Out-of-Hospital Intranasal Ketamine as an Adjunct to Fentanyl for the Treatment of Acute Traumatic Pain: A Randomized Clinical Trial.

STUDY OBJECTIVE: To evaluate if out-of-hospital administration of fentanyl and intranasal ketamine, compared to fentanyl alone, improves early pain control after injury. METHODS: We conducted an out-of-hospital randomized, placebo-controlled, blinded, parallel group clinical trial from October 2017 to December 2021. Participants were male, aged 18 to 65 years, receiving fentanyl to treat acute traumatic pain prior to hospital arrival, treated by an urban fire-based emergency medical services agency, and transported to the region's only adult Level I trauma center. Participants randomly received 50 mg intranasal ketamine or placebo. The primary outcome was the proportion with a minimum 2-point reduction in self-described pain on the verbal numerical rating scale 30 minutes after study drug administration assessed by 95% confidence interval overlap. Secondary outcomes were side effects, pain ratings, and additional pain medications through the first 3 hours of care. RESULTS: Among the 192 participants enrolled, 89 (46%) were White, (median age, 36 years; interquartile range, 27 to 53 years), with 103 receiving ketamine and 89 receiving placebo. There was no difference in the proportion experiencing improved pain 30 minutes after treatment (46/103 [44.7%] ketamine versus 32/89 [36.0%] placebo; difference in proportions, 8.7%; 95% confidence interval, -5.1% to 22.5%; P=.22) or at any time point through 3 hours. There was no difference in secondary outcomes or side effects. CONCLUSION: In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.

Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners.

The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.

Ketamine Stability over Six Months of Exposure to Moderate and High Temperature Environments.

Background: All medications should be stored within temperature ranges defined by manufacturers, but logistical and operational challenges of prehospital and military settings complicate adherence to these recommendations. Lorazepam and succinylcholine experience clinically relevant heat-related degradation, whereas midazolam does not. Because ketamine's stability when stored outside manufacturer recommendations is unknown, we evaluated the heat-related degradation of ketamine exposed to several temperature ranges. Methods: One hundred twenty vials of ketamine (50 mg/mL labeled concentration) from the same manufacturer lot were equally distributed and stored for six months in five environments: an active EMS unit in southwest Ohio (May-October 2019); heat chamber at constant 120 °F (C1); heat chamber fluctuating over 24 hours from 86 °F-120 °F (C2); heat chamber fluctuating over 24 hours from 40 °F-120 °F (C3); heat chamber kept at constant 70 °F (manufacturer recommended room temperature, C4). Four ketamine vials were removed every 30 days from each environment and sent to an FDA-accredited commercial lab for high performance liquid chromatography testing. Data loggers and thermistors allowed temperature recording every minute for all environments. Cumulative heat exposure was quantified by mean kinetic temperature (MKT), which accounts for additional heat-stress over time caused by temperature fluctuations and is a superior measure than simple ambient temperature. MKT was calculated for each environment at the time of ketamine removal. Descriptive statistics were used to describe the concentration changes at each time point. Results: The MKT ranged from 73.6 °F-80.7 °F in the active EMS unit and stayed constant for each chamber (C1 MKT: 120 °F, C2 MKT: 107.3 °F, C3 MKT: 96.5 °F, C4 MKT: 70 °F). No significant absolute ketamine degradation, or trends in degradation, occurred in any environment at any time point. The lowest median concentration occurred in the EMS-stored samples removed after 6 months [48.2 mg/mL (47.75, 48.35)], or 96.4% relative strength to labeled concentration. Conclusion: Ketamine samples exhibited limited degradation after 6 months of exposure to real world and simulated extreme high temperature environments exceeding manufacturer recommendations. Future studies are necessary to evaluate ketamine stability beyond 6 months.

Emergency Medical Services Traumatic Brain Injury Protocols Do Not Reflect Brain Trauma Foundation Guidelines.

