A Comparison of Paramedic First Pass Endotracheal Intubation Success Rate of the VividTrac VT-A 100, GlideScope Ranger, and Direct Laryngoscopy Under Simulated Prehospital Cervical Spinal Immobilization Conditions in a Cadaveric Model.

OBJECTIVE: The primary goal of this study was to compare paramedic first pass success rate between two different video laryngoscopes and direct laryngoscopy (DL) under simulated prehospital conditions in a cadaveric model. METHODS: This was a non-randomized, group-controlled trial in which five non-embalmed, non-frozen cadavers were intubated under prehospital spinal immobilization conditions using DL and with both the GlideScope Ranger (GL; Verathon Inc, Bothell, Washington USA) and the VividTrac VT-A100 (VT; Vivid Medical, Palo Alto, California USA). Participants had to intubate each cadaver with each of the three devices (DL, GL, or VT) in a randomly assigned order. Paramedics were given 31 seconds for an intubation attempt and a maximum of three attempts per device to successfully intubate each cadaver. Confirmation of successful endotracheal intubation (ETI) was confirmed by one of the six on-site physicians. RESULTS: Successful ETI within three attempts across all devices occurred 99.5% of the time overall and individually 98.5% of the time for VT, 100.0% of the time for GL, and 100.0% of the time for DL. First pass success overall was 64.4%. Individually, first pass success was 60.0% for VT, 68.8% for GL, and 64.5% for DL. A chi-square test revealed no statistically significant difference amongst the three devices for first pass success rates (P=.583). Average time to successful intubation was 42.2 seconds for VT, 38.0 seconds for GL, and 33.7 for seconds for DL. The average number of intubation attempts for each device were as follows: 1.48 for VT, 1.40 for GL, and 1.42 for DL. CONCLUSION: The was no statistically significant difference in first pass or overall successful ETI rates between DL and video laryngoscopy (VL) with either the GL or VT (adult). Hodnick R , Zitek T , Galster K , Johnson S , Bledsoe B , Ebbs D . A comparison of paramedic first pass endotracheal intubation success rate of the VividTrac VT-A 100, GlideScope Ranger, and direct laryngoscopy under simulated prehospital cervical spinal immobilization conditions in a cadaveric model. Prehosp Disaster Med. 2017;32(6):621-624.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field.

BACKGROUND: Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%). CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Pre-hospital assessment with ultrasound in emergencies:implementation in the field / 世界急诊医学杂志（英文）

@#BACKGROUND: Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89％, 95％CI 67％–99％). Paramedics accurately recorded 17 cases of cardiac activity (100％, 95％CI 84％–100％) and 2 cases of cardiac standstill (100％, 95％CI 22％–100％). CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Is it time to stop chilling? Induced therapeutic hypothermia doesn't appear to have the prehospital effect we thought it did.

The evidence is quite clear that ITH in the prehospital setting is of dubious benefit. But what is the harm in continuing the practice? Well, prehospital ITH most likely takes away from more beneficial therapies such as high-quality CPR, rapid defibrillation, recognition of ST-segment elevation myocardial infarction (STEMI), and similar essential treatments. Several studies have shown prehospital ITH, in many cases, delays hospital transport. When the initial studies of ITH were released, I was immediately on the ITH bandwagon. Interestingly, the American Heart Association (AHA) has never recommended prehospital ITH. Even the position paper on ITH by the National Association of EMS Physicians (NAEMSP) was cautious, saying, "A lack of evidence on induced hypothermia in the prehospital setting currently precludes recommending this treatment modality as standard of care for all emergency medical services (EMS) patients resuscitated from cardiac arrest. A systematic review of ITH recently published states, "In cardiac arrest, the initiation of therapeutic hypothermia in the out-of-hospital environment has not been shown to improve neurologic outcomes, although studies to date have been limited. We now know that caution Fxercised by the AHA and preMSP was appropriate. One medmy mentors in residency and ays said, "Never be the first- Univtor to prescribe a new drug or of Mlast doctor to prescribe an old is th" Lik" many things in EMS, EMS tms something that was put in Practe with good intent but lim- scientific evidence. We now P ITH is probably not a good ice and it is time to abandon it. However, we should still carry chilled IV fluids for hyperthermia, excited delirium and to main- tainormothermia in patients in cardiac arrest where transport times are long.

Glasgow Coma Scale Scoring is Often Inaccurate.

