A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke.

Introduction: Endovascular thrombectomy (EVT) significantly improves outcomes in large vessel occlusion stroke (LVOS). When a patient with a LVOS arrives at a hospital that does not perform EVT, emergent transfer to an endovascular stroke center (ESC) is required. Our objective was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in patients undergoing EVT. Methods: We conducted an analysis of the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry of 2,400 LVOS patients treated at nine ESCs in the United States. We examined the association between DIDO times and 90-day outcomes as measured by the modified Rankin scale. Results: A total of 435 patients were included in the final analysis. The mean DIDO time for patients with good outcomes was 17 minute shorter than patients with poor outcomes (122 minutes [min] vs 139 min, P = 0.04). Absolute DIDO cutoff times of ≤60 min, ≤90 min, or ≤120 min were not associated with improved functional outcomes (46.4 vs 32.3%, P = 0.12; 38.6 vs 30.6%, P = 0.10; and 36.4 vs 28.9%, P = 0.10, respectively). This held true for patients with hyperacute strokes of less than four-hour onset. Lower baseline National Institutes of Health Stroke Scale (NIHSS) score (11.9 vs 18.2, P = <.001) and younger age (62.5 vs 74.9 years (P < .001) were associated with improved outcomes. On multiple regression analysis, age (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.45-2.02) and baseline NIHSS score (OR 1.67, 95% CI 1.42-1.98) were associated with improved outcomes while DIDO time was not associated with better outcome (OR 1.13, 95% CI 0.99-1.30). Conclusion: Although the DIDO time was shorter for patients with a good outcome, this was non-significant in multiple regression analysis. Receipt of intravenous thrombolysis and time to EVT were not associated with better outcomes, while male gender, lower age, arrival by private vehicle, and lower NIHSS score portended better outcomes. No absolute DIDO-time cutoff or modifiable factor was associated with improved outcomes for LVOS. This study underscores the need to streamline DIDO times but not to set an artificial DIDO time benchmark to meet.

Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi.

Objectives: Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT. Methods: This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT. Results: Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of >4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49). Conclusion: Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of >4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.

Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular therapy.

INTRODUCTION: In the management of large vessel occlusion stroke (LVOS), patients are frequently evaluated first at a non-endovascular stroke center and later transferred to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals though there is no universally accepted nor evidenced-based DIDO time. The goal of this study was to identify factors affecting DIDO times in LVOS patients who ultimately underwent EVT. METHODS: The Optimizing Prehospital Use of Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry is comprised of all LVOS patients who underwent EVT at one of nine endovascular centers in the Northeast United States between 2015 and 2020. We queried the registry for all patients who were transferred from a non-ESC to one of the nine ESCs for EVT. Univariate analysis was performed using t-tests to obtain a p value. A priori, we defined a p value of <0.05 as significant. Multiple logistic regression was conducted to determine the association of variables to estimate an odds ratio. RESULTS: 511 patients were included in the final analysis. The mean DIDO times for all patients was 137.8 min. Vascular imaging and treatment at a non-certified stroke center were associated with longer DIDO times by 23 and 14 min, respectively. On multivariate analyses, the acquisition of vascular imaging was associated with 16 additional minutes spent at the non-ESC while presentation to a non-stroke certified hospital was associated with 20 additional minutes spent at the transferring hospital. The administration of intravenous thrombolysis (IVT) was associated with 15 min less spent at the non-ESC. DISCUSSION: Vascular imaging and non-stroke certified stroke centers were associated with longer DIDO times. Non-ESCs should integrate vascular imaging into their workflow as feasible to reduce DIDO times. Further work examining other details regarding the transfer process such as transfer via ground or air, could help further identify opportunities to improve DIDO times.

Timing and Outcomes After Coronary Angiography Following Out-of-Hospital Cardiac Arrest Without Signs of ST-Segment Elevation Myocardial Infarction.