OBJECTIVES: Implementation of traumatic brain injury (TBI) guideline recommendations for prehospital care is associated with improved outcomes, but prehospital guideline uptake is frequently delayed. Our objective was to estimate how well TBI guidelines are reflected in a national sample of prehospital TBI protocols in 2012 and 2018, 5 and 11 years after guideline publication. Methods: A purposeful sample of publicly accessible prehospital protocols were obtained in 2012, and updates of those protocols were obtained in 2018. Guideline recommendations were codified into a 23-item tool that was used to dual-abstract each prehospital protocol set. Descriptive statistics and chi-square testing were used to compare differences. Fifty-three sets of protocols representing 25 states and multiple administrative structures were identified. Results: None of the protocols contained all twenty-three elements of the guidelines, and more than one-third (19/53, 35%) did not have a TBI-specific protocol. While some individual items appeared more frequently in 2018 than 2012, more than half of the reviewed protocols do not contain guidance on ventilation or definitions of hypoxemia, hypotension, or pupil asymmetry. Conclusions: Evaluation of a diverse sample of EMS protocols demonstrates a significant deficit in the adoption of TBI guidelines more than a decade after publication.

The Cincinnati Prehospital Stroke Scale Compared to Stroke Severity Tools for Large Vessel Occlusion Stroke Prediction.

BACKGROUND: Various screening tools, ranging in complexity, have been developed to predict large vessel occlusion (LVO) stroke in the prehospital setting. Our objective was to determine whether newly-developed LVO stroke scales offer a clinically-meaningful advantage over the Cincinnati Prehospital Stroke Scale (CPSS). METHODS: We retrospectively analyzed prehospital patient care records linked with hospital data from 151 EMS agencies in the United States, between January 1, 2018 and December 31, 2018. We compared the CPSS to the Rapid Arterial Occlusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), and the Vision, Aphasia, Neglect (VAN) assessment for LVO prediction. For each stroke scale, we used the intersection of sensitivity and specificity curves to determine optimal prediction cut-points. We used area under the ROC curve and 95% confidence intervals to assess for differences in discriminative ability between scales. RESULTS: We identified 13,596 prehospital records with one or more documented stroke scales of interest. Among these, 4,228 patients were diagnosed with stroke. Over half (57%, n = 2,415) of patients diagnosed with stroke experienced an acute ischemic stroke. Of patients with ischemic stroke, 26% (n = 628) were diagnosed with LVO. A CPSS score of 2 or higher demonstrated sensitivity = 69% and specificity = 78% for LVO. A RACE score of 4 or higher demonstrated sensitivity = 63%, specificity = 73%. A LAMS score of 3 or higher demonstrated sensitivity = 63%, specificity = 72% and a positive VAN score demonstrated sensitivity = 86%, specificity = 65%. Comparing the area under the ROC curve for each scale revealed no statistically significant differences in discriminative ability for LVO stroke. CONCLUSIONS: In this large sample of real-world prehospital patient encounters, the CPSS demonstrated similar predictive performance characteristics compared to the RACE, LAMS, and VAN for detecting LVO stroke. Prior to implementing a specific screening tool, EMS agencies should evaluate ease of use and associated implementation costs. Scored 0-3, the simple, widely-used CPSS may serve as a favorable prehospital screening instrument for LVO detection with a cut-point of 2 or higher maximizing the tradeoff between sensitivity and specificity.

Predictors of Definitive Airway Sans Hypoxia/Hypotension on First Attempt (DASH-1A) Success in Traumatically Injured Patients Undergoing Prehospital Intubation.

