Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.

BACKGROUND: Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard management by emergency medical services (EMS). Whether and how much MSUs alter outcomes has not been extensively studied. METHODS: In an observational, prospective, multicenter, alternating-week trial, we assessed outcomes from MSU or EMS management within 4.5 hours after onset of acute stroke symptoms. The primary outcome was the score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes according to a patient value system, derived from scores on the modified Rankin scale of 0 to 6, with higher scores indicating more disability). The main analysis involved dichotomized scores on the utility-weighted modified Rankin scale (≥0.91 or <0.91, approximating scores on the modified Rankin scale of ≤1 or >1) at 90 days in patients eligible for t-PA. Analyses were also performed in all enrolled patients. RESULTS: We enrolled 1515 patients, of whom 1047 were eligible to receive t-PA; 617 received care by MSU and 430 by EMS. The median time from onset of stroke to administration of t-PA was 72 minutes in the MSU group and 108 minutes in the EMS group. Of patients eligible for t-PA, 97.1% in the MSU group received t-PA, as compared with 79.5% in the EMS group. The mean score on the utility-weighted modified Rankin scale at 90 days in patients eligible for t-PA was 0.72 in the MSU group and 0.66 in the EMS group (adjusted odds ratio for a score of ≥0.91, 2.43; 95% confidence interval [CI], 1.75 to 3.36; P<0.001). Among the patients eligible for t-PA, 55.0% in the MSU group and 44.4% in the EMS group had a score of 0 or 1 on the modified Rankin scale at 90 days. Among all enrolled patients, the mean score on the utility-weighted modified Rankin scale at discharge was 0.57 in the MSU group and 0.51 in the EMS group (adjusted odds ratio for a score of ≥0.91, 1.82; 95% CI, 1.39 to 2.37; P<0.001). Secondary clinical outcomes generally favored MSUs. Mortality at 90 days was 8.9% in the MSU group and 11.9% in the EMS group. CONCLUSIONS: In patients with acute stroke who were eligible for t-PA, utility-weighted disability outcomes at 90 days were better with MSUs than with EMS. (Funded by the Patient-Centered Outcomes Research Institute; BEST-MSU ClinicalTrials.gov number, NCT02190500.).

Association between a Post-Resuscitation Care Bundle and the Odds of Field Rearrest after Successful Resuscitation from Out-of-Hospital Cardiac Arrest: A Pre/Post Study.

OBJECTIVES: Rearrest after successful resuscitation from out-of-hospital cardiac arrest (OHCA) is common and is associated with worse patient outcomes. However, little is known about the effect of interventions designed to prevent rearrest. We assessed the association between a prehospital care protocol for immediate management after return of spontaneous circulation (ROSC) and rates of field rearrest and survival to discharge in patients with prehospital ROSC. METHODS: This was a retrospective study of adult patients with OHCA and field ROSC within a large EMS system before (April 2017-August 2018) and after (April 2019-February 2020) implementation of a structured prehospital post-ROSC care protocol. The protocol was introduced in September 2018 and provided on-scene stabilization direction including guidance on ventilation and blood pressure support. Field data and hospital outcomes were used to compare the frequency of field rearrest, hospital survival, and survival with good neurologic outcome before and after protocol implementation. Logistic regression was used to assess the association between the post-implementation period and these outcomes, and odds ratios were reported. The association between individual interventions on these outcomes was also explored. RESULTS: There were 2,706 patients with ROSC after OHCA in the pre-implementation period and 1,780 patients in the post-implementation period. The rate of prehospital rearrest was 43% pre-implementation vs 45% post-implementation (RD 2%, 95% CI -1, 4%). In the adjusted analysis, introduction of the protocol was not associated with decreased odds of rearrest (OR 0.87, 95% CI 0.73, 1.04), survival to hospital discharge (OR 1.01, 95% CI 0.81, 1.24), or survival with good neurologic outcome (OR 0.81, 95% CI 0.61, 1.06). Post-implementation, post-ROSC administration of saline and push-dose epinephrine increased from 11% to 25% (RD 14%, 95% CI 11, 17%) and from 3% to 12% (RD 9% 95% CI 7, 11%), respectively. In an exploratory analysis, push-dose epinephrine was associated with a decreased odds of rearrest (OR 0.68, 95% CI 0.50, 0.94). CONCLUSIONS: Introduction of a post-ROSC care protocol for patients with prehospital ROSC after OHCA was not associated with reduced odds of field rearrest. When elements of the care bundle were considered individually, push-dose epinephrine was associated with decreased odds of rearrest.