BACKGROUND: There is broad consensus that resuscitated out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation myocardial infarction (STEMI) should receive immediate coronary angiography (CAG); however, factors that guide patient selection and optimal timing of CAG for post-arrest patients without evidence of STEMI remain incompletely described. OBJECTIVE: We sought to describe the timing of post-arrest CAG in actual practice, patient characteristics associated with decision to perform immediate vs. delayed CAG, and patient outcomes after CAG. METHODS: We conducted a retrospective cohort study at seven U.S. academic hospitals. Resuscitated adult patients with OHCA were included if they presented between January 1, 2015 and December 31, 2019 and received CAG during hospitalization. Emergency medical services run sheets and hospital records were analyzed. Patients without evidence of STEMI were grouped and compared based on time from arrival to CAG performance into "early" (≤ 6 h) and "delayed" (> 6 h). RESULTS: Two hundred twenty-one patients were included. Median time to CAG was 18.6 h (interquartile range [IQR] 1.5-94.6 h). Early catheterization was performed on 94 patients (42.5%) and delayed catheterization was performed on 127 patients (57.5%). Patients in the early group were older (61 years [IQR 55-70 years] vs. 57 years [IQR 47-65] years) and more likely to be male (79.8% vs. 59.8%). Those in the early group were more likely to have clinically significant lesions (58.5% vs. 39.4%) and receive revascularization (41.5% vs. 19.7%). Patients were more likely to die in the early group (47.9% vs. 33.1%). Among survivors, there was no significant difference in neurologic recovery at discharge. CONCLUSIONS: OHCA patients without evidence of STEMI who received early CAG were older and more likely to be male. This group was more likely to have intervenable lesions and receive revascularization.

Evolution of endovascular stroke centers and disparities in access to stroke care in four Northeastern states: 2015-2019.

OBJECTIVES: Disparities exist throughout our healthcare system, especially related to access to care. Advanced stroke care for strokes is only available at selected endovascular centers (ESCs) in the United States. Although the number of ESCs increase each year, this does not necessarily reflect increased access to care. Here, we look at the evolution of ESC in four states and disparities in access to advanced stroke care. MATERIALS AND METHODS: This is a descriptive study of access to ESCs in four Northeastern states between 2015-2019. Using data from the United States Census Bureau and spatial analysis, we examined the proportion of the population with drive times of less than 60 minutes stratified by income, race/ethnicity, population density, and insurance. We also calculated the mean drive time for each of these socioeconomic groups from their census tracts to the nearest ESC. RESULTS: Between 2015 and 2019, the number of ESCs increased from 15 to 48. The proportion of patients within a 60-minute drive of an ESC increased from 77% to 88%. However, only 66% of the least densely populated quartile lived within 60 min of an ESC. By income, access to ESCs in the wealthiest quartile was 96.6% compared to 83.7% in the lowest quartile. Hispanics and non-Hispanic Blacks had the largest proportions of populations within 60 minutes of an ESC while Non-Hispanic Whites had the smallest. CONCLUSIONS: This study underscores the need to evaluate the placement of new ESCs to assure that these hospitals decrease disparities and increase access to advanced stroke care.

Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH): a pragmatic registry of large vessel occlusion stroke patients to create evidence-based stroke systems of care and eliminate disparities in access to stroke care.

BACKGROUND: Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients. To find this answer, an analysis of a large, real-world population of LVO stroke patients must be performed. METHODS: A pragmatic registry of LVO stroke patients from nine health systems across the United States. The nine health systems span urban and rural populations as well as the spectrum of socioeconomic statuses. We will use univariate and multivariate analysis to explore the relationships between type of EMS transport, socioeconomic factors, and LVO stroke outcomes. We will use geographic information systems and spatial analysis to examine the complex movements of patients in time and space. To detect an 8% difference between groups, with a 3:1 patient ratio of primary to secondary transports, 95% confidence and 80% power, we will need approximately 1600 patients. The primary outcome is the patients with modified Rankin Scale (mRS) ≤ 2 at 90 days. Subgroup analyses include patients who receive intravenous thrombolysis and duration of stroke systems. Secondary analyses include socioeconomic factors associated with poor outcomes after LVO stroke. DISCUSSION: Using the data obtained from the OPUS-REACH registry, we will develop evidence based algorithms for prehospital transport of LVO stroke patients. Unlike prior research, the OPUS-REACH registry contains patient-level data spanning from EMS dispatch to ninety day functional outcomes. We expect that we will find modifiable factors and socioeconomic disparities associated with poor outcomes in LVO stroke. OPUS-REACH with its breadth of locations, detailed patient records, and multidisciplinary researchers will design the optimal prehospital stroke system of care for LVO stroke patients.

