Workplace Health Promotion Programs Available to Emergency Medical Services Clinicians in North Carolina.

BACKGROUND: Emergency medical services (EMS) clinicians demonstrate a high prevalence of chronic medical conditions that place them at risk for early mortality. Workplace health promotion programs improve health outcomes, but the availably of such programs for EMS clinicians has not been described. We investigate the availability, scope, and participation of workplace health promotion programs available to EMS clinicians in North Carolina (NC). METHODS: We administered an electronic survey based on the Centers for Disease Control and Prevention Worksite Health ScoreCard to key representatives of EMS agencies within NC that provide primarily transport-capable 9-1-1 response with ground ambulances. We collected information on agency size, rurality, elements of health promotion programs offered, incentives for participation, and participation rate. We calculated descriptive statistics using frequency and percentage for worksite and health promotion program characteristics. We compared the participation rate for agencies who did and did not incentivize participation using Fisher's exact test. RESULTS: Complete responses were received from 69 of 92 agencies (response = 75%) that collectively employ 6679 EMS clinicians [median employees per agency 71 (IQR 50-131)]. Most agencies (88.4%, 61/69) offered at least one element of a worksite health program, but only 13.0% (9/69) offered all elements of a worksite health program. In descending order, the availability of program elements were employee assistance programs (73.9%, 51/69), supportive physical and social environment (66.7%, 46/69), health education (62.3%, 43/69), health risk assessments (52.2%, 36/69), and organization culture of health promotion (20.3%, 14/69). Of agencies with programs, few (11.5%, 7/61) required participation, but most (59.0%, 36/61) offered incentives to participate. Participation rates were <25% among nearly all of the agencies that did not offer incentives, but >50% among most agencies that did offer incentives (p < 0.001). CONCLUSION: While most agencies offer at least one element of a worksite health promotion program, few agencies offer all elements and participation rates are low.

Does Single Dose Epinephrine Improve Outcomes for Patients with Out-of-Hospital Cardiac Arrest and Bystander CPR or a Shockable Rhythm?

BACKGROUND: A single dose epinephrine protocol (SDEP) for out-of-hospital cardiac arrest (OHCA) achieves similar survival to hospital discharge (SHD) rates as a multidose epinephrine protocol (MDEP). However, it is unknown if a SDEP improves SHD rates among patients with a shockable rhythm or those receiving bystander cardiopulmonary resuscitation (CPR). METHODS: This pre-post study, spanning 11/01/2016-10/29/2019 at 5 North Carolina EMS systems, compared pre-implementation MDEP and post-implementation SDEP in patients ≥18 years old with non-traumatic OHCA. Data on initial rhythm type, performance of bystander CPR, and the primary outcome of SHD were sourced from the Cardiac Arrest Registry to Enhance Survival. We compared SDEP vs MDEP performance in each rhythm (shockable and non-shockable) and CPR (bystander CPR or no bystander CPR) subgroup using Generalized Estimating Equations to account for clustering among EMS systems and to adjust for age, sex, race, witnessed arrest, arrest location, AED availability, EMS response interval, and presence of a shockable rhythm or receiving bystander CPR. The interaction of SDEP implementation with rhythm type and bystander CPR was evaluated. RESULTS: Of 1690 patients accrued (899 MDEP, 791 SDEP), 19.2% (324/1690) had shockable rhythms and 38.9% (658/1690) received bystander CPR. After adjusting for confounders, SHD was increased after SDEP implementation among patients with bystander CPR (aOR 1.61, 95%CI 1.03-2.53). However, SHD was similar in the SDEP cohort vs MDEP cohort among patients without bystander CPR (aOR 0.81, 95%CI 0.60-1.09), with a shockable rhythm (aOR 0.96, 95%CI 0.48-1.91), and with a non-shockable rhythm (aOR 1.26, 95%CI 0.89-1.77). In the adjusted model, the interaction between SDEP implementation and bystander CPR was significant for SHD (p = 0.002). CONCLUSION: Adjusting for confounders, the SDEP increased SHD in patients who received bystander CPR and there was a significant interaction between SDEP and bystander CPR. Single dose epinephrine protocol and MDEP had similar SHD rates regardless of rhythm type.

EMS Involvement in COVID-19 Vaccination Efforts - Results of a North Carolina Statewide Survey.

