Safety and Effectiveness of Field Nitroglycerin in Patients with Suspected ST Elevation Myocardial Infarction.

Objective: While widely used in the treatment of cardiac conditions, only limited data characterize out-of-hospital nitroglycerin (NTG) use. We sought to determine the safety of out-of-hospital sublingual NTG administered for suspected ST-segment elevation myocardial infarction (STEMI) and its effect on the patient's pain score. Methods: We prospectively identified adult patients with suspected STEMI transported by paramedics to three percutaneous Coronary Intervention PCI-capable hospitals in a large urban-suburban emergency medical services (EMS) system. We compared patients who received field NTG to those who did not. The primary outcome was the change in systolic blood pressure (SBP) between initial EMS measurement and emergency department (ED) triage vital signs. Secondary outcomes included the frequency of hypotension (SBP < 100 mmHg) and bradycardia (HR < 60) on ED arrival, drop in SBP ≥ 30 mmHg, out-of-hospital cardiac arrest (OHCA), and the change in pain score compared to an a priori threshold of -1.39. Results: Among 940 EMS transports for suspected STEMI, we excluded 160 for initial SBP < 100 mmHg, leaving 780 subjects for the analysis. Median age was 67 with 61% male. NTG was administered to 340 (44%) patients. The median change in SBP was -10 mmHg (IQR -27, 2) and -3 mmHg (IQR -20, 9) in patients treated with and without NTG, respectively. The median difference in the decrease in SBP was 6 mmHg (95% CI 3, 9 mmHg). The frequencies of ED hypotension and bradycardia, the drop in SBP ≥ 30 mmHg, and the OHCA did not differ between groups. For patients with an initial pain score > 0, the average change in pain score for patients treated with NTG was -2.6 (95% CI -3.0, -2.2), while patients who did not receive NTG had a change in pain score of -1.4 (95% CI -1.8, -1.0). Conclusion: In this cohort, field NTG did not result in a clinically significant decrease in blood pressure when compared with patients who did not receive NTG. However, NTG did cause a clinically significant reduction in pain.

Emergency Medical Responses at US Immigration and Customs Enforcement Detention Centers in California.

Importance: Knowledge of medical care in US Immigration and Customs Enforcement (ICE) detention centers is limited. Reviews show high rates of preventable deaths while in detention due to substandard medical care within detention centers. Objective: To describe characteristics of medical emergencies at ICE detention centers in California. Design, Setting, and Participants: This cross-sectional study analyzed emergency medical services (EMS)-reported medical emergencies activated through 911 from January 1, 2018, to December 31, 2022, at 3 of the 5 ICE detention centers in California: Adelanto ICE Processing Center, Imperial Regional Detention Facility, and Otay Mesa Detention Center. Exposure: Medical services requiring 911 activation. Main Outcomes and Measures: Data included the number of EMS-reported medical emergencies; ICE-reported medical emergencies; patient age and sex; and medical data in the EMS report, including primary symptom, EMS provider (emergency medical technician or paramedic) impression, vital signs, and interventions performed, using descriptive statistics. Results: In this analysis of 3 detention centers with a mean daily census of 775 (range, 504-1001) individuals per center, there was a median of 68 (IQR, 10-88) EMS-reported emergencies per center per year for a total of 1224 emergencies. The EMS-reported emergencies involved 881 males (72%) and 338 females (28%) with a median age of 39.0 (IQR 30.0-49.0) years. The ratios of female-to-male EMS-reported emergencies were 0.51 (95% CI, 0.31-0.87) at Adelanto, 0.86 (95% CI, 0.31-2.43) at Imperial, and 1.60 (95% CI, 1.40-1.83) at Otay Mesa. Pregnancy-related emergencies accounted for 12.4% (42 of 338) of emergencies in females. A total of 357 individuals (29.2%) had at least 1 abnormal vital sign during their EMS encounter. Psychiatric emergencies comprised 48 EMS responses (3.9%), despite higher rates of ICE-reported psychiatric-related complaints. The median number of monthly EMS-reported emergencies across all 3 centers was 3 (IQR, 0-9) vs 4 ICE-reported emergencies (IQR, 1-15). Conclusions and Relevance: In this study of medical emergencies at 3 of 5 ICE detention facilities in California, there were discrepancies in EMS vs ICE reported emergencies. The data suggested that vulnerable populations, such as pregnant women, had an increased number of medical emergencies, while individuals with psychiatric emergencies accounted for fewer reported emergencies. Based on these findings, emergency medical care provision in ICE detention centers requires increased transparency to ensure appropriate delivery of care.

Implementation of a regional extracorporeal membrane oxygenation program for refractory ventricular fibrillation out-of-hospital cardiac arrest.

BACKGROUND: eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR. METHODS: The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome. RESULTS: From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs. CONCLUSION: We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.

Evaluation of Orthotopic Liver Transplant Recipients Presenting to the Emergency Department.

Improved survival rates and more centers performing liver transplantation have resulted in increasing numbers of liver transplant recipients presenting to emergency departments. This article familiarizes emergency physicians with orthotopic liver transplantation and complications that cause liver transplant recipients to visit EDs. Savitsky EA, Üner AB, Votey SR: Evaluation of orthotopic liver transplant recipients presenting to the emergency department. Ann Emerg Med April 1998;31:507-517.].