Implementation of the universal BLS termination of resuscitation rule in a rural EMS system.

BACKGROUND: Emergency Medical Services (EMS) are often the first medical providers to begin resuscitation of out-of-hospital cardiac arrest (OHCA) victims. The universal Basic Life Support Termination of Resuscitation (BLS-TOR) rule is a validated clinical prediction tool used to identify patients in which continued resuscitation efforts are futile. OBJECTIVE: The primary aim is to compare the rate of transport of OHCA cases before and after the implementation of a BLS-TOR protocol and to determine the compliance rate of EMS personnel with the new protocol in a largely volunteer, rural system. METHODS: A retrospective cohort study was conducted using the statewide EMS electronic patient care report system. Cases were identified by searching for any incident that had a primary impression of "cardiac arrest" or a primary symptom of "cardiorespiratory arrest" or "death." Data were collected from the two years prior to and following implementation of the BLS-TOR rule from January 1, 2012 through March 31, 2016. RESULTS: There were 702 OHCA cases were identified, with 329 cases meeting inclusion criteria. The transport rate was 91.1% in the pre-intervention group compared with 69.4% in the post-intervention group (χ2=24.8; p<0.001). EMS compliance rate with the BLS-TOR rule was 66.7%. Of the 265 patients transported during the study, 87 patients met (post-intervention group; n=22) or retrospectively met (pre-intervention group; n=65) the BLS-TOR requirements for field termination of resuscitation. None of these patients survived to hospital discharge. CONCLUSION: Rural EMS systems may benefit from implementation and utilization of the universal BLS-TOR rule.

Does Routine Midazolam Administration Prior to Nasogastric Tube Insertion in the Emergency Department Decrease Patients' Pain? (A Pilot Study).

OBJECTIVES: Patients report pain and discomfort with nasogastric tube (NGT) intubation. We tested the hypothesis that premedication with midazolam alleviates pain during NGT placement in the emergency department (ED) by > 13 on a 100-mm visual analog scale (VAS). METHODS: We performed a double-blind randomized controlled pilot study, assigning ED patients requiring NGT placement to midazolam or placebo. All patients received intranasal cophenylcaine; additionally, they received an intravenous (IV) dose of the study drug, either 2 mg of IV midazolam or saline control. Nurses placed NGTs while observed by research staff, who then interviewed subjects to determine the primary outcome of pain using a VAS. Additional data collected from patients and their nurses included discomfort during the procedure, difficulty of tube insertion, and complications. RESULTS: We enrolled 23 eligible patients and obtained complete data in all: 10 midazolam and 13 controls. We found a significant reduction in mean pain VAS score of -31 (95% confidence interval = -53 to -9 mm) with 2 mg of midazolam (mean ± SD = 52 ± 30 mm), compared to placebo (mean ± SD = 21 ± 18 mm), more than double the effect size considered clinically relevant. Treatment did not impact ease of placement and there were no serious adverse effects. CONCLUSIONS: Premedication with 2 mg of IV midazolam reduces pain of NGT insertion in ED patients without the need for full procedural sedation.

Airway, breathing, computed tomographic scanning: duplicate computed tomographic imaging after transfer to trauma center.

BACKGROUND: Trauma patients imaged at community hospitals often receive duplicate computed tomographic (CT) imaging after transfer to regional trauma centers (RTCs). CT scanning is expensive, is resource intensive, and has acknowledged radiation risk to the patient. The objective of this study was to review and evaluate the frequency, indications, impact on patient management, as well as associated radiation and charges for duplicate CT imaging of trauma patients transferred to our RTC from outside hospitals (OSH). METHODS: Patients transferred to our RTC between September 2009 and August 2010 were evaluated prospectively. The OSH patients' charts and provider interviews were used to determine the reasons for repeated scans. The primary outcome was frequency of duplicate CT scan, defined as a repeated CT image of the same body part within 24 hours. The reason for duplicate imaging and impact on patient management was categorized. Radiation exposure and charges for duplicate scans were also determined. RESULTS: Of the 185 patients transferred to our facility, 177 were eligible. CT examinations at the OSH were performed on 137 patients (77%). A duplicate CT examination occurred in 38 patients (28%). The most common reason for duplicate CT scanning was lack of thin-section multiplanar data, on images sent via CD-ROM (37%). There was a change in management in 16 patients (42%). The patients with duplicate scanning received a median of 10.2 mSv (interquartile range, 6.6-15.7 mSv) of additional radiation, with a median charge of $409 (interquartile range, $307-$734). CONCLUSION: More than one third of duplicated scans performed on transferred trauma patients were potentially avoidable, primary owing to inadequate transfer of data from the OSH CT scan. The capacity of a single CD-ROM is insufficient to contain full imaging data from a trauma scan, and establishing direct links to imaging data from OSHs would decrease the number of repeated CT scans performed on transferred trauma patients. LEVEL OF EVIDENCE: Care management study, level III.

Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.

BACKGROUND: Helicopters have become a major part of the modern trauma care system and are frequently used to transport patients from the scene of their injury to a trauma center. While early studies reported decreased mortality for trauma patients transported by helicopters when compared with those transported by ground ambulances, more recent research has questioned the benefit of helicopter transport of trauma patients. The purpose of this study was to determine the percentage of patients transported by helicopter who have nonlife-threatening injuries. METHODS: A meta-analysis was performed on peer-review research on helicopter utilization. The inclusion criteria were all studies that evaluated trauma patients transported by helicopter from the scene of their injury to a trauma center with baseline parameters defined by Injury Severity Score (ISS), Trauma Score (TS), Revised Trauma Score (RTS), and the likelihood of survival as determined via Trauma Score-Injury Severity Score (TRISS) methodology. RESULTS: There were 22 studies comprising 37,350 patients that met the inclusion criteria. According to the ISS, 60.0% [99% confidence interval (CI): 54.5-64.8] of patients had minor injuries, According to the TS, 61.4% (99% CI: 60.8-62.0) of patients had minor injuries. According to TRISS methodology, 69.3% (99% CI: 58.5-80.2) of patients had a greater than 90% chance of survival and thus nonlife-threatening injuries. There were 25.8% (99% CI: -1.0-52.6) of patients discharged within 24 hours after arrival at the trauma center. CONCLUSIONS: The majority of trauma patients transported from the scene by helicopter have nonlife-threatening injuries. Efforts to more accurately identify those patients who would benefit most from helicopter transport from the accident scene to the trauma center are needed to reduce helicopter overutilization.