Background: Prehospital intubation success is routinely treated as a dichotomous outcome based on an endotracheal tube passing through vocal cords regardless of number of attempts or occurrence of hypoxia, or hypotension, which are associated with worse outcomes. We explore patient, provider, and procedure-related variables associated with successful definitive airway sans hypoxia/hypotension on first attempt (DASH-1A) in traumatically injured subjects undergoing endotracheal intubation at the scene of injury by a helicopter EMS system.Methods: This single-center retrospective chart review included patients with traumatic injuries and at least one attempted intubation by helicopter EMS at the scene of injury. Demographic and clinical variables were tested for association with DASH-1A and overall first-attempt success using univariate comparisons and multivariable logistic regression to produce adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Purposeful backwards stepwise elimination was used to develop logistic regression models for outcomes. Initial inclusion of covariates in multivariable models was based on clinical judgement, known or suspected risk factors and confounders for intubation success, and univariate associations.Results: Of 419 subjects screened, 263 met inclusion criteria. Median age was 34 years and the majority of subjects were Caucasian (95%), male (76%), and suffered blunt trauma (90%). The endotracheal tube was successfully placed on the first attempt in 198 (75.3%) of patients, but only 142 (55.3%) had a successful DASH-1A, and overall, 246 (94%) had an endotracheal tube passed successfully before hospital arrival. Factors significantly associated with successful DASH-1A were no ground EMS intubation attempt prior to arrival [aOR 2.2 (CI 1.0-4.9)], lack of airway secretions/blood [1.9 (1.0-3.4)], Cormack-Lehane Score of I and II [12.3 (4.5-33.2) & 3.2 (1.2-9.1), respectively], and bougie use [5.4 (1.8-15.8)]. For endotracheal tube passing only, the following were significantly associated with first pass success: grade of view I and II [aORs 87.3 (CI 25.8-295.7) & 6.8 (2.3-19.5), respectively], lack of secretions/blood [4.9 (2.1-11.2), bougie use [7.8 (2.3-26.3)], direct laryngoscopy [5.1 (1.5-17.0)] and not using apneic oxygenation through a nasal cannula [2.5 (1.1-5.6)].Conclusion: In our helicopter EMS system, successful endotracheal intubation on the first attempt and without an episode of hypoxia was associated with no ground EMS intubation attempt prior to flight crew arrival, lack of airway secretions/blood, Cormack-Lehane Score, and bougie use.

Potential Impact of C-STAT for Prehospital Stroke Triage up to 24 Hours on a Regional Stroke System.

Background and Purpose: Thrombectomy for large vessel occlusion acute ischemic stroke (AIS-LVO) may benefit patients up to 24 hour since last known normal (LKN). Prehospital tools, like the Cincinnati Stroke Triage Assessment Tool (C-STAT), are used to select hospital destination for suspected AIS-LVO patients. The objective of this study was to estimate the potential impact of the expanded thrombectomy time window on suspected AIS-LVO cases transported to the regional comprehensive stroke center (CSC). Methods: From June to November 2015, C-STAT was performed by prehospital providers following a positive prehospital Cincinnati Prehospital Stroke Scale (CPSS) stroke screen in suspected stroke/TIA patients. There was no preferential triage based on C-STAT results. Final diagnoses, including the presence of AIS-LVO was ascertained via medical record review. Impact of positive C-STAT cases on CSC volumes was estimated for up to 24 hours since LKN. Results: Of 158 patients with prehospital suspicion for stroke/TIA, 105 were CPSS positive within 24 hours of onset and had complete C-STAT and clinical data available for analysis. Forty-six percent (17/37) of C-STAT + were non-strokes. C-STAT sensitivity and specificity for LVO were 71% (95% CI 36-92) and 67% (95% CI 58-80), respectively. C-STAT triage would increase transport of prehospital suspected stroke cases to the CSC by 11% (12/105) within six hours and 21% (22/105) within 24 hours. Of 37 C-STAT + patients, only 5 (13.5%) had LVO as final diagnosis. Conclusions: Preferential triage of prehospital suspected stroke patients using C-STAT would increase the number of patients transported to the CSC by 11% within six hours and an additional 10% from six to 24 hours. For every patient with LVO as final diagnosis, approximately an additional 6 non-LVO patients would be triaged to a CSC.

Mechanical Ventilation of Severe Traumatic Brain Injury Patients in the Prehospital Setting.

