The relationship of large city out-of-hospital cardiac arrests and the prevalence of COVID-19.

BACKGROUND: Though variable, many major metropolitan cities reported profound and unprecedented increases in out-of-hospital cardiac arrest (OHCA) in early 2020. This study examined the relative magnitude of those increases and their relationship to COVID-19 prevalence. METHODS: EMS (9-1-1 system) medical directors for 50 of the largest U.S. cities agreed to provide the aggregate, de-identified, pre-existing monthly tallies of OHCA among adults (age >18 years) occurring between January and June 2020 within their respective jurisdictions. Identical comparison data were also provided for corresponding time periods in 2018 and 2019.  Equivalent data were obtained from the largest cities in Italy, United Kingdom and France, as well as Perth, Australia and Auckland, New Zealand. FINDINGS: Significant OHCA escalations generally paralleled local prevalence of COVID-19. During April, most U.S. cities (34/50) had >20% increases in OHCA versus 2018-2019 which reflected high local COVID-19 prevalence. Thirteen observed 1·5-fold increases in OHCA and three COVID-19 epicenters had >100% increases (2·5-fold in New York City). Conversely, cities with lesser COVID-19 impact observed unchanged (or even diminished) OHCA numbers. Altogether (n = 50), on average, OHCA cases/city rose 59% during April (p = 0·03). By June, however, after mitigating COVID-19 spread, cities with the highest OHCA escalations returned to (or approached) pre-COVID OHCA numbers while cities minimally affected by COVID-19 during April (and not experiencing OHCA increases), then had marked OHCA escalations when COVID-19 began to surge locally. European, Australian, and New Zealand cities mirrored the U.S. experience. INTERPRETATION: Most metropolitan cities experienced profound escalations of OHCA generally paralleling local prevalence of COVID-19.  Most of these patients were pronounced dead without COVID-19 testing. FUNDING: No funding was involved. Cities provided de-identified aggregate data collected routinely for standard quality assurance functions.

Alcohol as a Factor in 911 Calls in Denver.

BACKGROUND: Excessive alcohol consumption is associated with a substantial number of emergency department visits annually and is responsible for a significant number of lives lost each year in the United States. However, a minimal amount is known about the impact of alcohol on the EMS system. OBJECTIVES: The primary objective was to determine the proportion of 9-1-1 calls in Denver, Colorado in which (1) alcohol was a contributing factor or (2) the individual receiving EMS services had recently ingested alcohol. The secondary objectives were to compare the characteristics of EMS calls and to estimate the associated costs. METHODS: This was a prospective observational cohort study of EMS calls for adults from July 1, 2012, to June 30, 2014. Primary outcomes for the study were alcohol as a contributing factor to the EMS call and recent alcohol consumption by the patient receiving EMS services. Logistic regression was utilized to determine the associations between EMS call characteristics and the outcomes. Cost was estimated using historic data. RESULTS: During the study period, 169,642 EMS calls were completed by the Denver Health Paramedic Division. Of these 71% were medical and 29% were trauma-related. The median age was 45 (interquartile range [IQR] 29-59) years, and 55% were male. 50,383 calls (30%) had alcohol consumption, and 49,165 (29%) had alcohol as a contributing factor. Alcohol related calls were associated with male sex, traumatic injuries including head trauma, emergent response, use of airway adjuncts, cardiac monitoring, glucose measurement, use of restraints, use of spinal precautions, and administration of medications for sedation. Estimated costs to the EMS system due to alcohol intoxication exceeded $14 million dollars over the study period and required in excess of 37 thousand hours of paramedic time. CONCLUSIONS: Compared to 9-1-1 calls that do not involve alcohol, alcohol-related calls are more likely to involve male patients, emergent response, traumatic injuries, advanced monitoring, airway adjuncts, and medications for sedation. This represents a significant burden on the emergency system and society. Further studies are needed to evaluate whether additional interventions such as social services could be used to lessen this burden.

Comparison of droperidol and haloperidol for use by paramedics: assessment of safety and effectiveness.