INTRODUCTION: The Glasgow Coma Scale (GCS) is widely applied in the emergency setting; it is used to guide trauma triage and for the application of essential interventions such as endotracheal intubation. However, inter-rater reliability of GCS scoring has been shown to be low for inexperienced users, especially for the motor component. Concerns regarding the accuracy and validity of GCS scoring between various types of emergency care providers have been expressed. Hypothesis/Problem The objective of this study was to determine the degree of accuracy of GCS scoring between various emergency care providers within a modern Emergency Medical Services (EMS) system. METHODS: This was a prospective observational study of the accuracy of GCS scoring using a convenience sample of various types of emergency medical providers using standardized video vignettes. Ten video vignettes using adults were prepared and scored by two board-certified neurologists. Inter-rater reliability was excellent (Cohen's κ = 1). Subjects viewed the video and then scored each scenario. The scoring of subjects was compared to expert scoring of the two board-certified neurologists. RESULTS: A total of 217 emergency providers watched 10 video vignettes and provided 2,084 observations of GCS scoring. Overall total GCS scoring accuracy was 33.1% (95% CI, 30.2-36.0). The highest accuracy was observed on the verbal component of the GCS (69.2%; 95% CI, 67.8-70.4). The eye-opening component was the second most accurate (61.2%; 95% CI, 59.5-62.9). The least accurate component was the motor component (59.8%; 95% CI, 58.1-61.5). A small number of subjects (9.2%) assigned GCS scores that do not exist in the GCS scoring system. CONCLUSIONS: Glasgow Coma Scale scoring should not be considered accurate. A more simplified scoring system should be developed and validated.

EMS provider compliance with infection control recommendations is suboptimal.

INTRODUCTION: Standard precautions are disease transmission prevention strategies recommended by both the World Health Organization (WHO) and by the Centers for Disease Control and Prevention (CDC). Emergency medical services (EMS) personnel are expected to utilize standard precautions. METHODS: This was a prospective observational study of the use of standard precautions by EMS providers arriving at a large urban emergency department (ED). Research assistants (RAs) observed EMS crews throughout their arrival and delivery of patients and recorded data related to the use of gloves, hand hygiene, and equipment disinfection. RESULTS: A total of 423 EMS deliveries were observed, allowing for observation of 899 EMS providers. Only 512 (56.9%) EMS providers arrived wearing gloves. Hand washing was observed in 250 (27.8%) of providers. Reusable equipment disinfection was noted in only 31.6% of opportunities. The most commonly disinfected item was the stretcher (55%). CONCLUSION: EMS provider compliance with standard precautions and equipment disinfection recommendations is suboptimal. Strategies must be developed to improve EMS provider compliance with internationally recognized infection control guidelines. Key words: Emergency medical services, hand washing, hygiene, disinfection, disease prevention.

The swelling airway. Angioedema is not always caused by allergic reaction.

The case detailed here is relatively rare but can be life-threatening. EMS personnel identified the case, provided the appropriate treatment presuming it to be an allergic reaction. Later, it was determined to have been caused by angioedema, but the staff believed that the prehospital care led to a more rapid diagnosis and subsequent care.

Electronic Prehospital Records are Often Unavailable for Emergency Department Medical Decision Making.

INTRODUCTION: To determine emergency physician (EP) opinions of prehospital patient care reports (PCRs) and whether such reports are available at the time of emergency department (ED) medical decision-making. METHODS: Prospective, cross-sectional, electronic web-based survey of EPs regarding preferences and availability of prehospital PCRs at the time of ED medical decision-making. RESULTS: We sent the survey to 1,932 EPs via 4 American College of Emergency Physicians (ACEP) email lists. As a result, 228 (11.8%) of email list members from 31 states and the District of Columbia completed the survey. Most respondents preferred electronic prehospital PCRs as opposed to handwritten prehospital PCRs (52.2% [95% confidence interval (CI): 49.1, 55.3] vs. 17.1% [95%CI: 11.7, 22.5]). The remaining respondents (30.5% [95%CI: 26.0, 35.0]) had no preference or had seen only one type of PCR. Of the respondents, 45.6% [95%CI: 42.1, 48.7] stated PCRs were "very important" while 43.0% [95% CI: 39.3, 46.7] rated PCRs as "important" in their ED practice. Most respondents (79.6% [95%CI: 76.5, 82.7]) reported electronic prehospital PCRs were available ≤50% of the time for medical decision-making while 20.4% [95%CI: 9.2, 31.6] reported that electronic prehospital PCRs were available > 50% of the time (P=0.00). A majority of participants (77.6% [95%CI: 74.5, 80.7]) reported that handwritten prehospital PCRs were available ≥ 50% while 22.4% [95%CI: 11.8, 33.0] of the time for medical decision-making (P=0.00). CONCLUSION: EPs in this study felt that prehospital PCRs were important to their ED practice and preferred electronic prehospital PCRs over handwritten PCRs. However, most electronic prehospital PCRs were unavailable at the time of ED medical decision-making. Although handwritten prehospital PCRs were more readily available, legibility and accuracy were reported concerns. This study suggest that strategies should be devised to improve the overall accuracy of PCRs and assure that electronic prehospital PCRs are delivered to the receiving ED in time for consideration in ED medical decision-making.