Upgrades to intensive care: The effects of COVID-19 on decision-making in the emergency department.

INTRODUCTION: The initial surge of critically ill patients in the COVID-19 pandemic severely disrupted processes at acute care hospitals. This study examines the frequency and causes for patients upgraded to intensive care unit (ICU) level care following admission from the emergency department (ED) to non-critical care units. METHODS: The number of ICU upgrades per month was determined, including the percentage of upgrades noted to have non-concordant diagnoses. Charts with non-concordant diagnoses were examined in detail as to the ED medical decision-making, clinical circumstances surrounding the upgrade, and presence of a diagnosis of COVID-19. For each case, a cognitive bias was assigned. RESULTS: The percentage of upgraded cases with non-concordant diagnoses increased from a baseline range of 14-20% to 41.3%. The majority of upgrades were due to premature closure (72.2%), anchoring (61.1%), and confirmation bias (55.6%). CONCLUSION: Consistent with the behavioral literature, this suggests that stressful ambient conditions affect cognitive reasoning processes.

Rate of Decompensation of Normoxic Emergency Department Patients with SARS-CoV-2.

INTRODUCTION: As of October 30, 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected over 44 million people worldwide and killed over 1.1 million people. In the emergency department (ED), patients who need supplemental oxygen or respiratory support are admitted to the hospital, but the course of normoxic patients with SARS-CoV-2 infection is unknown. In our health system, the policy during the coronavirus 2019 (COVID-19) pandemic was to admit all patients with abnormal chest imaging (CXR) regardless of their oxygen level. We also admitted febrile patients with respiratory complaints who resided in congregate living. We describe the rate of decompensation among patients admitted with suspected SARS-CoV-2 infection but who were not hypoxemic in the ED. METHODS: This is a retrospective observational study of patients admitted to our health system between March 1-May 5, 2020 with suspected SARS-CoV-2 infection. We queried our registry to find patients who were admitted to the hospital but had no recorded oxygen saturation of <92% in the ED and received no supplemental oxygen prior to admission. Our primary outcome was decompensation at 72 hours, defined by the need for respiratory support (oxygen, high-flow nasal cannula, non-invasive ventilation, or intubation). RESULTS: A total of 840 patients met our inclusion criteria. Of those patients, 376 (45%) tested positive for SARS-CoV-2. Sixty patients (7.1%) with suspected COVID-19 required respiratory support at 72 hours including 27 (3%) of confirmed SARS-CoV-2 positive patients. Among the 376 patients who tested positive for SARS-CoV-2, 54 patients (14%) had normal CXR in the ED. One-third of patients with normal CXRs decompensated at 72 hours. Seven SARS-CoV-2 positive patients in our cohort died during their hospitalization, of whom five had normal CXRs on admission. CONCLUSION: Sixty (7.1%) of suspected COVID-19 patients hospitalized at 72 hours required respiratory support despite being normoxic in the ED. Further research should look to identify the normoxic SARS-CoV-2 patients at risk for decompensation.

Validation of a clinical decision instrument for emergent neuroimaging after a seizure: Let's image malignancy, intracranial hemorrhage, and trauma (LIMIT).

