Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only.

OBJECTIVE: The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only. METHODS: We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury. RESULTS: Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10-69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49-5.80, and OR =2.15, 95% CI, 1.07-4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate. CONCLUSIONS: This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.

Familial Anaphylaxis after Silkworm Ingestion.

Herein, we present a case of anaphylaxis in multiple family members after ingesting silkworms, an Asian delicacy. While food allergies, including anaphylaxis are unfortunately common, there are no previous reports of multiple family members suffering an anaphylactic reaction after eating silkworms. In addition, both family members required multiple doses of epinephrine and eventually an epinephrine infusion to improve their blood pressures. All interventions, including the epinephrine infusions, were started by emergency medical services (EMS) with on-line medical direction. Both the reaction and the required treatment are not extensively documented in the medical literature.

Use of point-of-care lactate in the prehospital aeromedical environment.

INTRODUCTION: Lactate measurement has been used to identify critical medical illness and initiate early treatment strategies. The prehospital environment offers an opportunity for very early identification of critical illness and commencement of care. HYPOTHESIS: The investigators hypothesized that point-of-care lactate measurement in the prehospital aeromedical environment would: (1) identify medical patients with high mortality; (2) influence fluid, transfusion, and intubation; and (3) increase early central venous catheter (CVC) placement. METHODS: Critically ill, medical, nontrauma patients who were transported from September 2007 through February 2009 by University of Massachusetts (UMass) Memorial LifeFlight, a university-based emergency medical helicopter service, were eligible for enrollment. Patients were prospectively randomized to receive a fingerstick whole-blood lactate measurement on an alternate-day schedule. Flight crews were not blinded to results. Flight crews were asked to inform the receiving attending physician of the results. The primary endpoint was the ability of a high, prehospital lactate value [> 4 millimoles per liter (mmol/L)] to identify mortality. Secondary endpoints included differences in post-transport fluid, transfusion, and intubation, and decrease in time to central venous catheter (CVC) placement. Categorical variables were compared between groups by Fisher's Exact Test, and continuous variables were compared by t-test. RESULTS: Patients (N = 59) were well matched for age, gender, and acuity. In the lactate cohort (n = 20), mean lactate was 7 mmol/L [Standard error of the mean, SEM = 1]. Initial analysis revealed that prehospital lactate levels of ≥ 4 mmol/L did show a trend toward higher mortality with an odds ratio of 2.1 (95% CI, 0.3-13.8). Secondary endpoints did not show a statistically significant change in management between the lactate and non lactate groups. There was a trend toward decreased time to post-transport CVC in the non lactate faction. CONCLUSION: Prehospital aeromedical point-of-care lactate measurement levels ≥ 4 mmol/L may help stratify mortality. Further investigation is needed, as this is a small, limited study. The initial analysis did not find a significant change in post-transport management.

Evaluation of an emergency medical services-based social services referral program for elderly patients.

OBJECTIVE: To describe the preliminary experience of an emergency medical services (EMS)-based follow-up program providing elderly patients access to community-based social services. METHODS: This was a retrospective, case series report. Inclusion criteria were adults aged 60 years and older requesting EMS for fall or lift assist; against medical advice (AMA) refusal of transport for a medical complaint; any social service or home care needs; request for nonmedical transportation; multiple prior EMS visits; or cases of elder abuse or neglect. Patients were identified either by paramedics at the time of the call or an EMS physician during routine chart review of "no-transport" calls. Patients were then contacted and offered referral follow-up with a social services worker. Data were collected for age, gender, presence of established social services, referral strategy, complaint type, referral acceptance rate, and follow-up plan. RESULTS: Seventy patients were referred over eight months. Paramedics provided 33% of referrals (23/70) as well as a significantly higher number of social service-related complaints (48% vs. 15%, p = 0.005). Follow-up from a fall occurred more often after EMS physician chart review (53% vs. 30%, p = 0.07). Rates of established social services were similar for patients who accepted and those who declined follow-up (89% vs. 90%, p = 0.95) and between patients who were referred by paramedics and those who were referred by EMS physicians (93% vs. 90%, p = 0.72). Paramedic referral was associated with a significantly higher rate of acceptance (94% vs. 28%, p < 0.001). CONCLUSION: EMS provides an invaluable opportunity to connect the elderly with social services at the time of contact. In this study, paramedics appeared to refer more social service-related complaints compared with other categories such as fall assistance. This highlights a difference in perception of social service needs among paramedics and represents an area for further training and education.

Carbon monoxide poisoning during natural disasters: the Hurricane Rita experience.

We report the incidence and mechanisms of carbon monoxide exposure during the first 5 days after Hurricane Rita, as experienced by a Disaster Medical Assistance Team staffing the only open health care facility in the Beaumont, Texas region after the storm. Improper placement of portable generators in indoor locations or proximate to home air conditioning intake systems were completely responsible for the 21 exposures including 5 fatalities, 1 brain dead, 2 transfers for hospitalization, and 13 treated and released. We discuss the clinical presentations and treatment approaches, provide a brief overview of carbon monoxide and offer novel preventive recommendations. Portable generator use after disasters represents a predictable risk to the public. Proper ventilation requirements for generators are not adequately appreciated and engineered safeties should be explored to mitigate illness.

Improving use of prehospital 12-lead ECG for early identification and treatment of acute coronary syndrome and ST-elevation myocardial infarction.

BACKGROUND: Performance of prehospital ECGs expedites identification of ST-elevation myocardial infarction and reduces door-to-balloon times for patients receiving reperfusion therapy. To fully realize this benefit, emergency medical service performance must be measured and used in feedback reporting and quality improvement. METHODS AND RESULTS: This quasi-experimental design trial tested an approach to improving emergency medical service prehospital ECGs using feedback reporting and quality improvement interventions in 2 cities' emergency medical service agencies and receiving hospitals. All patients age > or =30 years, calling 9-1-1 with possible acute coronary syndrome, were included. In total, 6994 patients were included: 1589 patients in the baseline period without feedback and 5405 in the intervention period when there were feedback reports and quality improvement interventions. Mean age was 66+/-17 years, and women represented 51%. Feedback and quality improvement increased prehospital ECG performance for patients with acute coronary syndrome from 76% to 93% (P=<0.0001) and for patients with ST-elevation myocardial infarction from 77% to 99% (P=<0.0001). Aspirin administration increased from 75% to 82% (P=0.001), but the median total emergency medical service run time remained the same at 22 minutes. The proportion of patients with door-to-balloon times of < or =90 minutes increased from 27% to 67% (P=0.006). CONCLUSIONS: Feedback reports and quality improvement improved prehospital ECG performance for patients with acute coronary syndrome and ST-elevation myocardial infarction and increased aspirin administration without prehospital transport delays. Improvements in door-to-balloon times were also seen.