Objective: The COVID-19 pandemic has necessitated the vaccination of large numbers of people across the United States, mobilizing public health resources on a massive scale. The purpose of this study is to determine how emergency medical services (EMS) clinicians and agencies in North Carolina have been utilized in these vaccination efforts.Methods: This retrospective survey was sent to EMS medical directors and EMS system administrators for all 100 county EMS systems in North Carolina. Participation was voluntary, and survey questions asked about the contribution of EMS systems to vaccination efforts, the levels of EMS clinicians being utilized, the activities carried out by those clinicians, and any identifiable barriers to EMS involvement in COVID-19 vaccination efforts.Results: Ninety-eight of the 100 counties in North Carolina responded to the survey, with 88 contributing to vaccination efforts in the communities. Reasons cited by the 10 counties for not being involved in vaccination efforts include: county health departments not needing assistance (two counties), vaccine hesitancy amongst clinicians and the politicization of COVID (three counties), inadequate staffing (one county), and the presence of "robust vaccination clinics" in the community (one county). An additional 12 counties listed staffing shortages as limiting their vaccination efforts. Among the counties supporting vaccine efforts, activities included planning and logistics (54 counties), non-medical roles (38 counties), vaccine preparation (35 counties), medical screening pre-vaccination (41 counties), vaccine administration (74 counties), medical observation post-vaccination (79 counties), and home vaccinations (53 counties). Of the 74 counties that used EMS personnel in vaccine administration, 27 used EMTs (37%), 36 used Advanced EMTs (49%), and 73 used Paramedics (99%).Conclusion: This study demonstrates the large role that EMS clinicians and systems have played and continue to play in COVID-19 vaccination efforts in the state of North Carolina, including planning and logistics, patient screening and observation, vaccine preparation and administration, and home vaccination. Furthermore, it supports the expanded use of EMTs as a potential vaccination workforce. As the public health response to this pandemic continues, EMS clinicians and systems are a valuable resource to their communities and states.

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study.

BACKGROUND: Cardiac arrest guidelines recommend epinephrine every 3-5 minutes during cardiac arrest resuscitation. However, it is unclear if multiple epinephrine doses are associated with improved outcomes. The objective of this study was to determine if a single-dose epinephrine protocol was associated with improved survival compared to traditional multidose protocols. METHODS: We conducted a pre-post study across five North Carolina EMS agencies from 11/1/2016 to 10/29/2019. Patients ≥18 years old with attempted resuscitation for non-traumatic prehospital cardiac arrest were included. Data were collected 1 year before and after implementation of the single-dose epinephrine protocol. Prior to implementation, all agencies used a multidose epinephrine protocol. The Cardiac Arrest Registry to Enhance Survival (CARES) was used to obtain patient outcomes. Study outcomes were survival to hospital discharge (primary) and return of spontaneous circulation (ROSC). Analysis was by intention to treat. Outcomes were compared pre- vs. post-implementation using generalized estimating equations to account for clustering within EMS agencies. Adjusted analyses included age, sex, race, shockable vs. non-shockable rhythm, witnessed arrest, automatic external defibrillator availability, EMS response interval, and bystander cardiopulmonary resuscitation. RESULTS: During the study period there were 1,690 encounters (899 pre- and 791 post-implementation). The population was 74.7% white, 61.1% male, and had a median age of 65 (IQR 53-76) years. Survival to hospital discharge was similar pre- vs. post-implementation [13.6% (122/899) vs. 15.4% (122/791); OR 1.19, 95%CI 0.89-1.59]. However, ROSC was more common post-implementation [42.3% (380/899) vs. 32.5% (257/791); OR 0.66, 95%CI 0.54-0.81]. After adjusting for covariates, the single-dose protocol was associated with similar survival to discharge rates (aOR 0.88, 95%CI 0.77-1.29), but with decreased ROSC rates (aOR 0.58, 95%CI 0.47-0.72). CONCLUSION: A prehospital single-dose epinephrine protocol was associated with similar survival to hospital discharge, but decreased ROSC rates compared to the traditional multidose epinephrine protocol.

Community Socioeconomic and Urban-Rural Disparities in Prehospital Notification of Stroke by Emergency Medical Services in North Carolina.