BACKGROUND: Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. However, a CT exposes patients to 100 times more radiation than a chest radiograph. Previously, we developed a four-item clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) do not require emergent neuroimaging. In this study, we seek to prospectively validate our CDI in patients with a history of seizures with both SE and generalized tonic-clonic seizures. METHODS: This was a prospective observational study of 1,739 consecutive patients who were recruited from two urban hospitals in Philadelphia, Pennsylvania. All patients, 18 years and older, who presented with a chief complaint of seizure and had emergency neuroimaging performed were eligible for inclusion. Patients were excluded from analysis if this was a first-time seizure, had a ventriculoperitoneal shunt, or had focal neurologic deficits. RESULTS: A total of 376 patients were in the final analysis. Of the 376 patients, 10 patients (3%) had positive CTs. Nine of the 10 of the patients were identified by our CDI, resulting in a negative predictive value (NPV) of 99.5%. On secondary analysis, we refined our CDI from four to three criteria: 1) history of intracranial hemorrhage (ICH), 2) active malignancy, and 3) trauma. These criteria also had a NPV of >99% when applied to patients in SE. CONCLUSION: The validation of our CDI showed improved NPV when compared to the derivation set. Use of the criteria of history of ICH, active malignancy, and trauma could have reduced the use of emergent neuroimaging in our cohort by up to 49%. This CDI should be validated in a larger subset of patients and in multiple centers prior to widespread adoption.

Males Receive Low-Tidal Volume Component of Lung Protective Ventilation More Frequently than Females in the Emergency Department.

INTRODUCTION: Mechanical ventilation is a commonly performed procedure in the emergency department (ED). Approximately 240,000 patients per year receive mechanical ventilation in the ED representing 0.23% of ED visits. An ED-based trial published in 2017 showed that a bundle of interventions in mechanically ventilated patients, including low tidal volume ventilation, reduced the development of acute respiratory distress syndrome by nearly 50%. Prior literature has shown that as many as 40% of ED patients do not receive lung protective ventilation. Our goal was to determine whether differences exist between the percent of males vs females who are ventilated at ≥ 8 milliliters per kilogram (mL/kg) of predicted body weight. METHODS: We conducted this study at Temple University Hospital, a tertiary care center located in Philadelphia, Pennsylvania. This was a planned subgroup analysis of study looking at interventions to improve adherence to recommended tidal volume settings. We used a convenience sample of mechanically ventilated patients in our ED between September 1, 2017, and September 30, 2018. All adult patient > 18 years old were eligible for inclusion in the study. Our primary outcome measure was the number of patients who had initial tidal volumes set at > 8 mL/kg of predicted body weight. Our secondary outcome was the number of patients who had tidal volumes set at ≥ 8 mL/kg at 60 minutes after initiation of mechanical ventilation. RESULTS: A total of 130 patients were included in the final analysis. We found that significantly more females were initially ventilated with tidal volumes ≥ 8 mL/kg compared to men: 56% of females vs 9% of males (p=<0.001). Data was available for 107 patients (82%) who were in the ED at 60 minutes after initiation of mechanical ventilation. Again, a significantly larger percentage of females were ventilated with tidal volumes ≥ 8 mL/kg at 60 minutes: 56% of females vs 10% of males (p<0.001). CONCLUSION: The vast majority of tidal volumes ≥ 8 mL/kg during mechanical ventilation occurs in females. We suggest that objective measurements, such as a tape measure and tidal volume card, be used when setting tidal volumes for all patients, especially females.

Derivation of a clinical decision instrument to identify patients with status epilepticus who require emergent brain CT.