Short-Term Outcomes and Patient Perceptions after Paramedic Non-Transport during the COVID-19 Pandemic.

BACKGROUND: EMS frequently encounter patients who decline transport, yet there are little data to inform the safety of patient and/or paramedic-initiated assess, treat, and refer (ATR) protocols. We determined patient decision-making and short-term outcomes after non-transport by EMS during the COVID-19 pandemic. METHODS: This was a prospective, observational study of a random sample of patients evaluated and not transported by EMS from August 2020 to March 2021. From the EMS database, we randomly selected a daily sample of adult patients with disposition of ATR. We excluded patients dispositioned against medical advice (AMA) and those in police custody. Investigators contacted patients by phone to administer a standardized survey regarding decision-making, symptom progression, follow-up care, and satisfaction with non-transport decision. We also determined the proportion of patients who re-contacted 9-1-1 within 72 h, and unexpected deaths within 72 h using coroner data. Descriptive statistics were calculated. RESULTS: Of 4613 non-transported patients, 3330 (72%) patients for whom the disposition was ATR were included. Patients were 46% male with a median age of 49 (inter-quartile range (IQR) 31-67). Median vital signs measurements fell within the normal range. Investigators successfully contacted 584/3330 patients (18%). The most common reason for failure was lack of accurate phone number. The most common reasons patients reported for not going to the ED on initial encounter were: felt reassured after the paramedic assessment (151/584, 26%), medical complaint resolved (113/584, 19%), paramedic suggested transport was not required (73/584, 13%), concern for COVID-19 exposure (57/584, 10%), and initial concern was not medical (46/584, 8%). Ninety-five percent (552/584) were satisfied with the non-transport decision and 49% (284/584) had sought follow-up care. The majority (501/584, 86%) reported equal, improved, or resolved symptoms, while 80 patients (13%) reported worse symptoms, of whom (64/80, 80%) remained satisfied with the non-transport decision. Overall, there were 154 of 3330 (4.6%) 9-1-1 recontacts within 72 h. Based on coroner data, three unexpected deaths (0.09%) occurred within 72 h of the initial EMS calls. CONCLUSION: Paramedic disposition by ATR protocols resulted in a low rate of 9-1-1 recontact. Unexpected deaths were extremely rare. Patient satisfaction with the non-transport decision was high.

Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations.

Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals' wishes.

Equitable Allocation of Remdesivir for the COVID-19 Pandemic in Los Angeles County.