OBJECTIVE: Suboptimal ventilation may impact outcomes in patients with traumatic brain injury (TBI). This study compares the incidence of eucapnia between manually and mechanically ventilated patients with severe TBI during helicopter transport. METHODS: This retrospective chart review included consecutive intubated adults with severe TBI (Glasgow Coma Scale score < 9) transported by helicopter from the scene of injury to a level 1 trauma center between 2009 and 2015. The primary outcome was the first venous partial pressure of carbon dioxide obtained in the emergency department. Hypocapnia, eucapnia, and hypercapnia were defined based on the normal range for the testing instrument. The Fisher exact test was used to compare groups. RESULTS: Of 1,070 trauma patients intubated and transported, 93 met the inclusion criteria with full data. The mean age was 43 years, 81 of 93 were white, and 70 of 93 were men. The mean Injury Severity Score was 29, and 26 of 93 were mechanically ventilated. Hypocapnia occurred in 4 of 93 and hypercapnia in 56 of 93. There was no difference in the rate of eucapnia in manually ventilated compared with mechanically ventilated patients (36% vs. 35%, P = 1.00). CONCLUSION: Eucapnia at emergency department arrival occurred in 36% of patients and was unaffected by whether ventilation was manually or mechanically controlled. Few patients were hypocapnic, indicating a low incidence of hyperventilation during helicopter transport.

Timing of Advanced Airway Placement after Witnessed Out-of-Hospital Cardiac Arrest.

Background: Advanced airways (endotracheal tubes, supraglottic airways) are frequently placed by Emergency Medical Services (EMS) in patients with out-of-hospital cardiac arrest (OHCA). However, if an airway is to be placed, it is unknown whether this should occur early or late in the sequence of resuscitation events. This study evaluated the association between the timing of airway placement and the minute-to-minute probability of achieving return of spontaneous circulation (ROSC). Methods: This secondary analysis of Resuscitation Outcomes Consortium Prehospital Resuscitation using an Impedance Valve and Early versus Delayed (ROC PRIMED) study data included adult, non-traumatic, witnessed OHCA patients with airway placement by EMS before ROSC. The primary exposure variable was time from EMS arrival to advanced airway placement. The outcome was prehospital ROSC. Since resuscitations occur over time, a Cox proportional hazards model was fit to estimate the probability of ROSC as a function of the airway timing, adjusting for Utstein variables. Results: A total of 7,547 patients were included. Time to airway placement was 0-5 minutes in 12% of the cohort, >5-10 (36%), >10-15 (29%), >15-20 (14%), >20-25 (5%), >25-30 (2%), and >30 (2%). ROSC occurred in 43%. Time to airway had a statistically significant impact on ROSC. A negative association between the time to airway placement and the hazard of ROSC was observed, such that increasing intervals between EMS arrival and airway placement were associated with decreasing probabilities of ROSC, regardless of initial cardiac rhythm. Conclusions: EMS advanced airway placement has a time-dependent association with ROSC. In witnessed OHCA patients receiving advanced airways, early airway placement is associated with increased probability of ROSC.

Prehospital Prediction of Large Vessel Occlusion in Suspected Stroke Patients.

PURPOSE OF REVIEW: Recent advances in endovascular thrombectomy have made acute ischemic stroke due to a large vessel occlusion more treatable than ever. Rapid access to treatment remains paramount and multiple large vessel occlusion prediction scales have been created to enhance prehospital identification and triage of these patients. This review summarizes the current state of large vessel occlusion prediction scales, proposes a set of ideal scale features, and discusses the future of these scales and prehospital neurological emergency response systems. RECENT FINDINGS: A meta-analysis of the available data concluded that none of the currently published scales are more accurate than the others. However, other studies provide insight into important qualitative features beyond accuracy. At present, only a few large vessel occlusion prediction scales have been studied in the necessary prehospital suspected stroke patient population. Among these small studies, 26-51% of patients identified by scales had large vessel occlusions and 63-84% qualified for triage to a Comprehensive Stroke Center. Valuable scale features include binary scoring, inclusion of gaze deviation and arm weakness, exclusion of neglect, and prehospital validation in a suspected stroke cohort. Patients with neurological emergencies that mimic large vessel occlusion, such as intracranial hemorrhage, may also benefit from triage to Comprehensive Stroke Centers. Prehospital triage is more complex than ever and guidelines, tools, and systems continue to evolve.

Prehospital Triage of Acute Ischemic Stroke Patients to an Intravenous tPA-Ready versus Endovascular-Ready Hospital: A Decision Analysis.