BACKGROUND: Studies have shown the value of CT brain imaging in adults with first-time seizures, but there are no recommendations regarding emergent brain CTs in persons with an established seizure disorders. Our study aimed to derive a clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) require emergent brain imaging. METHODS: This was a retrospective chart review of patients who presented to our emergency department with SE between 2010 and 2018. Patients with first-time seizures were excluded. A priori, we defined high risk criteria for emergent imaging as well as positive findings on brain CT. High risk criteria included known malignancy, trauma, and immunosuppression. Positive CT scans included findings such as intracranial hemorrhage (ICH) and mass. RESULTS: We identified 214 patients who met inclusion criteria Of the 181 patients without high risk criteria, 3% had positive CT scans. Of the 33 patients with high risk criteria, 10% had positive CT scans. The sensitivity, specificity, PPV, and NPV for our initial CDI were 38%, 85%, 9%, and 97%. Adding the criterion of prior ICH would have lowered our miss rate to 0.6%. Modifying our CDI to 1) History of ICH, 2) Malignancy, 3) Immunosuppression, and 4) Trauma would result in a CDI with sensitivity, specificity, PPV, and NPV of 87.5%, 87.4%, 21.2%, and 99.5%. CONCLUSIONS: By using four criteria to identify high risk patients, we can defer CT scanning in the vast majority of patients with SE and known seizure disorders. This CDI should be prospectively validated before adoption.

Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients.

INTRODUCTION: In 2013 the Society for Critical Care Medicine (SCCM) published guidelines for the management of pain and agitation in the intensive care unit (ICU). These guidelines recommend using an analgesia-first strategy in mechanically ventilated patients as well as reducing the use of benzodiazepines. Benzodiazepines increase delirium in ICU patients thereby increasing ICU length of stay. We sought to determine whether a simple educational intervention for emergency department (ED) staff, as well as two simple changes in workflow, would improve adherence to the SCCM guidelines. METHODS: This was a cohort study that took place from 2014-2016. All patients who were intubated in the ED by an emergency physician (EP) during this time were eligible for inclusion in this study. In January 2015, we began an educational campaign with the ED staff consisting of a series of presentations and online trainings. The impetus for our educational campaign was to have best practices in place for our new emergency medicine residency program starting in July 2016. We made two minor changes in our ED workflow to support this educational objective. First, fentanyl infusions were stocked in the ED. Second, we instituted a medication order set for mechanically ventilated patients. This order set nudged EPs to choose medications consistent with the SCCM guidelines. We then evaluated the use of opioids and benzodiazepines in mechanically ventilated patients from 2014 through 2016 using Fisher's exact test. All analyses were conducted in the overall sample (n=509) as well as in subgroups after excluding patients with seizures/status epilepticus as their primary admission diagnosis (n=461). RESULTS: In 2014 prior to the interventions, 41% of mechanically ventilated patients received an opioid, either as an intravenous (IV) push or IV infusion. In 2015 immediately after the intervention, 71% of patients received an opioid and 64% received an opioid in 2016. The use of benzodiazepine infusions decreased from 22% in 2014 to 7% in 2015 to 1% in 2016. CONCLUSION: A brief educational intervention along with two simple changes in ED workflow can improve compliance with the SCCM guidelines for the management of pain and agitation in mechanically ventilated patients.

A Case of Acute Traumatic Lumbar Paraspinal Compartment Syndrome.

BACKGROUND: Compartment syndrome is a life-threatening complication of traumatic injury, most commonly, direct trauma. Back pain is a common cause of visits to the emergency department (ED) and often is treated without imaging or diagnostic testing. Lumbar paraspinal compartment syndrome is a rare cause of acute back pain. CASE REPORT: A 43-year-old woman presented to the ED after direct trauma to the lower back. Laboratory studies revealed rhabdomyolysis and acute kidney injury, with examination findings and imaging consistent with lumbar paraspinal compartment syndrome. She was taken to the operating room for emergent fasciotomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is the job of the emergency physician to identify the red flags in history and physical examination that warrant further diagnostic testing. Early diagnosis and surgical consultation is the key in avoiding morbidity and achieving good outcomes in all forms of compartment syndrome.

Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment.