OBJECTIVE: Subsequent to the Emergency Use Authorization (EUA) by the Food and Drug Administration, Gilead Sciences Inc. donated a supply of remdesivir to the United States government for immediate treatment of patients with COVID-19. The Los Angeles County Emergency Medical Services Agency (LAC-EMS) was tasked with the allocation. The objective of this study was to describe the process for allocation and the patients who were treated with the donated remdesivir in LAC. METHODS: LAC-EMS developed a strategic plan to distribute federal allocations of remdesivir to LAC hospitals based on the proportion of patients admitted with COVID-19 at each hospital. Criteria for treatment and its duration were based on the EUA at local hospital discretion. Data were collected on patients treated from May to December 2020. Variables included characteristics (age, sex, race/ethnicity), hospital care (level of care and respiratory support at start of treatment, ventilator support, total ventilator days), and outcomes (length of intensive care (ICU) and hospital stay, survival to discharge, disposition). We compared demographics of treated patients to the overall population of hospitalized patients in LAC. RESULTS: LAC-EMS distributed 34,250 vials of remdesivir in 7 allocations, which treated 5,376 patients. The median age was 60 (IQR 48-70); 62% were male, 59% Hispanic, 17% White, 6% Asian, 5% Black. Prior to remdesivir, 96% of patients required respiratory support including 49% supplemental oxygen, 35% high-flow nasal cannula, 3% continuous or bilevel positive airway pressure and 9% mechanical ventilation, with one quarter of patients in the ICU. Overall, 26% of patients were mechanically ventilated during the hospitalization, median 11 days (IQR 8-23), while 41% required ICU care, median 10 days (IQR 5-19). Median length of stay for all patients was 10 days (IQR 7-18) with 4,218 patients (74%) surviving to discharge and 80% of survivors discharged home. Compared with overall hospitalized patients with COVID-19, treated patients more likely to be male and middle-aged, and less likely to be Black. CONCLUSION: LAC-EMS's strategic plan to distribute donated remdesivir to hospitals based on the number of inpatients with COVID-19 resulted in the treatment of 5,376 patients of whom 74% survived to hospital discharge.

The Correlation between COVID-19 Hospitalizations and Emergency Medical Services Responses for Time-Sensitive Emergencies during the COVID-19 Pandemic.

OBJECTIVE: COVID-19 has had significant secondary effects on health care systems, including effects on emergency medical services (EMS) responses for time-sensitive emergencies. We evaluated the correlation between COVID-19 hospitalizations and EMS responses for time-sensitive emergencies in a large EMS system. METHODS: This was a retrospective study using data from the Los Angeles County EMS Agency. We abstracted data on EMS encounters for stroke, ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest (OHCA), and trauma from April 5, 2020 to March 6, 2021 and for the same time period in the preceding year. We also abstracted daily hospital admissions and censuses (total and intensive care unit [ICU]) for COVID-19 patients. We designated November 29, 2020 to February 27, 2021 as the period of surge. We calculated Spearman's correlations between the weekly averages of daily hospital admissions and census and EMS responses overall and for stroke, STEMI, OHCA, and trauma. RESULTS: During the study period, there were 70,616 patients admitted for confirmed COVID-19, including 12,467 (17.7%) patients admitted to the ICU. EMS responded to 899,794 calls, including 9,944 (1.1%) responses for stroke, 3,325 (0.4%) for STEMI, 11,207 (1.2%) for OHCA, and 114,846 (12.8%) for trauma. There was a significant correlation between total hospital COVID-19 positive patient admissions and EMS responses for all time-sensitive emergencies, including a positive correlation with stroke (0.41), STEMI (0.37), OHCA (0.78), and overall EMS responses (0.37); and a negative correlation with EMS responses for trauma (-0.48). ICU COVID-19 positive patient admissions also correlated with increases in EMS responses for stroke (0.39), STEMI (0.39), and OHCA (0.81); and decreased for trauma (-0.53). Similar though slightly weaker correlations were found when evaluating inpatient census. During the period of surge, the correlation with overall EMS responses increased substantially (0.88) and was very strong with OHCA (0.95). CONCLUSION: We found significant correlation between COVID-19 hospitalizations and the frequency of EMS responses for time-sensitive emergencies in this regional EMS system. EMS systems should consider the potential effects of this and future pandemics on EMS responses and prepare to meet non-pandemic resource needs during periods of surge, particularly for time-sensitive conditions.

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care.

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

Design of a novel clinical trial of prehospital pediatric airway management.

