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1.
Resusc Plus ; 5: 100078, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34223344

RESUMO

Background: Sudden death accounts for up to 15% of all deaths among working age adults. A better understanding of victims' medical care and symptoms reported at their last medical encounter may identify opportunities for interventions to prevent sudden deaths. Methods: From 2013-15, all out-of-hospital deaths, ages 18-64 reported by Emergency Medical Services (EMS) in Wake County, North Carolina were screened and adjudicated to identify 399 victims of sudden death, 264 of whom had available medical records. Demographic and clinical characteristics and prescribed medications were compared between victims with versus without a medical encounter within one month preceding death with chi-square tests and t-tests, as appropriate. Symptoms reported in medical encounters within one month preceding death were analyzed. Results: Among the 264 victims with available medical records, 73 (27.7%) had at least one encounter within a month preceding death. These victims were older and more likely to have multiple chronic illnesses, yet most were not prescribed evidence-based medicines. Of these 73 victims, 30 (41.1%) reported cardiac symptoms including dyspnea, edema, and chest pain. Conclusions: Many victims seek medical care and report cardiac symptoms in the month prior to sudden death. However, medications that might prevent sudden death are under prescribed. These findings suggest that there are opportunities for intervention to prevent sudden death.

2.
J Neurointerv Surg ; 2021 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-33893209

RESUMO

BACKGROUND: There is limited evidence on the performance of emergent large-vessel occlusion (LVO) stroke screening tools when used by emergency medical services (EMS) and emergency department (ED) providers. We assessed the validity and predictive value of the vision, aphasia, neglect (VAN) assessment when completed by EMS and in the ED among suspected stroke patients. METHODS: We conducted a retrospective study of VAN performed by EMS providers and VAN inferred from the National Institutes of Health Stroke Scale performed by ED nurses at a single hospital. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAN by EMS and in the ED for LVO and a combined LVO and intracerebral hemorrhage (ICH) outcome. RESULTS: From January 2018 to June 2020, 1,547 eligible patients were identified. Sensitivity and specificity of ED VAN were similar for LVO (72% and 74%, respectively), whereas EMS VAN was more sensitive (84%) than specific (68%). PPVs were low for both EMS VAN (26%) and ED VAN (21%) to detect LVO. Due to several VAN-positive ICHs, PPVs were substantially higher for both EMS VAN (44%) and ED VAN (39%) to detect LVO or ICH. EMS and ED VAN had high NPVs (97% and 96%, respectively). CONCLUSIONS: Among suspected stroke patients, we found modest sensitivity and specificity of VAN to detect LVO for both EMS and ED providers. Moreover, the low PPV in our study suggests a significant number of patients with non-LVO ischemic stroke or ICH could be over-triaged with VAN.

3.
Prehosp Emerg Care ; 25(1): 8-15, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33074060

RESUMO

The COVID-19 pandemic is a worldwide historical event that will continue to affect nearly every aspect of ordinary life, including affecting our economic, political, and healthcare eco-systems. An effective pandemic response demands a coordinated and integrated response across community healthcare stakeholders, including Public Health and Emergency Management Officials. EMS systems are in a unique position and perform an essential role on the frontlines of COVID-19, including facilitating coordination of response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. EMS physicians serve their communities at a unique intersection as clinical leaders, population health experts, and advocates. This paper examines and recommends crucial roles for EMS physician leaders as communities work together in pandemic response.


Assuntos
COVID-19 , COVID-19/epidemiologia , Atenção à Saúde , Serviço Hospitalar de Emergência , Humanos , Pandemias , Papel do Médico , Saúde Pública , SARS-CoV-2
4.
Prehosp Emerg Care ; 25(5): 697-705, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32986490