INTRODUCTION: Violent patients in the prehospital environment pose a threat to health care workers tasked with managing their medical conditions. While research has focused on methods to control the agitated patient in the emergency department (ED), there is a paucity of data looking at the optimal approach to subdue these patients safely in the prehospital setting. Hypothesis This study evaluated the efficacy of two different intramuscular medications, midazolam and haloperidol, to determine their efficacy in sedating agitated patients in the prehospital setting. METHODS: This was a prospective, randomized, observational trial wherein agitated patients were administered intramuscular haloperidol or intramuscular midazolam to control agitation. Agitation was quantified by the Richmond Agitation and Sedation Scale (RASS). Paramedics recorded the RASS and vital signs every five minutes during transport and again upon arrival to the ED. The primary outcome was mean time to achieve a RASS less than +1. Secondary outcomes included mean time for patients to return to baseline mental status and adverse events. RESULTS: Five patients were enrolled in each study group. In the haloperidol group, the mean time to achieve a RASS score of less than +1 was 24.8 minutes (95% CI, 8-49 minutes), and the mean time for the return of a normal mental status was 84 minutes (95% CI, 0-202 minutes). Two patients required additional prehospital doses for adequate sedation. There were no adverse events recorded in the patients administered haloperidol. In the midazolam group, the mean time to achieve a RASS score of less than +1 was 13.5 minutes (95% CI, 8-19 minutes) and the mean time for the return of normal mental status was 105 minutes (95% CI, 0-178 minutes). One patient required additional sedation in the ED. There were no adverse events recorded among the patients administered midazolam. CONCLUSIONS: Midazolam and haloperidol administered intramuscularly appear equally effective for sedating an agitated patient in the prehospital setting. Midazolam appears to have a faster onset of action, as evidenced by the shorter time required to achieve a RASS score of less than +1 in the patients who received midazolam. Haloperidol offers an alternative option for the sedation of an agitated patient. Further studies should focus on continued investigation into appropriate sedation of agitated patients in the prehospital setting.

Characteristics of Trauma Patients With Potential Cervical Spine Injuries Underimmobilized by Prehospital Providers.

STUDY DESIGN: This study was a retrospective chart review to determine characteristics of patients under-immobilized by prehospital providers. OBJECTIVE: Our goal was to examine the characteristics of patients who met the criteria for spinal immobilization but were inappropriately cleared. SUMMARY OF BACKGROUND DATA: Many emergency medical services (EMS) use selective spinal immobilization (SSI) based on the NEXUS criteria. However, there is been research examining patients who are under-immobilized by EMS. METHODS: This was a retrospective chart review over 18 months of a single EMS service. We reviewed all charts dispatched as "motor vehicle crash" (MVC) or "fall". We then determined, whether the patient met the criteria for SSI under Pennsylvania protocols, which mirror the NEXUS criteria. RESULTS: Our EMS system responded to 1151 falls and MVCs over the study period. Seventy-six patients were immobilized leaving 1075 patients who had clinical clearance of their cervical spine. Of these patients, 4/1075 (0.3%) were considered to be under-immobilized. All 4 of these patients had intoxication or altered mentation mentioned in their charts. Two of these patients had CT scans of their cervical spine, with both being negative. One patient eloped from the ED before any imaging, and 1 patient was clinically cleared. CONCLUSION: EMTs are very proficient in following the SSI guidelines with an under-immobilization rate of approximately 0.3% in our study. However, all patients who were under-immobilized were under the influence of alcohol. There were no patients who were not immobilized and had cervical spine injuries. This was a limited chart review involving only 2 dispatch categories. EMTs should be cautious while evaluating patients with possible spinal injuries who are under the influence of alcohol. LEVEL OF EVIDENCE: 4.

A simple method of maintaining chilled saline in the prehospital setting.