BACKGROUND: Since the 2001 "black box" warning on droperidol, its use in the prehospital setting has decreased substantially in favor of haloperidol. There are no studies comparing the prehospital use of either drug. The goal of this study was to compare QTc prolongation, adverse events, and effectiveness of droperidol and haloperidol among a cohort of agitated patients in the prehospital setting. METHODS: In this institutional review board-approved before and after study, we collected data on 532 patients receiving haloperidol (n = 314) or droperidol (n = 218) between 2007 and 2010. We reviewed emergency department (ED) electrocardiograms when available (haloperidol, n = 78, 25%; droperidol, n = 178, 76%) for QTc length (in milliseconds), medical records for clinically relevant adverse events (defined a priori as systolic blood pressure (SBP) <90 mmHg, seizure, administration of anti-dysrhythmic medications, cardioversion or defibrillation, bag-valve-mask ventilation, intubation, cardiopulmonary arrest, and prehospital or in-hospital death). We also compared effectiveness of the medications, using administration of additional sedating medications within 30 minutes of ED arrival as a proxy for effectiveness. RESULTS: The mean haloperidol dose was 7.9 mg (median 10 mg, range 4-20 mg). The mean droperidol dose was 2.9 mg (median 2.5 mg, range 1.25-10 mg.) Haloperidol was given i.m. in 289 cases (92%), and droperidol was given i.m. in 132 cases (61%); in all other cases, the medication was given i.v.. There was no statistically significant difference in median QTc after medication administration (haloperidol 447 ms, 95% CI: 440-454 ms; droperidol 454 ms, 95% CI: 450-457). There were no statistically significant differences in adverse events in the droperidol group as compared to the haloperidol group. One patient in the droperidol group with a history of congenital heart disease suffered a cardiopulmonary arrest and was resuscitated with neurologically intact survival. There was no significant difference in the use of additional sedating medications within 30 minutes of ED arrival after receiving droperidol (2.9%, 95% CI: -2.5-8.4%). CONCLUSIONS: In this cohort of agitated patients treated with haloperidol or droperidol in the prehospital setting, there was no significant difference found in QTc prolongation, adverse events, or need for repeat sedation between haloperidol and droperidol.

Safety of prehospital intravenous fentanyl for adult trauma patients.

BACKGROUND: Little is known about the safety of intravenous fentanyl for adult trauma patients in the prehospital setting. Our objective was to study the hemodynamic effect of prehospital intravenous fentanyl in initially normotensive adult trauma patients. METHODS: A quasi-experimental design was used to compare adult trauma patients who received intravenous fentanyl and those who did not receive fentanyl in a large regional prehospital system and its affiliated Level I trauma center. Emergent adult trauma patients were included with an initial prehospital Glasgow Coma Scale score of ≥13 and systolic blood pressure >90 mm Hg. Patients were stratified into two groups, those who received a single dose of intravenous fentanyl (100 µg) and those who did not. The outcome was initial emergency department (ED) shock index (heart rate divided by systolic blood pressure). Multivariable linear regression was used to estimate the effect of fentanyl on ED shock index while adjusting for prehospital shock index, age, gender, Trauma Injury Severity Score, and the propensity for receiving fentanyl. RESULTS: Seven hundred sixty-three patients were included, of whom 217 (28%) received fentanyl. The groups had comparable demographics (age, gender, and race/ethnicity) but different clinical characteristics (ED vital signs, Injury Severity Score, mechanism, and ED disposition). The adjusted ED shock index of fentanyl patients improved (-0.03; 95% confidence interval: -0.05 to 0.00; p = 0.02) compared with no fentanyl. CONCLUSION: Prehospital intravenous fentanyl did not adversely affect the initial ED shock index in adult trauma patients. Additional research should be performed to confirm and extend our findings. LEVEL OF EVIDENCE: III.

Task force St. Bernard: operational issues and medical management of a National Guard disaster response operation.

After Hurricane Katrina struck the Gulf Coast of the United States on 29 August 2005, it became obvious that the country was facing an enormous national emergency. With local resources overwhelmed, governors across the US responded by deploying thousands of National Guard soldiers and airmen. The National Guard has responded to domestic disasters due to natural hazards since its inception, but an event with the magnitude of Hurricane Katrina was unprecedented. The deployment of >900 Army National Guard soldiers to St. Bernard Parish, Louisiana in the aftermath of the Hurricane was studied to present some of the operational issues involved with providing medical support for this type of operation. In doing so, the authors attempt to address some of the larger issues of how the National Guard can be incorporated into domestic disaster response efforts. A number of unforeseen issues with regards to medical operations, medical supply, communication, preventive medicine, legal issues, and interactions with civilians were encountered and are reviewed. A better understanding of the National Guard and how it can be utilized more effectively in future disaster response operations can be developed.

Surge capacity: a proposed conceptual framework.

There is a need for emergency planners to accurately plan for and accommodate a potentially significant increase in patient volume in response to a disaster. In addition, an equally large political demand exists for leaders in government and the healthcare sector to develop these capabilities in a financially feasible and evidence-based manner. However, it is important to begin with a clear understanding of this concept on a theoretical level to create this capacity. Intuitively, it is easy to understand that surge capacity describes the ability of a healthcare facility or system to expand beyond its regular operations and accommodate a greater number of patients in response to a multiple casualty-producing event. The way a response to this need is implemented will, of course, vary dramatically depending on numerous issues, including the type of event that has transpired, the planning that has occurred before its occurrence, and the resources that are available. Much has been written on strategies for developing and implementing surge capacity. However, despite the frequency with which the term is used in the medical literature and by the lay press, a clear description of surge capacity as a concept is lacking. The following article will provide this foundation. A conceptual framework of surge capacity will be described, and some new nomenclature will be proposed. This is done to provide the reader with a comprehensive yet simplified view of the various elements that make up the concept of surge capacity. This framework will cover the types of events that can cause a surge of patients, the general ways in which healthcare facilities respond to these events, and the categories of people who would make up the population of affected victims.