RESUMO

INTRODUCTION: The likelihood of survival from ventricular fibrillation (VF) declines 7%-10% per minute until successful defibrillation. When VF duration is prolonged, immediate defibrillation of the ischemic myocardium is less likely to result in ROSC, and repeated unsuccessful defibrillations are associated with post-resuscitation myocardial dysfunction. Thus, the timing of defibrillation should be based upon the probability of shock success-a function of VF duration. Unfortunately, VF duration is often unknown in out-of-hospital cardiac arrest (OHCA) and a better predictor of shock success is needed. OBJECTIVE: To assess the ability of end-tidal carbon dioxide (EtCO2) to predict successful defibrillation in OHCA. METHODS: This retrospective study included adult patients among four EMS systems who experienced non-traumatic OHCA from August, 2015-July, 2017 and received one or more defibrillations. First and succedent shocks were analyzed separately. First shocks represented EMS-attempted defibrillation of patients who had not received a prior AED shock, whereas succedent shocks included all shocks subsequent to the first. Logistic regression provided odds ratios (OR) for first shocks resulting in ROSC, while a generalized estimating equation was used to analyze succedent shocks. RESULTS: Among 324 patients, 869 shocks were delivered by EMS (153 first and 716 succedent shocks). Layperson CPR was performed in 48.1% of cases and 21.6% received an AED shock before EMS arrival. First defibrillation ROSC was more likely with layperson CPR (OR = 4.41;p = 0.01) and increasing EtCO2 (OR = 1.03/mmHg;p = 0.01). No other variables were statistically significant. Notably, only one patient with EtCO2 < 20 mmHg was successfully defibrillated on the first shock. The probability of ROSC was higher with increasing values of EtCO2 when layperson CPR was provided, yet remained relatively unchanged across all values of EtCO2 ≥ 20 mmHg without layperson CPR. The optimal threshold first shock EtCO2 was 27 and 32 mmHg for those with/without layperson CPR, respectively. EtCO2 was not a predictor of ROSC for succedent shocks. CONCLUSIONS: An optimal defibrillation threshold EtCO2 of 27 and 32 mmHg was observed for patients with and without layperson CPR, respectively. Further studies are warranted to verify these results and to evaluate the clinical effect of delaying defibrillation in favor of chest compressions until these values are attained.


Assuntos
Reanimação Cardiopulmonar , Serviços Médicos de Emergência , Parada Cardíaca Extra-Hospitalar , Adulto , Dióxido de Carbono , Cardioversão Elétrica , Humanos , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Retrospectivos , Fibrilação Ventricular/terapia
5.
Prehosp Emerg Care ; 25(2): 182-190, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32176548

RESUMO

OBJECTIVES: The opioid crisis is a growing cause of mortality in the United States and may be mitigated by innovative approaches to identifying individuals at-risk of fatal opioid overdose. We examined Emergency Medical Services (EMS) utilization among a cohort of individuals who died from opioid overdose in order to identify potential opportunities for intervention. Methods: Individuals who died of unintentional opioid overdose in a large North Carolina county between 01/01/2014 and 12/31/2016 were studied in a retrospective cohort. Death records obtained from North Carolina Vital Records were linked to EMS patient care records obtained from the county EMS System in order to describe the EMS encounters of each decedent in the year preceding their death. Patient demographics and EMS encounters were assessed to identify encounter characteristics that may be targeted for intervention. Chi-square tests and odds ratios were used to evaluate and characterize the statistical significance of differences in EMS utilization. Results: Of the 218 individuals who died from unintentional opioid overdose in the study interval, 30% (n = 66) utilized EMS in the year before their death and 17% (n = 38) had at least one EMS encounter with documented drug or alcohol use (i.e. "drug-related encounter"). The mean age at death was 38 (range 19-74) years, 30% were female, 89% were White, and 8% were Black/African American. Factors associated with higher incidence of EMS utilization included age (P<.001), gender (P=.006), and race (P<.001). Decedents aged 56-65 had the highest EMS utilization (47%) and patients aged <25 and 25-35 had more drug-related EMS encounters (29% and 20%, respectively). The most common reasons for EMS utilization were "other medical" (27%), "non-traumatic pain" (20%), "traumatic injury" (16%), and "poisoning/drug ingestion" (14%). Drug or alcohol use was documented by EMS in 33% of all encounters and an opioid prescription was reported in 22% of encounters. Conclusions: Nearly one-third of individuals who died from accidental opioid overdose utilized EMS in the year before their death and nearly one-fifth had a drug-related encounter. EMS encounters may present an opportunity to identify individuals at-risk of opioid overdose and, ultimately, reduce overdose mortality.


Assuntos
Overdose de Drogas , Serviços Médicos de Emergência , Overdose de Opiáceos , Preparações Farmacêuticas , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Naloxona/uso terapêutico , North Carolina/epidemiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
6.
Prehosp Emerg Care ; 24(6): 804-812, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32011202