BACKGROUND: American Stroke Association guidelines for prehospital acute ischemic stroke recommend against bypassing an intravenous tPA-ready hospital (IRH), if additional transportation time to an endovascular-ready hospital (ERH) exceeds 15-20 min. However, it is unknown when the benefit of potential endovascular therapy at an ERH outweighs the harm from delaying intravenous therapy at a closer IRH, especially since large vessel occlusion (LVO) status is initially unknown. We hypothesized that current time recommendations for IRH bypass are too short to achieve optimal outcomes for certain patient populations. METHODS: A decision analysis model was constructed using population-based databases, a detailed literature review, and interventional trial data containing time-dependent modified Rankin Scale distributions. The base case was triaged by Emergency Medical Services (EMS) 110 min after stroke onset and had a 23.6% LVO rate. Base case triage choices were (1) transport to the closest IRH (12 min), (2) transport to the ERH (60 min) bypassing the IRH, or (3) apply the Cincinnati Stroke Triage Assessment Tool and transport to the ERH if positive for LVO. Outcomes were assessed using quality-adjusted life years (QALYs). Sensitivity analyses were performed for all major variables, and alternative prehospital stroke scales were assessed. RESULTS: In the base case, transport to the IRH was the optimal choice with an expected outcome of 8.47 QALYs. Sensitivity analyses demonstrated that transport to the ERH was superior until bypass time exceeded 44 additional minutes, or when the onset to EMS triage interval exceeded 99 min. As the probability of LVO increased, ERH transport was optimal at longer onset to EMS triage intervals. The optimal triage strategy was highly dependent on specific interactions between the IRH transportation time, ERH transportation time, and onset to EMS triage interval. CONCLUSIONS: No single time difference between IRH and ERH transportation optimizes triage for all patients. Allowable IRH bypass time should be increased and acute ischemic stroke guidelines should incorporate the onset to EMS triage interval, IRH transportation time, and ERH transportation time.

Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool.

BACKGROUND AND PURPOSE: A simple, easily adoptable scale with good performance characteristics is needed for EMS providers to appropriately triage suspected stroke patients to comprehensive stroke centers (CSC). Many existing tools are complex, require substantial training, or have not been prospectively validated in the prehospital setting. We describe the feasibility and effectiveness of prehospital implementation of our previously retrospectively derived and validated Cincinnati Stroke Triage Assessment Tool (C-STAT) to identify subjects with severe stroke (NIHSS ≥15) among all prehospital patients with clinical suspicion of stroke/TIA. Secondarily, we evaluated the tool's ability to identify subjects with NIHSS ≥10, large vessel occlusion (LVO), or needing services available only at a CSC. METHODS: Without formalized training, Cincinnati Fire Department providers performed standard stroke screening ("face, arm, speech, time;" FAST) and C-STAT as part of their assessment of suspected stroke/TIA patients. Outcomes for patients brought to the region's only CSC or assessed by the regional stroke team were determined through structured chart review by a stroke team nurse. C-STAT test characteristics for each outcome were calculated with 95% confidence intervals. RESULTS: Complete prehospital and outcome data were available for 58 FAST-positive subjects among 158 subjects with prehospital suspicion for stroke/TIA. Subjects were excluded if FAST was negative (n = 22), FAST or C-STAT was incompletely documented (n = 24), if the patient was taken to a non-CSC and did not receive a stroke team consult (n = 48), or if outcome data were missing (n = 6). C-STAT sensitivity and specificity for each outcome were: NIHSS ≥ 15, 77% (95% CI 46-95) and 84% (95% CI 69-93); NIHSS ≥10, 64% (95% CI 41-83) and 91% (95% CI 76-98); LVO, 71% (95% CI 29-96) and 70% (95% CI 55-83); overall CSC need 57% (95% CI 34-78) and 79% (95% CI 61-91). CONCLUSION: In this pilot prospective evaluation performed in the prehospital setting by EMS providers without formalized training, C-STAT is comparable to other published tools in test characteristics and may inform appropriate CSC triage beyond LVO ascertainment alone.

Reducing Door-in Door-out Intervals in Helicopter ST-segment Elevation Myocardial Infarction Interhospital Transfers.