OBJECTIVE: Mild therapeutic hypothermia has been shown to improve neurologic outcomes after sudden cardiac arrest. Therapeutic hypothermia should be started as soon as return of spontaneous circulation occurs. However, saline is difficult to keep chilled in the prehospital environment. We sought to determine whether a cooler and ice packs could keep saline cold under prehospital conditions. METHODS: In phase 1 of the experiment, two 1000-mL bags of prechilled 0.9% normal saline were placed in a cooler with 3 ice packs. An additional bag of 1000-mL 0.9% normal saline remained outside the cooler as a control. Over 9 consecutive days, we measured the ambient air temperature and the temperature of each bag of saline every 4 hours. In phase 2 of the experiment, the cooler was kept sealed, and the temperature of the saline was measured after 24 hours. RESULTS: The mean temperatures over 24 hours ranged as follows: ambient temperature, 24°C to 27.2°C; bottom bag, 0.6°C to 3.5°C; top bag, 1.4°C to 5.7°C; and control bag, 9.8°C to 26.8°C. A t test was used to compare the chilled saline against the control bag. Statistical significance (P < .05) was achieved at all times. In phase 2 of the experiment, after 24 hours, 100% of the bottom bags and 93% of the top bags were less than 6°C. CONCLUSIONS: Our data demonstrate that saline can be kept chilled in ambulances for 24 hours using ice packs and coolers. The estimated cost is less than $50.00 per ambulance. Using coolers and ice packs is an inexpensive way for emergency medical service agencies to initiate prehospital hypothermia.

Does advanced life support provide benefits to patients?: A literature review.

INTRODUCTION: Emergency medical services have invested substantial resources to establish advanced life support (ALS) programs. However, it is unclear whether ALS care provides better outcomes to patients compared to basic life support (BLS) care. OBJECTIVE: To evaluate the current evidence regarding the benefits of ALS. METHODS: Electronic medical databases were searched to identify articles that directly compared ALS versus BLS care. A total of 455 articles were found. Articles were excluded for the following reasons: (1) the article was not written in English; (2) BLS response was not compared to an ALS response; (3) a physician or nurse was included as part of the ALS response; (4) it was an aeromedical response; or (5) defibrillation was included in the ALS, but not the BLS, scope of care. Twenty-one articles met the inclusion criteria for this literature review. RESULTS: Results were divided into four categories: (1) trauma; (2) cardiac arrest; (3) myocardial infarction; and (4) altered mental status. Trauma: The majority of articles showed that ALS provided no benefits over BLS in urban trauma patients. In fact, most studies showed higher mortality rates for trauma patients receiving ALS care. Further research is needed to evaluate the benefits of ALS for rural trauma patients, and whether ALS care improves outcomes in subgroups of urban trauma patents. Cardiac Arrest: Cardiac arrest studies show that early CPR plus early defibrillation provide the greatest improvement in survival. However, most cardiac arrest research includes defibrillation as an ALS skill which has now moved into the BLS scope of care. The 2004 multi-center OPALS study provided good evidence that ALS does not improve cardiac arrest survival over early defibrillation. Further research is needed to address whether any ALS interventions improve cardiac arrest outcome. Myocardial Infarction: Only one study directly compared the outcome of BLS and ALS care on myocardial infarction. The study found no difference in outcomes between BLS and ALS care in an urban setting. Advanced Life Support: Only one study directly compared the outcome of BLS and ALS care on patients with altered mental status. The study found that the same number of patients had improved to "alert" on arrival at the emergency department, but there was a decreased length of emergency department stay for patients treated by ALS for hypoglycemia. LIMITATIONS: This review article does not take into account the benefits of 2005 ALS interventions, such as thrombolytics, dextrose, or nitroglycerin, since no studies directly compared these interventions to BLS care. Furthermore, only one study in this literature review was a large, multi-center trial. CONCLUSIONS: ALS shows little, if any, benefits for urban trauma patients. Cardiac arrest studies show that ALS does not provide additional benefits over BLS-defibrillation care, but more research is needed in this area. In two small studies, ALS care did not provide benefits over BLS care for patients with myocardial infarctions or altered mental status. Larger-scale studies are needed to evaluate which specific ALS interventions improve patient outcomes.