. A systematic review of ITH recently published states, "In cardiac arrest, the initiation of therapeutic hypothermia in the out-of-hospital environment has not been shown to improve neurologic outcomes, although studies to date have been limited. We now know that caution Fxercised by the AHA and preMSP was appropriate. One medmy mentors in residency and ays said, "Never be the first- Univtor to prescribe a new drug or of Mlast doctor to prescribe an old is th" Lik" many things in EMS, EMS tms something that was put in Practe with good intent but lim- scientific evidence. We now P ITH is probably not a good ice and it is time to abandon it. However, we should still carry chilled IV fluids for hyperthermia, excited delirium and to main- tainormothermia in patients in cardiac arrest where transport times are long.