BACKGROUND: Many health systems rely on helicopter EMS (HEMS) to transfer ST-elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI) to a hospital with a catheterization laboratory. Mortality rates increase with the time to reperfusion, so reducing delays is imperative. For interhospital STEMI transfers, the time spent in the initial hospital from arrival until departure (door-in to door-out interval or DIDO) should be minimized. OBJECTIVE: To evaluate the impact of a series of process improvements to reduce DIDO intervals for STEMI patients transferred via a hospital based HEMS program. METHODS: Changes made to the STEMI transfer protocol in March 2011 were: (a) allowing transferring facilities to request HEMS before identifying an accepting cardiologist or hospital, with one hospital serving as a default PCI center in the case of delays, (b) limiting continuous infusions to those absolutely necessary for the transfer flights and (c) training flight crews to minimize time at bedside. Trained dual abstractors conducted structured medical record reviews for all STEMI patients 18 years and older, transferred to a PCI facility by HEMS from March 2011 to December 2012. Discrepancies were adjudicated. We compared DIDO intervals to a historical control cohort from 2007. We used the Mann-Whitney U test to compare times, and calculated differences with 95% confidence intervals. RESULTS: Of 244 patients identified, six were excluded due to incomplete data. The historical cohort included 179 cases. Mean age was 59 (SD 14) years, 81% were white and 66% male. There were no differences in patient characteristics or door to EKG times between the cohorts. Median door-in to door-out interval decreased from 83 minutes (IQR 43) to 68 minutes (IQR 31) (difference 15 minutes, 95% CI 8 to 21, P <.0001). EKG to HEMS request decreased 21 minutes (95% CI 17 to 25, P <.0001), and HEMS ground time decreased 3 minutes (95% CI 2 to 4, P <.0001). There was a 32% absolute increase in the proportion of patients with EKG to helicopter request interval <35 minutes (83% vs 51%, difference 32%, 95% CI 24% to 41%, P <.0001). CONCLUSION: HEMS-focused process improvements can significantly reduce the DIDO interval times for STEMI patients transferred for PCI.

Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale.

BACKGROUND AND PURPOSE: We derived and validated the Cincinnati Prehospital Stroke Severity Scale (CPSSS) to identify patients with severe strokes and large vessel occlusion (LVO). METHODS: CPSSS was developed with regression tree analysis, objectivity, anticipated ease in administration by emergency medical services personnel and the presence of cortical signs. We derived and validated the tool using the 2 National Institute of Neurological Disorders and Stroke (NINDS) tissue-type plasminogen activator Stroke Study trials and Interventional Management of Stroke III (IMS III) Trial cohorts, respectively, to predict severe stroke (National Institutes of Health Stroke Scale [NIHSS]≥15) and LVO. Standard test characteristics were determined and receiver operator curves were generated and summarized by the area under the curve. RESULTS: CPSSS score ranges from 0 to 4; composed and scored by individual NIHSS items: 2 points for presence of conjugate gaze (NIHSS≥1); 1 point for presence of arm weakness (NIHSS≥2); and 1 point for presence abnormal level of consciousness commands and questions (NIHSS level of consciousness≥1 each). In the derivation set, CPSSS had an area under the curve of 0.89; score≥2 was 89% sensitive and 73% specific in identifying NIHSS≥15. Validation results were similar with an area under the curve of 0.83; score≥2 was 92% sensitive, 51% specific, a positive likelihood ratio of 3.3, and a negative likelihood ratio of 0.15 in predicting severe stroke. For 222 of 303 IMS III subjects with LVO, CPSSS had an area under the curve of 0.67; a score≥2 was 83% sensitive, 40% specific, positive likelihood ratio of 1.4, and negative likelihood ratio of 0.4 in predicting LVO. CONCLUSIONS: CPSSS can identify stroke patients with NIHSS≥15 and LVO. Prospective prehospital validation is warranted.

Randomized controlled trial of a scoring aid to improve Glasgow Coma Scale scoring by emergency medical services providers.

