Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population.

Opiates are addicting and have a high potential for dependency. In the past decades, opiates remained the first-line pharmaceutical option of prehospital treatment for acute traumatic pain in the civilian population. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that has analgesic properties and may serve as an alternative agent for the treatment of acute traumatic pain in prehospital settings. This study aims to assess the safety and efficacy of ketamine administration by paramedics in civilian prehospital settings for the treatment of acute traumatic pain. This was a prospective observational study in San Bernardino, Riverside and Stanislaus counties. Patients were included if they were > 15 years of age with complaints of traumatic or burn-related pain. Patients were excluded if they received opiates up to six hours prior to or concurrently with ketamine administration. The dose administered was 0.3 mg/kg intravenously over five minutes with a maximum dose of 30 mg. The option to administer a second dose was available to paramedics if the patient continued to have pain after 15 minutes following the first administration. Paired-T tests were conducted to assess the change in the primary outcome (pain score) and secondary outcomes (e.g. systolic blood pressure, pulse, and respiratory rate). P-value<0.05 was considered to be statistically significant. A total of 368 patients were included in the final analysis. The average age was 52.9 ± 23.1 years, and the average weight was 80.4 ± 22.2 kg. There was a statistically significant reduction in the pain score (9.13 ± 1.28 vs 3.7 ± 3.4, delta=5.43 ± 3.38, p<0.0001). Additionally, there was a statistically significant change in systolic blood pressure (143.42 ± 27.01 vs 145.65 ± 26.26, delta=2.22 ± 21.1, p=0.044), pulse (88.06 ± 18 vs 84.64 ± 15.92, delta= -3.42 ± 12.12, p<0.0001), and respiratory rate (19.04 ± 3.59 vs 17.74 ± 3.06, delta=-1.3 ± 2.96, p<0.0001). The current study suggested that paramedics are capable of safely identifying the appropriate patients for the administration of sub-dissociative doses of ketamine in the prehospital setting. Furthermore, the current study suggested that ketamine may be an effective analgesic in a select group of adult trauma patients.

Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study.

INTRODUCTION: Hemorrhage is one of the leading causes of death in trauma victims. Historically, paramedics have not had access to medications that specifically target the reversal of trauma-induced coagulopathies. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to evaluate the safety and efficacy of tranexamic acid (TXA) use in the civilian prehospital setting in cases of traumatic hemorrhagic shock. METHODS: The Cal-PAT study is a multi-centered, prospective, observational cohort study with a retrospective comparison. From March 2015 to July 2017, patients ≥ 18 years-old who sustained blunt or penetrating trauma with signs of hemorrhagic shock identified by first responders in the prehospital setting were considered for TXA treatment. A control group was formed of patients seen in the five years prior to data collection cessation (June 2012 to July 2017) at each receiving center who were not administered TXA. Control group patients were selected through propensity score matching based on gender, age, Injury Severity Scores, and mechanism of injury. The primary outcome assessed was mortality recorded at 24 hours, 48 hours, and 28 days. Additional variables assessed included total blood products transfused, the hospital and intensive care unit length of stay, systolic blood pressure taken prior to TXA administration, Glasgow Coma Score observed prior to TXA administration, and the incidence of known adverse events associated with TXA administration. RESULTS: We included 724 patients in the final analysis, with 362 patients in the TXA group and 362 in the control group. Reduced mortality was noted at 28 days in the TXA group in comparison to the control group (3.6% vs. 8.3% for TXA and control, respectively, odds ratio [OR]=0.41 with 95% confidence interval [CI] [0.21 to 0.8]). This mortality difference was greatest in severely injured patients with ISS >15 (6% vs 14.5% for TXA and control, respectively, OR=0.37 with 95% CI [0.17 to 0.8]). Furthermore, a significant reduction in total blood product transfused was observed after TXA administration in the total cohort as well as in severely injured patients. No significant increase in known adverse events following TXA administration were observed. CONCLUSION: Findings from the Cal-PAT study suggest that TXA use in the civilian prehospital setting may safely improve survival outcomes in patients who have sustained traumatic injury with signs of hemorrhagic shock.

Efficacy and Safety of Tranexamic Acid in Prehospital Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study.

INTRODUCTION: The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols. METHODS: This is an ongoing multi-centered, prospective, observational cohort study with a retrospective chart-review comparison. Trauma patients identified in the prehospital setting with signs of hemorrhagic shock by first responders were administered one gram of TXA followed by an optional second one-gram dose upon arrival to the hospital, if the patient still met inclusion criteria. Patients administered TXA make up the prehospital intervention group. Control group patients met the same inclusion criteria as TXA candidates and were matched with the prehospital intervention patients based on mechanism of injury, injury severity score, and age. The primary outcomes were mortality, measured at 24 hours, 48 hours, and 28 days. Secondary outcomes measured included the total blood products transfused and any known adverse events associated with TXA administration. RESULTS: We included 128 patients in the prehospital intervention group and 125 in the control group. Although not statistically significant, the prehospital intervention group trended toward a lower 24-hour mortality rate (3.9% vs 7.2% for intervention and control, respectively, p=0.25), 48-hour mortality rate (6.3% vs 7.2% for intervention and control, respectively, p=0.76), and 28-day mortality rate (6.3% vs 10.4% for intervention and control, respectively, p=0.23). There was no significant difference observed in known adverse events associated with TXA administration in the prehospital intervention group and control group. A reduction in total blood product usage was observed following the administration of TXA (control: 6.95 units; intervention: 4.09 units; p=0.01). CONCLUSION: Preliminary evidence from the Cal-PAT study suggests that TXA administration may be safe in the prehospital setting with no significant change in adverse events observed and an associated decreased use of blood products in cases of trauma-induced hemorrhagic shock. Given the current sample size, a statistically significant decrease in mortality was not observed. Additionally, this study demonstrates that it may be feasible for paramedics to identify and safely administer TXA in the prehospital setting.

Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department.

INTRODUCTION: Alternative destination transportation by emergency medical services (EMS) is a subject of hot debate between those favoring all patients being evaluated by an emergency physician (EP) and those recognizing the need to reduce emergency department (ED) crowding. This study aimed to determine whether paramedics could accurately assess a patient's acuity level to determine the need to transport to an ED. METHODS: We performed a prospective double-blinded analysis of responses recorded by paramedics and EPs of arriving patients' acuity level in a large Level II trauma center between April 2015 and November 2015. Under-triage was defined as lower acuity assessed by paramedics but higher acuity by EPs. Over-triage was defined as higher acuity assessed by paramedics but lower acuity by EPs. The degree of agreement between the paramedics and EPs' evaluations of patient's acuity level was compared using Chi-square test. RESULTS: We included a total of 503 patients in the final analysis. For paramedics, 2 51 (49.9%) patients were assessed to be emergent, 178 (35.4%) assessed as urgent, and 74 (14.7%) assessed as non-emergent/non-urgent. In comparison, the EPs assessed 296 (58.9%) patients as emergent, 148 (29.4%) assessed as urgent, and 59 (11.7%) assessed as non-emergent/non-urgent. Paramedics agreed with EPs regarding the acuity level assessment on 71.8% of the cases. The overall under- and over-triage were 19.3% and 8.9%, respectively. A moderate Kappa=0.5174 indicated moderate inter-rater agreement between paramedics' and EPs' assessment on the same cohort of patients. CONCLUSION: There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories. The field triage of a patient to an alternative destination by paramedics under their current scope of practice and training cannot be supported.

Ondansetron is safe and effective for prehospital treatment of nausea and vomiting by paramedics.

UNLABELLED: OBJCTIVE: The objectives were to evaluate the safety and efficacy of ondansetron in the out-of-hospital treatment of undifferentiated nausea or vomiting. METHODS: Patients with severe nausea or intractable vomiting who were transported by paramedic-staffed ambulances in eight California counties were treated with intravenous (IV), intramuscular (IM), or oral dissolving tablet (ODT) administration of ondansetron. Data were collected prospectively for a six-month period using an online database. Prospectively defined outcome measures were 1) efficacy as measured by a quantitative visual analog nausea scale and 2) incidence of adverse effects. There were no control or placebo groups. RESULTS: Data was collected for 2072 patients, but one patient did not receive the medication. Therefore, Ondansetron was administered to 2,071 patients (3.7% of transported patients). Most patients were adult, with only 66 patients less than 18 years old. Of the 2,071 patients, 1,320 (64%) received IV administration, 77 (4%) received IM administration, and 674 (33%) received ODT administration of ondansetron. Intravenous administration resulted in the largest improvements in nausea scores (mean 4.4; 95% confidence interval [CI] 4.2, 4.5), followed by IM (mean 3.6; 95% CI 3.0, 4.3) and ODT (mean 3.3; 95% CI 3.1, 3.5). Overall, the mean decrease in nausea score was 4.0 (95% CI 3.9, 4.1; p < 0.001) on a 10-point scale. After medication administration, four patients had mild hypotension, one had hypertension, two had itching or rash, and one had a brief episode of supraventricular tachycardia that resolved spontaneously. CONCLUSIONS: Ondansetron is safe and effective for out-of-hospital treatment of nausea and vomiting when administered by paramedics via the IV, IM, or oral route. When available to paramedics, ondansetron is used frequently.

On-site physicians reduce ambulance transports at mass gatherings.

OBJECTIVES: To prospectively determine if on-site physicians at a mass gathering reduced the number of ambulance transports to local medical facilities. The authors also wished to determine the level of care provider (emergency medical technician, EMT-P, registered nurse, or medical doctor) required to treat and disposition each patient. METHODS: This study determined whether each patient presenting to on-site first aid stations at California Speedway during a large motorsports event would require ambulance transport to the hospital per the local emergency medical services (EMS) protocols. Whether the on-site physician prevented certain ambulance transports also was determined. Additionally, the minimum level of provider that could treat and disposition each patient was determined. RESULTS: On-site physicians significantly reduced (p < 0.001) the number of ambulance transports at this mass gathering. Ambulance transports to local hospitals were reduced by 89% (from 116 to 13). Fifty-two percent of the patients were able to be treated and dispositioned (cardiac arrests, minor first aid, etc.) by a paramedic. Registered nurses were able to treat and disposition another 39% of the patients with pre-established protocols written by the track medical director. These patients had abrasions requiring tetanus shots, mild to moderate heat exhaustion that resolved with intravenous hydration, and other minor complaints. Finally, about 9% of the patients required physician-level care (suturing, prescriptions, etc.) to treat and disposition them. CONCLUSION: On-site physician-level medical care at large mass gatherings significantly reduces the number of patients requiring transport to hospitals, thus reducing the impact on the local EMS system and surrounding medical facilities.