Emergency Medical Services personnel are often the first to intervene in the care of critically ill children. Airway management is a fundamental step in prehospital resuscitation, yet there is significant variation in current prehospital airway management practices. Our objective is to present a methodologic approach to determine the optimal strategy for prehospital pediatric airway management. We describe the conceptual premise for the Pediatric Prehospital Airway Resuscitation Trial, a novel Bayesian adaptive sequential platform trial. We developed an innovative design to enable comparison of the three predominant prehospital pediatric airway techniques (bag-mask-ventilation, supraglottic airway insertion, and endotracheal intubation) in three distinct disease groups (cardiac arrest, major trauma, and other respiratory failure). We used a Bayesian statistical approach to provide flexible modeling that can adapt based on prespecified rules according to accumulating trial data with patient enrollment continuing until stopping rules are met. The approach also allows the comparison of multiple interventions in sequence across the different disease states. This Bayesian hierarchical model will be the primary analysis method for the Pediatric Prehospital Airway Resuscitation Trial. The model integrates information across subgroups, a technique known as "borrowing" to generate accurate global and subgroup-specific estimates of treatment effects and enables comparisons of airway intervention arms within the overarching trial. We will use this Bayesian hierarchical linear model that adjusts for subgroup to estimate treatment effects within each subgroup. The model will predict a patient-centered score of 30-day intensive care unit-free survival using arm, subgroup, and emergency medical services agency as predictors. The novel approach of Pediatric Prehospital Airway Resuscitation Trial will provide a feasible method to determine the optimal strategy for prehospital pediatric airway management and may transform the design of future prehospital resuscitation trials.

A Standardized Formulary to Reduce Pediatric Medication Dosing Errors: A Mixed Methods Study.

Objective: We hypothesized that implementation of a Medical Control Guideline (MCG) with a standardized formulary (fixed medication concentrations) and pre-calculated medication dosages in a large emergency medical services (EMS) system would reduce pediatric dosing errors. To assess the effectiveness of the standardized formulary to reduce errors, we chose to evaluate midazolam administration for seizures, because it is the most frequently dosed medication by EMS for children, and seizures are a time-sensitive condition. The objective of this study was to compare: 1) frequency of midazolam dosing errors during the field treatment of pediatric seizures and 2) paramedic anxiety and confidence in dosing midazolam for pediatric seizures, before and after implementation of the MCG.Methods: In this mixed-methods study, we utilized the Los Angeles County EMS data registry to identify pediatric patients ≤14 years-old treated with midazolam for seizure. We defined a dosing error as outside the dose directed by the color code on the length-based resuscitation tape, or ±20% the weight-based midazolam dose when color code was absent. We compared dosing errors during a two-year period before and after implementation of the MCG with the standardized formulary in February 2017. We surveyed paramedics to assess their level of anxiety and confidence in dosing midazolam and conducted semi-structured interviews with 20 respondents to further explore its impact on paramedic practice.Results: There were 80 dosing errors in 569 patients treated post-formulary (14.1%) compared with 92 dosing errors in 497 patients treated pre-formulary (18.5%), risk difference -4.5% (95% CI -8.9 to 0.0), p = 0.049. Among 304 paramedic survey respondents who had experience with the formulary, anxiety decreased (p < 0.001) and confidence increased (p < 0.001) post-formulary. Paramedics expressed the challenges of pediatric calls, the benefits of the MCG with the standardized formulary, and the ongoing challenges of pediatric medication dosing. Benefits included simplifying paramedic tasks, increasing paramedic self-efficacy, facilitating provider communication, and improving patient care.Conclusion: Implementation of a MCG with standardized formulary and pre-calculated medication dosing by weight reduced pediatric medication dosing errors and increased paramedic confidence in pediatric medication dosing. It may have the potential to facilitate patient care through improved communications and task simplification.

Prehospital Manual Ventilation: An NAEMSP Position Statement and Resource Document.