Vegas stings.

The case detailed here is relatively straight-forward. We describe the case of a tourist who sustained a scorpion sting in a local state park. Her symptoms were more significant than typically seen with simple scorpion stings. The scorpion that was caught by her boyfriend was later determined to be a bark scorpion. However, following adequate prehospital treatment and detailed evaluation in the emergency department, the patient improved. It was determined that scorpion antivenin wasn't indicated bacause of the lack of systemic signs and symptoms. The patient ultimately did well and completed her vacation in Las Vegas.

Thin blood. Risk of internal bleeding heightened with anticoagulant therapy.

The case detailed here is not uncommon. A day rarely passes at UMC where we don't evaluate and subsequently admit a patient from the Las Vegas valley and surrounding regions that has sustained an intracranial hemorrhage secondary to oral anticoagulants. Because of this, EMS and emergency department personnel should have an increased incidence of suspicion for the possibility of a bleeding complication in patients taking oral anticoagulants. You should always question patients who have atrial fibrillation in regard to oral anticoagulant usage. In the case discussed here, probing questions by paramedics were able to elucidate a history of atrial fibrillation and the use of an oral anticoagulant. This allowed the paramedics to stratify the patient's risk for hemorrhage and need for further medical care. Ultimately, the patient was assessed and transported to a hospital that could care for any possible complications related to the injury.

Silent struggle.

The past 40-50 years of research and experience have given us improved knowledge of the pathophysiology and treatment of drowning injuries. Still, an all-too-common event, the morbidity and mortality of drowning can be mitigated by prevention, recognition and target treatment. Old terms, such as "near drowning" and "secondary drowning," are confusing and misleading, and use of these terms should be abandoned. Most importantly, EMS personnel should understand that drowning is a hypoxic event resulting from submersion in a liquid. Most BLS and ALS strategies are designed to treat cardiac causes of respiratory and cardiac arrests (with recent change to a CAB algorithm). Drowning, however, is initially a purely hypoxic event and should be treated as such with ventilation and oxygenation (with an ABC algorithm). EMS and the fire service, because of their presence in the community, are uniquely positioned to play a major role in drowning prevention and treatment.

Breaking the surface: Arm yourself with knowledge about penetrating trauma.

Penetrating trauma is a serious emergency that requires prompt prehospital identification, transport, and often, immediate surgical intervention. It's easy to miss some penetrating wounds unless you do a detailed secondary assessment. Remember that penetrating injuries to the head, neck and chest have significant morbidity and mortality. Victims of penetrating trauma have the best outcomes when they're treated in a comprehensive trauma center that allows rapid assessment, necessary imaging and quick access to surgical care in the operating room setting. The role of prehospital personnel is to detect these injuries, provide essential emergency care and ensure that the patient is delivered to the closest appropriate facility.

Miracle in the desert. Cardiac case at remote burning man event presents challenges.

This was a miraculous case that illustrates the importance of seamless interaction between field EMS crews and physicians. First, this case occurred in one of the most austere and hostile environments imaginable. Next, it included a patient who was resuscitated from pulseless v tach with a precordial thump performed by a paramedic crew. The patient was subsequently evaluated and diagnosed with a thoracic aorta dissection by medical staff in a tent (with a diagnosis made by plain chest X-ray) and emergently transported 150 miles to a hospital where successful surgery was carried out. It truly was a "perfect storm," or perhaps, it was the general goodwill and spirit of Burning Man. Or maybe those crystals that were everywhere actually worked.