STUDY OBJECTIVE: Emergency medical services (EMS) personnel frequently use the Glasgow Coma Scale (GCS) to assess injured and critically ill patients. This study assesses the accuracy of EMS providers' GCS scoring, as well as the improvement in GCS score assessment with the use of a scoring aid. METHODS: This randomized, controlled study was conducted in the emergency department (ED) of an urban academic trauma center. Emergency medical technicians or paramedics who transported a patient to the ED were randomly assigned one of 9 written scenarios, either with or without a GCS scoring aid. Scenarios were created by consensus of expert attending emergency medicine, EMS, and neurocritical care physicians, with universal consensus agreement on GCS scores. χ(2) And Student's t tests were used to compare groups. RESULTS: Of 180 participants, 178 completed the study. Overall, 73 of 178 participants (41%) gave a GCS score that matched the expert consensus score. GCS score was correct in 22 of 88 (25%) cases without the scoring aid. GCS was correct in 51 of 90 (57%) cases with the scoring aid. Most (69%) of the total GCS scores fell within 1 point of the expert consensus GCS score. Differences in accuracy were most pronounced in scenarios with a correct GCS score of 12 or below. Subcomponent accuracy was eye 62%, verbal 70%, and motor 51%. CONCLUSION: In this study, 60% of EMS participants provided inaccurate GCS score estimates. Use of a GCS scoring aid improved accuracy of EMS GCS score assessments.

Degradation of benzodiazepines after 120 days of EMS deployment.

INTRODUCTION: EMS treatment of status epilepticus improves outcomes, but the benzodiazepine best suited for EMS use is unclear, given potential high environmental temperature exposures. OBJECTIVE: To describe the degradation of diazepam, lorazepam, and midazolam as a function of temperature exposure and time over 120 days of storage on active EMS units. METHODS: Study boxes containing vials of diazepam, lorazepam, and midazolam were distributed to 4 active EMS units in each of 2 EMS systems in the southwestern United States during May-August 2011. The boxes logged temperature every minute and were stored in EMS units per local agency policy. Two vials of each drug were removed from each box at 30-day intervals and underwent high-performance liquid chromatography to determine drug concentration. Concentration was analyzed as mean (and 95%CI) percent of initial labeled concentration as a function of time and mean kinetic temperature (MKT). RESULTS: 192 samples were collected (2 samples of each drug from each of 4 units per city at 4 time-points). After 120 days, the mean relative concentration (95%CI) of diazepam was 97.0% (95.7-98.2%) and of midazolam was 99.0% (97.7-100.2%). Lorazepam experienced modest degradation by 60 days (95.6% [91.6-99.5%]) and substantial degradation at 90 days (90.3% [85.2-95.4%]) and 120 days (86.5% [80.7-92.3%]). Mean MKT was 31.6°C (95%CI 27.1-36.1). Increasing MKT was associated with greater degradation of lorazepam, but not midazolam or diazepam. CONCLUSIONS: Midazolam and diazepam experienced minimal degradation throughout 120 days of EMS deployment in high-heat environments. Lorazepam experienced significant degradation over 120 days and appeared especially sensitive to higher MKT exposure.

ED disposition of the Glasgow Coma Scale 13 to 15 traumatic brain injury patient: analysis of the Transforming Research and Clinical Knowledge in TBI study.

OBJECTIVE: Mild traumatic brain injury (mTBI) patients are frequently admitted to high levels of care despite limited evidence suggesting benefit. Such decisions may contribute to the significant cost of caring for mTBI patients. Understanding the factors that drive disposition decision making and how disposition is associated with outcomes is necessary for developing an evidence-base supporting disposition decisions. We evaluated factors associated with emergency department triage of mTBI patients to 1 of 3 levels of care: home, inpatient floor, or intensive care unit (ICU). METHODS: This multicenter, prospective, cohort study included patients with isolated head trauma, a cranial computed tomography as part of routine care, and a Glasgow Coma Scale (GCS) score of 13 to 15. Data analysis was performed using multinomial logistic regression. RESULTS: Of the 304 patients included, 167 (55%) were discharged home, 76 (25%) were admitted to the inpatient floor, and 61 (20%) were admitted to the ICU. In the multivariable model, admission to the ICU, compared with floor admission, varied by study site, odds ratio (OR) 0.18 (95% confidence interval [CI], 0.06-0.57); antiplatelet/anticoagulation therapy, OR 7.46 (95% CI, 1.79-31.13); skull fracture, OR 7.60 (95% CI, 2.44-23.73); and lower GCS, OR 2.36 (95% CI, 1.05-5.30). No difference in outcome was observed between the 3 levels of care. CONCLUSION: Clinical characteristics and local practice patterns contribute to mTBI disposition decisions. Level of care was not associated with outcomes. Intracranial hemorrhage, GCS 13 to 14, skull fracture, and current antiplatelet/anticoagulant therapy influenced disposition decisions.