OBJECTIVES: Notification by emergency medical services (EMS) to the destination hospital of an incoming suspected stroke patient is associated with timelier in-hospital evaluation and treatment. Current data on adherence to this evidence-based best practice are limited, however. We examined the frequency of EMS stroke prenotification in North Carolina by community socioeconomic status (SES) and rurality. METHODS: Using a statewide database of EMS patient care reports, we selected 9-1-1 responses in 2019 with an EMS provider impression of stroke or documented stroke care protocol use. Eligible patients were 18 years old and older with a completed prehospital stroke screen. Incident street addresses were geocoded to North Carolina census tracts and linked to American Community Survey socioeconomic data and urban-rural commuting area codes. High, medium, and low SES tracts were defined by SES index tertiles. Tracts were classified as urban, suburban, and rural. We used multivariable logistic regression to estimate independent associations between tract-level SES and rurality with EMS prenotification, adjusting for patient age, sex, and race/ethnicity; duration of symptoms; incident day of week and time of day; 9-1-1 dispatch complaint; EMS provider primary impression; and prehospital stroke screen interpretation. RESULTS: The cohort of 9527 eligible incidents was mostly at least 65 years old (65%), female (55%), and non-Hispanic White (71%). EMS prenotification occurred in 2783 (29%) patients. Prenotification in low SES tracts (27%) occurred less often than in medium (30%) and high (32%) SES tracts. Rural tracts had the lowest frequency (21%) compared with suburban (28%) and urban (31%) tracts. In adjusted analyses, EMS prenotification was less likely in low SES (vs high SES; odds ratio 0.76, 95% confidence interval 0.67-0.88) and rural (vs urban; odds ratio 0.64, 95% confidence interval 0.52-0.77) tracts. CONCLUSIONS: Across a large, diverse population, EMS prenotification occurred in only one-third of suspected stroke patients. Furthermore, low SES and rural tracts were independently associated with a lower likelihood of prehospital notification. These findings suggest the need for education and quality improvement initiatives to increase EMS stroke prenotification, particularly in underserved communities.

The behavioral neuroendocrinology of dopamine systems in differently reared juvenile male rhesus monkeys (Macaca mulatta).

Dopamine (DA) is a critical neuromodulator of behavior. With propensities for addiction, hyper-activity, cognitive impairment, aggression, and social subordinance, monkeys enduring early maternal deprivation evoke human disorders involving dopaminergic dysfunction. To examine whether DA system alterations shape the behavioral correlates of adverse rearing, male monkeys (Macaca mulatta) were either mother-reared (MR: N = 6), or separated from their mothers at birth and nursery-reared (NR: N = 6). Behavior was assessed during 20-minute observations of subjects interacting with same- or differently-reared peers. Cerebrospinal fluid (CSF) biogenic amines, and serum testosterone (T), cortisol (CORT), and prolactin (PRL) were collected before and after pharmacologic challenge with saline or the DA receptor-2 (DRD2) antagonist Raclopride (RAC). Neuropeptide correlations observed in MR were non-existent in NR monkeys. Compared to MR, NR showed reduced DA tone; higher basal serum T; and lower CSF serotonin (5-HT). RAC increased PRL, T and CORT, but the magnitude of responses varied as a function of rearing. Levels of PRL significantly increased following RAC in MR, but not NR. Elevations in T following RAC were only significant among MR. Contrastingly, the net change (RAC CORT - saline CORT) in CORT was greater in NR than MR. Finally, observations conducted during the juvenile phase in a novel play-arena revealed more aggressive, self-injurious, and repetitive behaviors, which negatively correlated with indexes of dopaminergic tone in NR monkeys. In conclusion, early maternal deprivation alters brain DA systems, and thus may be associated with characteristic cognitive, social, and addiction outcomes.

Computed Tomography Scans in Children With Hemophilia After Minor Head Trauma.