Manual ventilation using a self-inflating bag device paired with a facemask (bag-valve-mask, or BVM ventilation) or invasive airway (bag-valve-device, or BVD ventilation) is a fundamental airway management skill for all Emergency Medical Services (EMS) clinicians. Delivery of manual ventilations is challenging. Several strategies and adjunct technologies can increase the effectiveness of manual ventilation. NAEMSP recommends:All EMS clinicians must be proficient in bag-valve-mask ventilation.BVM ventilation should be performed using a two-person technique whenever feasible.EMS clinicians should use available techniques and adjuncts to achieve optimal mask seal, improve airway patency, optimize delivery of the correct rate, tidal volume, and pressure during manual ventilation, and allow continual assessment of manual ventilation effectiveness.

Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest.

Objective: Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes.Methods: This was a retrospective analysis of OHCA in a large, regional EMS system from 2011 to 2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome.Results: There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. Of the 32,780 patients with a documented POC glucose result who were identified as hypoglycemic, only 27 (0.08%) received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference -2.0% (95%CI -4.4%, 0.4%), p = 0.1.Conclusion: In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.

The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study.

Background: Intranasal (IN) midazolam allows for rapid, painless treatment of pediatric seizures in the prehospital setting and may be a preferred administration route if determined to be non-inferior to intravenous (IV) or intramuscular (IM) routes. We sought to evaluate the effectiveness of IN midazolam for terminating prehospital pediatric seizures compared to midazolam administered by alternate routes. Methods: We performed a retrospective, non-inferiority analysis using data from a regional Emergency Medical Services (EMS) database. We included pediatric patients ≤ 14 years treated with midazolam (0.1 mg/kg) by EMS for non-traumatic seizures. The primary outcome was the proportion of patients requiring redosing of midazolam after initial treatment with IN midazolam compared to those that received IV or IM midazolam. We established a priori a risk difference of 6.5% as the non-inferiority margin. Results: We evaluated outcomes from 2,034 patients (median age 6 years [interquartile range 3 - 10 years], 55% male). Initial administration routes were 461 (23%) IN, 547 (27%) IM, 1024 (50%) IV, and 2 (0.1%) intraosseous (IO). Midazolam redosing occurred in 116 patients (25%) who received IN midazolam versus 222 patients (14%) treated initially with midazolam via alternate routes (risk difference 11% [95%CI 7 - 15%]). The age-adjusted odds ratio for redosing midazolam after intranasal administration compared to alternate route administration was 2.0 (95% CI 1.6 - 2.6). Conclusion: Prehospital treatment of pediatric seizure with intranasal midazolam was associated with increased frequency of redosing compared to midazolam administered by other routes, suggesting that 0.1 mg/kg is a subtherapeutic dose for intranasal midazolam administration.

Critical Factors in Planning a Pediatric Prehospital Airway Trial.

Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying "The Eagles," a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials.

Optimizing Physiology During Prehospital Airway Management: An NAEMSP Position Statement and Resource Document.

Airway management is a critical component of resuscitation but also carries the potential to disrupt perfusion, oxygenation, and ventilation as a consequence of airway insertion efforts, the use of medications, and the conversion to positive-pressure ventilation. NAEMSP recommends:Airway management should be approached as an organized system of care, incorporating principles of teamwork and operational awareness.EMS clinicians should prevent or correct hypoxemia and hypotension prior to advanced airway insertion attempts.Continuous physiological monitoring must be used during airway management to guide the timing of, limit the duration of, and inform decision making during advanced airway insertion attempts.Initial and ongoing confirmation of advanced airway placement must be performed using waveform capnography. Airway devices must be secured using a reliable method.Perfusion, oxygenation, and ventilation should be optimized before, during, and after advanced airway insertion.To mitigate aspiration after advanced airway insertion, EMS clinicians should consider placing a patient in a semi-upright position.When appropriate, patients undergoing advanced airway placement should receive suitable pharmacologic anxiolysis, amnesia, and analgesia. In select cases, the use of neuromuscular blocking agents may be appropriate.

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.

Variation in Post-Cardiac Arrest Care Within a Regional EMS System.