How well do paramedics predict admission to the hospital? A prospective study.

A study was designed to determine whether paramedics accurately predict which patients will require admission to the hospital, and in those requiring admission, whether they will need a ward bed or intensive care unit (ICU) monitoring. This prospective, cross-sectional study of consecutive Emergency Medical Service (EMS) transport patients was conducted at an urban city hospital. Paramedics were asked to predict if the patient they were transporting would require admission to the hospital, and if so, whether that patient would be admitted to a ward bed or require an ICU bed. Predictions were compared to actual patient disposition. During the study period, 1349 patients were transported to our hospital. Questionnaires were submitted in 985 cases (73%) and complete data were available for 952 (97%) of these patients. Paramedics predicted 202 (22%) patients would be admitted to the hospital, of whom 124 (61%) would go the ward and 78 (39%) would require intensive care. The actual overall admission rate was 21%, although the sensitivity of predicting any admission was 62% with a positive prediction value (PPV) of 59%. Further, the paramedics were able to predict admission to intensive care with a sensitivity of 68% and PPV of 50%. It is concluded that paramedics have very limited ability to predict whether transported patients require admission and the level of required care. In our EMS system, the prehospital diversion policies should not be based solely on paramedic determination.

Treatment of suspected cardiac ischemia with aspirin by paramedics in an urban emergency medical services system.

BACKGROUND: Aspirin (ASA) has unquestioned benefit to patients with cardiac ischemia. Previous studies indicate health care providers may not adequately treat patients experiencing cardiac ischemia with ASA. OBJECTIVE: To determine the rate of ASA use for patients being treated for chest pain suggestive of cardiac ischemia in the prehospital setting. METHODS: This was a retrospective study of paramedic encounters identified through billing records for all patients receiving the combination of an intravenous catheter, supplemental oxygen, and cardiac monitoring from November 2001 to January 2002. Prehospital medical records were reviewed in order to determine the proportion of patients with suspected cardiac ischemia who received ASA. The setting was a single prehospital emergency medical services system serving an urban population. RESULTS: A total of 2,457 paramedic encounters were reviewed over a three-month period. Two hundred thirty-two patients were assessed as having cardiac ischemia, of whom 169 (73%) had no absolute or relative contraindication to ASA. Of the 169 patients, only 92 (54%) received ASA. Of the 99 patients, who received nitroglycerin for presumed cardiac ischemia and had no contraindication to receiving ASA, only 78 (79%) received ASA. Of the 453 patients complaining of nontraumatic chest pain and without a contraindication, 157 (35%) received ASA. CONCLUSIONS: Paramedics do not use ASA optimally and may choose therapies with less proven benefit.

An evaluation of out-of-hospital advanced airway management in an urban setting.

OBJECTIVES: To determine the success and complication rates associated with endotracheal intubation in an urban emergency medical services (EMS) system. METHODS: This study evaluated consecutive airway interventions between March 2001 and May 2001 performed by paramedics from the Denver Health Paramedic Division in Denver, Colorado. Patients were identified and enrolled prospectively with the identification of all patients for whom intubation was attempted. A retrospective chart review of the emergency department (ED), intensive care unit, other hospital records, and the coroner's records was then conducted with the intent of identifying all complications related to attempted intubation, including the placement of each endotracheal tube. RESULTS: A total of 278 patients were included in this study. Of these, 154 (55%) had an initial nasal intubation attempt, and 124 (45%) had an initial oral intubation attempt. Of the 278 patients for whom an intubation was attempted, 234 (84%, 95% CI = 77% to 88%) were reported by paramedics to be successfully intubated. Of 114 nasal intubations reported as successful by paramedics, two (2%; 95% CI = 0.2% to 6%) were found to be misplaced. Of the 120 oral intubations reported as successful by paramedics, one (1%; 95% CI = 0.02% to 5%) was found to be misplaced. Of the 278 patients, 22 (8%; 95% CI = 5% to 12%) had complications; three (1%; 95% CI = 0.2% to 3%) endotracheal tubes were incorrectly positioned, two (0.7%; 95% CI = 0.08% to 3%) of which were undetected esophageal intubations and one (0.4%; 95% CI = 0 to 2%) of which was in the posterior pharynx. CONCLUSIONS: Reasonable success and complication rates of endotracheal intubation in the out-of-hospital setting can be achieved in a busy, urban EMS system without the assistance of medications.