Burning Man 2011: mass gathering medical care in an austere environment.

INTRODUCTION: Burning Man is a large weeklong outdoor arts festival held annually in the rugged and austere Black Rock Desert in northern Nevada. The 2011 event presented several unusual challenges in terms of emergency medical services (EMS) and medical care provision. OBJECTIVE: This paper details the planning and subsequent emergency medical care for Burning Man 2011. METHODS: This was a retrospective, observational review of the preparation, management, and medical care at Burning Man 2011. RESULTS: Attendance at Burning Man 2011 was 53,735. Of these attendees, 2,307 were treated in the field hospital. While most patients had minor injuries, 33 were subsequently transported to a hospital (28 by ambulance and five by helicopter). The most common conditions treated were soft-tissue injuries, dehydration, eye problems, and urinary tract infections. There was one death (subarachnoid hemorrhage) and one patient in cardiac arrest (thoracic aortic dissection) who was successfully resuscitated and transferred. Burning Man 2011 presented numerous challenges in provision of EMS and medical care because of attendance size, the austere environment, and significant distance (150 miles) to definitive medical care. EMS operations included six dedicated ambulances, three quick-response vehicles, two first-aid stations, and a physician-staffed field hospital. The hospital had limited diagnostic capabilities (e.g., x-ray, ultrasound, basic laboratory analysis) and a limited formulary. We found that the use of physicians was necessary because much of the care provided was beyond the scope of paramedics. CONCLUSIONS: We describe the preparation and medical care for a large outdoor mass-gathering event held in a remote and austere environment. We met the stated goals of providing needed medical care while minimizing the need to transport attendees offsite for additional care. Our experience with Burning Man 2011 may aid planners with similar events.

Late-night wheezer: providers respond to pediatric asthma patient.

Asthma is a common disease. The main stay of "rescue" therapy in asthma is the administration of nebulized bronchodilators. The prompt administration of these agents can be life saving. Always question the patient about home beta-2 agonist used. Remember the phenomenon of tachyphylaxis and consider switching to a different medication in the same class if the patient reports prolonged usage or ineffectiveness of their current bronchodilator. Remember asthma can be life threatening.

Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting.

OBJECTIVE: The objective of this study was to determine the effects of low-fractional concentration of inspired oxygen (FiO(2)) continuous positive airway pressure (CPAP) in prehospital noninvasive ventilation (NIV). With increasing concerns about the detrimental effects of hyperoxia, we sought to determine whether CPAP using a low FiO(2) (28%-30%) was effective in the prehospital setting. METHODS: The study was a six-month prospective, nonblinded observational study conducted in a large, busy urban emergency medical services (EMS) system (Las Vegas, NV). RESULTS: A total of 340 patients participated in the study. Most patients presented with symptoms consistent with a diagnosis of congestive heart failure/acute pulmonary edema (47.4%), followed by chronic obstructive pulmonary disease (COPD) (40.9%), asthma (22.7%), and pneumonia (15.9%). Improvements were seen in respiratory rate (p = 0.00) and oxygen saturation (p = 0.00). The overall CPAP discontinuation rate was 16.5%. The most common reason for CPAP discontinuation was anxiety/claustrophobia. The total number of patients requiring prehospital intubation was 5.6%. Subjective paramedic assessment of patient status at hospital delivery found that 71.5% of patients' conditions were improved, 15.1% remained unchanged, and 13.4% were worse. CONCLUSIONS: CPAP using a low FiO(2) (28%-30%) was highly effective in the treatment of commonly encountered prehospital respiratory emergencies.

Enigmatic rhythm: swift action is key in complex cardiac case.

This was an interesting, yet enigmatic, case. An elderly male with a prolonged QT interval developed a third-degree block with a slow ventricular rate. This spontaneously converted to a polymorphic v tach (probably torsades) that worsened his cardiac output causing pulmonary congestion and hypoxia. He ultimately converted back to a third-degree block following treatment with amiodarone and magnesium sulfate. More importantly, paramedics recognized the complexity of the case and, because of the very short transport time, elected to rapidly transport the patient. Complex cases such as this do not fit into any standardized EMS protocol. Because of this, we need paramedics who see and recognize serious conditions that don't fall within the constraints of algorithmic protocols. In this case, they identified the problem, transported promptly and alerted the staffin a busy ED of the patient's complex and deteriorating condition.