Objective: Within Emergency Medical Systems (EMS) regional systems, there may be significant differences in the approach to patient care despite efforts to promote standardization. Identifying hospital-level factors that contribute to variations in care can provide opportunities to improve patient outcomes. The purpose of this analysis was to evaluate variation in post-cardiac arrest care within a large EMS system and explore the contribution of hospital-level factors. Methods: This was a retrospective analysis from a regional cardiac system serving over 10 million persons. Patients with out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) are transported to 36 cardiac arrest centers with 24/7 emergent coronary angiography (CAG) capabilities and targeted temperature management (TTM) policies based on regional guidelines. We included adult patients ≥18 years with non-traumatic OHCA from 2016-2018. Patients with a Do-Not-Resuscitate order and those who died in the emergency department (ED) were excluded. For the TTM analysis, we also excluded patients who were alert in the ED. The primary outcome was receiving CAG or TTM after cardiac arrest. The secondary outcome was neurologic recovery (dichotomized to define a "good" outcome as cerebral performance category (CPC) 1 or 2). We used generalized estimating equations including patient-level factors (age, sex, witnessed arrest, initial rhythm) and hospital-level factors (academic status, hospital size based on licensed beds, annual OHCA patient volume) to estimate the odds ratios associated with these variables. Results: There were 7831 patients with OHCA during the study period; 4694 were analyzed for CAG and 3903 for TTM. The median and range for treatment with CAG and TTM after OHCA was 23% (12-49%) and 58% (17-92%) respectively. Hospital size was associated with increased likelihood of CAG, adjusted odds ratio 1.71, 95% CI 1.05-2.86, p = 0.03. Academic status approached significance in its association with TTM, adjusted odds ratio 1.69, 95% CI 0.98-2.91, p = 0.06. Overall, 28% of patients survived with good neurologic outcome, ranging from 17 to 43% across hospitals. Conclusion: Within this regional cardiac system, there was significant variation in use of CAG and TTM after OHCA, which was not fully explained by patient-level factors. Hospital size was associated with increased CAG.

Prehospital Predictors of Atypical STEMI Symptoms.

Introduction: Rapid prehospital identification of patients with ST-elevation myocardial infarction (STEMI) is a critical step to reduce time to treatment. Broad screening with field 12-lead ECGs can lead to a high rate of false positive STEMI activations due to low prevalence. One strategy to reduce false positive STEMI interpretations is to limit acquisition of 12-lead ECGs to patients who have symptoms strongly suggestive of STEMI, but this may delay care in patients who present atypically and lead to disparities in populations with more atypical presentations. We sought to assess patient factors associated with atypical STEMI presentation.Methods: We retrospectively analyzed consecutive adult patients for whom Los Angeles Fire Department paramedics obtained a field 12-lead ECG from July 2011 through June 2012. The regional STEMI receiving center registry was used to identify patients with STEMI. Patients were designated as having typical symptoms if paramedics documented provider impressions of chest pain/discomfort, cardiac arrest, or cardiac symptoms, otherwise they were designated as having atypical symptoms. We utilized logistic regression to determine patient factors (age, sex, race) associated with atypical STEMI presentation.Results: Of the 586 patients who had STEMI, 70% were male, 43% White, 16% Black, 20% Hispanic, 5% Asian and 16% were other or unspecified race. Twenty percent of STEMI patients (n = 117) had atypical symptoms. Women who had STEMI were older than men (74 years [IQR 62-83] vs. 60 years [IQR 53-70], p < 0.001). Univariate predictors of atypical symptoms were older age and female sex (p < 0.0001), while in multivariable analysis older age [odd ratio (OR) 1.05 per year, [95%CI 1.04-1.07, p < 0.0001] and black race (OR vs White 2.18, [95%CI 1.20-3.97], p = 0.011) were associated with atypical presentation.Conclusion: Limiting prehospital acquisition of 12-lead ECGs to patients with typical STEMI symptoms would result in one in five patients with STEMI having delayed recognition, disproportionally impacting patients of older age, women, and Black patients. Age, not sex, may be a better predictor of atypical STEMI presentation.