OBJECTIVES: Children with hemophilia have the usual childhood risk of falls and head trauma. Head computed tomographies (HCTs) are fast, detailed, and readily available, but increased radiation exposure in the pediatric population is now recognized as causing increased brain malignancy. By examining the incidence of intracranial cerebral hemorrhage in this population, we will be able to weigh risks and benefits of HCT use more accurately. METHODS: Using a retrospective chart review, we examined past medical records of pediatric patients, aged 0 to 15 years, with hemophilia presenting to 1 academic medical center. Primary outcomes included number of head CTs ordered, total and per patient over the years studied, and the incidence of positive findings, as defined by presence of blood products as documented by radiologist final read/interpretation. RESULTS: The mean number of head CTs per child was 2.5 (range, 1-10). None of the HCT scans were read as intracranial cerebral hemorrhage, and none of the patients had findings that lead to neurosurgical intervention. In a sensitivity analysis, applying Pediatric Emergency Care Applied Research Network head injury criteria, 11 HCT scans would be ordered for a reduction of 80 HCTs, or a decrease of 2 HCT scans per child. No incidence of intracranial cerebral hemorrhage would have been missed. CONCLUSIONS: Our findings suggest that in the child with hemophilia and a history of minor head trauma, exposure to the radiation of a HCT based on the diagnosis of hemophilia alone may not be necessary but that imaging decisions need to be made in conjunction with clinical examination findings and neurologic status.

One-Year Mortality and Associated Factors in Patients Receiving Out-of-Hospital Naloxone for Presumed Opioid Overdose.

STUDY OBJECTIVE: Out-of-hospital naloxone has been championed as a lifesaving solution during the opioid epidemic. However, the long-term outcomes of out-of-hospital naloxone recipients are unknown. The objectives of this study are to describe the 1-year mortality of presumed opioid overdose victims identified by receiving out-of-hospital naloxone and to determine which patient factors are associated with subsequent mortality. METHODS: This was a regional retrospective cohort study of out-of-hospital records from 7 North Carolina counties from January 1, 2015 to February 28, 2017. Patients who received out-of-hospital naloxone were included. Out-of-hospital providers subjectively assessed patients for improvement after administering naloxone. Naloxone recipients were cross-referenced with the North Carolina death index to examine mortality at days 0, 1, 30, and 365. Naloxone recipient mortality was compared with the age-adjusted, at-large population's mortality rate in 2017. Generalized estimating equations and Cox proportional hazards models were used to assess for mortality-associated factors. RESULTS: Of 3,085 out-of-hospital naloxone encounters, 72.7% of patients (n=2,244) improved, whereas 27.3% (n=841) had no improvement with naloxone. At day 365, 12.0% (n=269) of the improved subgroup, 22.6% (n=190) of the no improvement subgroup, and 14.9% (n=459) of the whole population were dead. Naloxone recipients who improved were 13.2 times (95% confidence interval 13.0 to 13.3) more likely to be dead at 1 year than a member of the general populace after age adjusting of the at-large population to match this study population. Older age and being black were associated with 1-year mortality, whereas sex and multiple overdoses were not. CONCLUSION: Opioid overdose identified by receiving out-of-hospital naloxone with clinical improvement carries a 13-fold increase in mortality compared to the general population. This suggests that this is a high-risk population that deserves attention from public health officials, policymakers, and health care providers in regard to the development of long-term solutions.

Point-of-Care Troponin Testing during Ambulance Transport to Detect Acute Myocardial Infarction.

Objective: Use of point-of-care (POC) troponin (cTn) testing in the Emergency Department (ED) is well established. However, data examining POC cTn measurement in the prehospital setting, during ambulance transport, are limited. The objective of this study was to prospectively test the performance of POC cTn measurement by paramedics to detect myocardial infarction (MI) among patients transported to the ED for acute chest pain. Methods: A prospective cohort study of adults with non-traumatic chest pain was conducted in three Emergency Medical Services agencies (December 2016 to January 2018). Patients with ST-elevation MI on ECG were excluded. During ambulance transport paramedics initiated intravenous access, collected blood, and used a POC device (i-STAT; Abbott Laboratories) to measure cTn. Following ED arrival, participants received standard evaluations including clinical blood draws for cTn measurement in the hospital central lab (AccuTnI +3 assay; Beckman Coulter, or cTnI-Ultra assay; Siemens). Blood collected during ambulance transport was also analyzed for cTn in the central lab. Index visit MI was adjudicated by 3 experts using central lab cTn measures from the patient's clinical blood draws. Test characteristics (sensitivity, specificity, and predictive values) for detection of MI were calculated for POC and central lab cTn measurement of prehospital blood and compared with McNemar's test. Results: During the study period prehospital POC cTn results were obtained on 421 patients, of which 5.0% (21/421) had results >99th percentile upper reference limit. MI was adjudicated in 16.2% (68/421) during the index visit. The specificity and positive predictive value of the POC cTn measurement were 99.2% (95% CI 97.5-99.8%) and 85.7% (95% CI 63.7-97.0%) for MI. However, the sensitivity and NPV of prehospital POC cTn were 26.5% (95% CI 16.5-38.6%) and 87.5% (95% CI 83.9-90.6%). Compared to POC cTn, the central lab cTn measurement of prehospital blood resulted in a higher sensitivity of 67.9% (95% CI 53.7-80.1%, p < 0.0001), but lower specificity of 92.4% (95% CI 88.4-95.4%, p = 0.0001). Conclusions: Prehospital POC i-STAT cTn measurement in patients transported with acute chest pain was highly specific for MI but had low sensitivity. This suggests that prehospital i-STAT POC cTn could be useful to rule-in MI, but should not be used to exclude MI.