Intra-arrest blood-based biomarkers for out-of-hospital cardiac arrest: A scoping review.

Objective: Blood-based biomarkers play a central role in the diagnosis and treatment of critically ill patients, yet none are routinely measured during the intra-arrest phase of out-of-hospital cardiac arrest (OHCA). Our objective was to describe methodological aspects, sources of evidence, and gaps in research surrounding intra-arrest blood-based biomarkers for OHCA. Methods: We used scoping review methodology to summarize existing literature. The protocol was designed a priori following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. Inclusion criteria were peer-reviewed scientific studies on OHCA patients with at least one blood draw intra-arrest. We excluded in-hospital cardiac arrest and animal studies. There were no language, date, or study design exclusions. We conducted an electronic literature search using PubMed and Embase and hand-searched secondary literature. Data charting/synthesis were performed in duplicate using standardized data extraction templates. Results: The search strategy identified 11,834 records, with 118 studies evaluating 105 blood-based biomarkers included. Only eight studies (7%) had complete reporting. The median number of studies per biomarker was 2 (interquartile range 1-4). Most studies were conducted in Asia (63 studies, 53%).  Only 22 studies (19%) had blood samples collected in the prehospital setting, and only six studies (5%) had samples collected by paramedics. Pediatric patients were included in only three studies (3%). Out of eight predefined biomarker categories of use, only two were routinely assessed: prognostic (97/105, 92%) and diagnostic (61/105, 58%). Conclusions: Despite a large body of literature on intra-arrest blood-based biomarkers for OHCA, gaps in methodology and knowledge are widespread.

The 60-day temperature-dependent degradation of midazolam and Lorazepam in the prehospital environment.

BACKGROUND: The choice of the optimal benzodiazepine to treat prehospital status epilepticus is unclear. Lorazepam is preferred in the emergency department, but concerns about nonrefrigerated storage limits emergency medical services (EMS) use. Midazolam is increasingly popular, but its heat stability is undocumented. OBJECTIVE: This study evaluated temperature-dependent degradation of lorazepam and midazolam after 60 days in the EMS environment. METHODS: Lorazepam or midazolam samples were collected prior to (n = 139) or after (n = 229) 60 days of EMS deployment during spring-summer months in 14 metropolitan areas across the United States. Medications were stored in study boxes that logged temperature every minute and were stored in EMS units per local agency policy. Mean kinetic temperature (MKT) exposure was derived for each sample. Drug concentrations were determined in a central laboratory by high-performance liquid chromatography. Concentration as a function of MKT was analyzed by linear regression. RESULTS: Prior to deployment, measured concentrations of both benzodiazepines were 1.0 relative to labeled concentration. After 60 days, midazolam showed no degradation (mean relative concentration 1.00, 95% confidence interval [CI] 1.00-1.00) and was stable across temperature exposures (adjusted R(2) -0.008). Lorazepam experienced little degradation (mean relative concentration 0.99, 95% CI 0.98-0.99), but degradation was correlated to increasing MKT (adjusted R(2) 0.278). The difference between the temperature dependence of degradation of midazolam and lorazepam was statistically significant (T = -5.172, p < 0.001). CONCLUSIONS: Lorazepam experiences small but statistically significant temperature-dependent degradation after 60 days in the EMS environment. Additional study is needed to evaluate whether clinically significant deterioration occurs after 60 days. Midazolam shows no degradation over this duration, even in high-heat conditions.