Increased Access to and Use of Endovascular Therapy Following Implementation of a 2-Tiered Regional Stroke System.

Background and Purpose- We quantified population access to endovascular-capable centers, timing, and rates of thrombectomy in Los Angeles County before and after implementing 2-tiered routing in a regional stroke system of care. Methods- In 2018, the Los Angeles County Emergency Medical Services Agency implemented transport of patients with suspected large vessel occlusions identified by Los Angeles Motor Scale ≥4 directly to designated endovascular-capable centers. We calculated population access to a designated endovascular-capable center within 30 minutes comparing 2016, before 2-tiered system planning began, to 2018 after implementation. We analyzed data from stroke centers in the region from 1 year before and after implementation to delineate changes in rates and speed of administration of tPA (tissue-type plasminogen activator) and thrombectomy and frequency of interfacility transfer. Results- With implementation of the 2-tier system, certified endovascular-capable hospitals increased from 4 to 19 centers, and within 30-minute access to endovascular care for the public in Los Angeles County, from 40% in 2016 to 93% in 2018. Comparing Emergency Medical Services-transported stroke patients in the first post-implementation year (N=3303) with those transported in the last pre-implementation year (N=3008), age, sex, and presenting deficit severity were similar. The frequency of thrombolytic therapy increased from 23.8% to 26.9% (odds ratio, 1.2 [95% CI, 1.05-1.3]; P=0.006), and median first medical contact by paramedic-to-needle time decreased by 3 minutes ([95% CI, 0-5] P=0.03). The frequency of thrombectomy increased from 6.8% to 15.1% (odds ratio, 2.4 [95% CI, 2.0-2.9]; P<0.0001), although first medical contact-to-puncture time did not change significantly, median decrease of 8 minutes ([95% CI, -4 to 20] P=0.2). The frequency of interfacility transfers declined from 3.2% to 1.0% (odds ratio, 0.3 [95% CI, 0.2-0.5]; P<0.0001). Conclusions- After implementation of 2-tiered stroke routing in the most populous US county, thrombectomy access increased to 93% of the population, and the frequency of thrombectomy more than doubled, whereas interfacility transfers declined.

Critical Medication Shortages: Effective Strategies to Maintain Continuous Medication Availability for Emergency Medical Services.

Objective: Critical shortages of generic injectable medications are an ongoing challenge for Emergency Medical Services (EMS) systems. Mitigation strategies have been proposed to address the issue, but a limited amount of data exists quantifying the scope of the problem or describing strategies being used to ensure access to essential medications for prehospital care. In this study, we sought to quantify specific medication shortages and to determine the most frequently employed mitigation strategies to maintain medication availability in a large, regional EMS system. Methods: A survey was distributed to the 30 public advanced life support (ALS) provider agencies in Los Angeles County (LAC) to assess the prevalence of specific medication shortages and types of shortage mitigation strategies implemented. Survey responses were reviewed and presented using descriptive statistics. Results: Survey responses were received from 29 of 30 (97%) provider agencies. All but one of the responding agencies reported being impacted by medication shortages. Strategies to maintain the supply of medications included use of alternative vendors 20/28 (71%), rotating medications from low to high volume units (54%), utilizing expired medication FDA-approved extensions (50%), substituting medications (43%), borrowing medications from the LAC EMS Agency (39%) or other EMS provider agencies (32%), utilizing expired medications with medical director approval (29%), diluting medications to obtain desired concentration (18%), reducing minimum periodic automatic replacement (PAR) levels (14%), and using alternate medication concentrations/formulations (14%). The medications most frequently reported to have shortages included epinephrine (0.1 mg/mL), morphine, dextrose 10%, and normal saline. None of the provider agencies self-reported adverse events due to the shortages. Conclusions: Critical medication shortages remain a problem for many EMS systems. EMS medical directors need to implement multiple mitigation strategies to maintain supply of critical medications for prehospital patient care.