The Functions of ZIP8, ZIP14, and ZnT10 in the Regulation of Systemic Manganese Homeostasis.

As an essential nutrient, manganese is required for the regulation of numerous cellular processes, including cell growth, neuronal health, immune cell function, and antioxidant defense. However, excess manganese in the body is toxic and produces symptoms of neurological and behavioral defects, clinically known as manganism. Therefore, manganese balance needs to be tightly controlled. In the past eight years, mutations of genes encoding metal transporters ZIP8 (SLC39A8), ZIP14 (SLC39A14), and ZnT10 (SLC30A10) have been identified to cause dysregulated manganese homeostasis in humans, highlighting the critical roles of these genes in manganese metabolism. This review focuses on the most recent advances in the understanding of physiological functions of these three identified manganese transporters and summarizes the molecular mechanisms underlying how the loss of functions in these genes leads to impaired manganese homeostasis and human diseases.

Automated Early Identification of an Excessive Air-in-Oil X-ray Tube Artifact That Mimics Acute Cerebral Infarct.

PURPOSE: This study aimed to develop an automated, quantitative method to increase the likelihood of identifying and preventing such air-in-oil (AIO) artifact. METHODS: A 1-dimensional radial representation of the 2-dimensional noise power spectrum (NPS) was calculated from AIO artifact images and compared with artifact-free images. A quality control (QC) software program was modified to include measurements of NPS average frequency within the water section of daily phantom scans. Threshold values for each CT system were incorporated into daily QC. RESULTS: Noise power spectrum for AIO artifact images included a large low-frequency peak compared with artifact-free images; NPS average frequencies were 0.197 and 0.319 line pairs per millimeter for AIO artifact and artifact-free images, respectively. Automated QC successfully identified 3 AIO artifacts before detrimental clinical effect occurred. CONCLUSIONS: Serious clinical problems associated with AIO artifact can be detected and avoided by incorporating NPS average frequency measurements of daily phantom images into an automated QC program.

Assessment of Key Health and Wellness Indicators Among North Carolina Emergency Medical Service Providers.

OBJECTIVE: The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce. METHODS: Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively. RESULTS: A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations. CONCLUSIONS: These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce.

Prehospital Administration of Epinephrine in Pediatric Anaphylaxis - A Statewide Perspective.

OBJECTIVE: Timely administration of epinephrine is critical in the treatment of anaphylaxis. This study sought to determine the frequency of administration of epinephrine by EMS providers caring for pediatric patients in the prehospital setting. METHODS: We examined data from the NC EMS database (PreMIS) from 2010-3 to determine frequency of epinephrine administration in pediatric patients with anaphylaxis. We studied patients <18 years of age with an EMS provider impression of "allergic reaction." Anaphylaxis was present if there was hypotension (defined as SBP < 90 or DBP < 45 for patients age 11 and older, and SBP < 70 + (2 × age) for patients ages 0-10), or impaired respirations (defined as description of labored or absent respirations, or RR < 12 or > 30). We determined the overall frequency of epinephrine administration. A multivariate logistic regression was then constructed to examine the impact of the following variables on appropriate epinephrine administration: age < 10, non-white race, rural county of case origin, duration of transportation from scene, and presence of a paramedic. RESULTS: A total of 504 patients met inclusion criteria, of which 471 demonstrated anaphylaxis as previously defined. A total of 153 patients with anaphylaxis received epinephrine (32.4%, 95% CI 28.3-36.9%). Age < 10 was associated with increased odds of not receiving epinephrine appropriately (OR 2.90, 95% CI 1.85-4.54, p < 0.001). Other variables did not have statistically significant impact on epinephrine administration. CONCLUSION: There are missed opportunities for prehospital administration of epinephrine in pediatric patients with anaphylaxis. Very young children (age < 10) had increased odds for not receiving epinephrine.

Automated Technique to Measure Noise in Clinical CT Examinations.

OBJECTIVE: The purpose of this study was to develop and validate an automated method to measure noise in clinical CT examinations. MATERIALS AND METHODS: An automated algorithm was developed to measure noise in CT images. To assess its validity, the global noise level was compared with image noise measured using an image subtraction technique in an anthropomorphic phantom. The global noise level was further compared with image noise values from clinical patient CT images obtained by an observer study. Finally, the clinical utility of the global noise level was shown by assessing variability of image noise across scanner models for abdominopelvic CT examinations performed in 2358 patients. RESULTS: The global noise level agreed well with the phantom-based and clinical image-based noise measurements, with an average difference of 3.4% and 4.7% from each of these measures, respectively. No significant difference was detected between the global noise level and the validation dataset in either case. It further indicated differences across scanners, with the median global noise level varying significantly between different scanner models (15-35%). CONCLUSION: The global noise level provides an accurate, robust, and automated method to measure CT noise in clinical examinations for quality assurance programs. The significant difference in noise across scanner models indicates the unexploited potential to efficiently assess and subsequently improve protocol consistency. Combined with other automated characterization of imaging performance (e.g., dose monitoring), the global noise level may offer a promising platform for the standardization and optimization of CT protocols.

North Carolina College of Emergency Physicians' Guidance Document on Emergency Medical Services.

The North Carolina College of Emergency Physicians (NCCEP) Emergency Medical Services (EMS) Committee uses an evidence-based approach in writing its protocols and procedures. The most recent revision of the NCCEP document, which was started in late 2010, lasted for more than 1 year and utilized committee members from across the state. Four meetings were held at locations across North Carolina. In addition, 2 surveys were sent to get input from EMS providers. Since 2010, the document has been updated on an ongoing basis, aligning it with the latest evidence-based medicine.

Creating a state medical response system for medical disaster management: the North Carolina experience.

The purpose of this work was to examine the creation and evolution of the North Carolina state medical response system (SMRS). During the past 30 years, states and local communities have developed a somewhat incongruent patchwork of medical disaster response systems. Several local or regional programs participated in the National Disaster Medical System; however, aside from the Disaster Medical Assistance Teams, most of these local resources lacked national standards and national direction. The September 11, 2001 terrorist attacks in Washington, DC and New York, and the anthrax-laced letters mailed to prominent individuals in the US media and others (bioterrorism) in the months that followed were tragic, but they served as both a tipping point and a unifying factor to drive preparedness activities on a national level. Each state responded to the September 11, 2001 attacks by escalating planning and preparedness efforts for a medical disaster response. The North Carolina SMRS was created based on the overall national direction and was tailored to meet local needs such as hurricane response. This article reviews the accomplishments to date and examines future aims. From regional medical response teams to specialty programs such as ambulance strike teams, burn surge planning, electronic inventory and tracking systems, and mobile pharmacy resources, the North Carolina SMRS has emerged as a national leader. Each regional coalition, working with state leadership, has developed resources and has used those resources while responding to disasters in North Carolina. The program is an example of how national leadership can work with state and local agencies to develop a comprehensive and effective medical disaster response system.

Are Data Driving Our Ambulances? Liberal Use of Tranexamic Acid in the Prehospital Setting.

BACKGROUND: Current data on tranexamic acid (TXA) supports early administration for severe hemorrhagic shock. Administration by EMS has been facilitated by developing protocols and standing orders informed by these data. In this study, patterns of TXA use by EMS agencies serving a large level 1 trauma center were examined. We hypothesized that current widespread TXA use often includes administration outside of data-driven indications. METHODS: The trauma registry at a level 1 trauma center was queried for patients who received TXA. To determine the practice patterns and appropriateness of administration of TXA, patients' physiologic state in the prehospital environment based on EMS records, physiologic state on arrival to hospital, and interventions performed in both settings were examined. Over 20 separately managed EMS systems that administer TXA transport patients to this trauma center, allowing for a broad survey of practices. RESULTS: From 2016 to 2021 1089 patients received TXA, 406 (37.3%) having treatment initiated by EMS services. Of these, the average prehospital systolic blood pressure (SBP) was 108.2 mmHg and initial ED SBP was 107.8 mmHg. Only 58.4% of these patients received blood transfusion after arrival to this trauma center. Compliance with standard indications was low with only 14.6% of administrations meeting any data-driven SBP indication. Similar levels of compliance were seen across high volume EMS services. DISCUSSION: Tranexamic acid use has become common in trauma and has been adopted by many EMS systems. These results indicate TXA in the prehospital setting is over-used as administration is not being limited to indications that have shown benefit in prior data.

Long QT syndrome unmasked in an adult subject presenting with excited delirium.

BACKGROUND: Excited delirium is increasingly recognized as a risk factor for sudden death, though the specific pathophysiology of these deaths is typically unclear. OBJECTIVES: We describe a survivor of excited delirium that displayed a transient severe prolongation of the QT interval, suggesting unmasking of long QT syndrome as a possible mechanism of sudden death. CASE REPORT: A 30-year-old man was arrested by police for violent assaultive behavior. Officers at the scene noted confusion, nonsensical speech, sweating, and bizarre agitated behavior; he was transported to the Emergency Department for medical evaluation of possible excited delirium. His initial electrocardiogram revealed a markedly prolonged corrected QT interval of over 600 ms. Intravenous hydration and sodium bicarbonate were administered, with normalization of the QT; he was admitted and recovered uneventfully. CONCLUSIONS: We discuss the possible association between long QT syndrome and unexplained sudden deaths seen with excited delirium. Sodium bicarbonate may be considered when long QT syndrome is identified during or after agitated delirium, though its routine use cannot be recommended based on a case report.

Transcranial ultrasonography to detect intracranial pathology: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Transcranial ultrasonography (TCU) can be a useful diagnostic tool in evaluating intracranial pathology in patients with limited or delayed access to routine neuroimaging in critical care or austere settings. We reviewed available literature investigating the diagnostic utility of TCU for detecting pediatric and adult patient's intracranial pathology in patients with intact skulls and reported diagnostic accuracy measures. METHODS: We performed a systematic review of PubMed® , Cochrane Library, Embase® , Scopus® , Web of Science™, and Cumulative Index to Nursing and Allied Health Literature databases to identify articles evaluating ultrasound-based detection of intracranial pathology in comparison to routine imaging using broad Medical Subject Heading sets. Two independent reviewers reviewed the retrieved articles for bias using the Quality Assessment of Diagnostic Accuracy Studies tools and extracted measures of diagnostic accuracy and ultrasound parameters. Data were pooled using meta-analysis implementing a random-effects approach to examine the sensitivity, specificity, and accuracy of ultrasound-based diagnosis. RESULTS: A total of 44 studies out of the 3432 articles screened met the eligibility criteria, totaling 2426 patients (Mean age: 60.1 ± 14.52 years). We found tumors, intracranial hemorrhage (ICH), and neurodegenerative diseases in the eligible studies. Sensitivity, specificity, and accuracy of TCU and their 95% confidence intervals were 0.80 (0.72, 0.89), 0.71 (0.59, 0.82), and 0.76 (0.71, 0.82) for neurodegenerative diseases; 0.88 (0.74, 1.02), 0.81 (0.50, 1.12), and 0.94 (0.92, 0.96) for ICH; and 0.97 (0.92, 1.03), 0.99 (0.96, 1.01), and 0.99 (0.97, 1.01) for intracranial masses. No studies reported ultrasound presets. CONCLUSIONS: TCU has a reasonable sensitivity and specificity for detecting intracranial pathology involving ICH and tumors with clinical applications in remote locations or where standard imaging is unavailable. Future studies should investigate ultrasound parameters to enhance diagnostic accuracy in diagnosing intracranial pathology.