RESUMO

Introduction: Hurricane Florence made landfall in North Carolina as a Category 1 hurricane on September 14, 2018 causing catastrophic flooding throughout much of eastern North Carolina. Large numbers of evacuees were housed in evacuation shelters established by state emergency management and county governments. The purpose of this study was to evaluate the implementation of a telemedicine service in evacuation shelters to determine whether the presence of telemedicine could alter EMS and ED utilization. Methods: We conducted a cross-sectional study that described the EMS and Emergency Department utilization of patients housed in disaster shelters during a 12 day period following Hurricane Florence. Subjects were those shelter residents in Wake or Orange counties utilizing emergency services. Data were collected from Wake County EMS, Orange County EMS, and RelyMD, the telemedicine service utilized in the shelters. Data included subject demographics, chief complaint, case disposition, telemedicine processing times, and an after-call survey to assess satisfaction and emergency department avoidance rates. De-identified data were compiled into Excel spread sheets. Results: There were a total of 194 combined telemedicine and EMS patient encounters, including 63 EMS transports, 25 refusals, 13 referrals (Wake County EMS), and 93 telemedicine patient encounters. Of the telemedicine encounters, 64 evaluations took place in Wake County shelters and 29 evaluations in the Orange County shelter. Average patient age was 49 years old; 67% were female. Forty three patients (46%) utilized the telemedicine service for obtaining medication refills, of whom 19 (44%) indicated they would have otherwise utilized an ED to refill their medication. Forty patients (43%) indicated they would have otherwise gone to an ED for care had the service not been provided, with the needs of 33 (83%) of these patients successfully managed without evaluation in an ED. Only 9 (9.7%) patients were referred by the telemedicine service to an ED for an evaluation, with 3 (3.2%) being admitted. Conclusion: Our descriptive findings suggest telemedicine can be effectively utilized in a general population evacuation shelter to reduce EMS and ED utilization and address the medical needs of the population. Further studies should be performed to assess applicability to other disaster settings.


Assuntos
Tempestades Ciclônicas , Serviços Médicos de Emergência , Abrigo de Emergência , Telemedicina , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina
7.
J Spinal Cord Med ; 43(2): 264-267, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-30231216

RESUMO

Context: While uncommon, spinal cord injuries most frequently occur in adolescent and young adult males. Established treatment options are limited and focused on supportive care. Therapeutic systemic hypothermia is an emerging experimental treatment currently undergoing clinical trials in adults.Findings: Here we report a case of a 13-year-old male with an American Spinal Injury Association Impairment Scale grade C traumatic cervical spinal cord injury treated with 48 hours of therapeutic systemic hypothermia who made a complete neurological recovery. To our knowledge, this is the youngest such case report.Clinical relevance: This case suggests that consideration should be given to including pediatric patients in future clinical trials of therapeutic hypothermia for spinal cord injury.


Assuntos
Hipotermia Induzida , Traumatismos da Medula Espinal/terapia , Adolescente , Medula Cervical , Vértebras Cervicais/lesões , Humanos , Imageamento por Ressonância Magnética , Masculino , Tomografia Computadorizada por Raios X , Resultado do Tratamento
8.
Prehosp Emerg Care ; 23(3): 309-318, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30204511

RESUMO

OBJECTIVE: An integrated response to active threat events is essential to saving lives. Coordination of law enforcement officer (LEO) and emergency medical services (EMS) roles requires joint training, as maximizing survival is a shared responsibility. We sought to evaluate the performance of an integrated LEO-EMS Rescue Task Force (RTF) response to a simulated active shooter incident utilizing objective performance measures. METHODS: Following prior didactic training, we conducted a series of evaluation scenarios for EMS providers and patrol officers in our urban/suburban advanced life support EMS system (pop. 1,000,000). The scenario-tested command staff, LEOs tasked with neutralizing an active shooter threat, and two RTFs of LEOs and EMS providers each tasked with triage and treatment of 11 simulated casualties scattered over 2 office building floors totaling 13,000 square feet. Trained evaluators recorded performance on 30 objective data elements related to LEO-EMS operations/communication, time intervals, and trauma care. Data were analyzed using descriptive statistics and t-tests for between group comparisons. RESULTS: Over 18 days, 69 scenario events evaluated 388 EMS providers and 468 LEOs. Overall median (90th percentile) times in minutes from dispatch were: unified command established 4.1 (5.5), RTF assembled 9.4 (13.5), first victim contact 11.9 (16.5), first victim to internal casualty collection point (CCP) 16.6 (20.8), all victims ready for evacuation 21.6 (26.0). Life-saving interventions included tourniquet placed: 96% (95% CI 92-99) and LEO placed tourniquet: 88% (79-94). Clinical delays included inappropriate chest decompression: 4% (2-9) and unnecessary initial treatment: 17% (12-25). Correct operational actions included communication with LEO to ensure EMS was safe to treat: 70% (61-77) and appropriate CCP selection: 84% (74-91). Incorrect operational actions included failure to maintain protective LEO-EMS formation: 49% (45-62) and inappropriate single patient evacuation: 20% (14-28). Limitations included the lack of a pre-training control group for this novel program. CONCLUSIONS: We described the performance of an integrated LEO-EMS Rescue Task Force response to a simulated active shooter event in a large city. In general, clinical care was appropriate while operational targets can be improved. Objective measurement of response goals may be used for benchmarking and performance improvement for active threat events.


Assuntos
Comitês Consultivos , Serviços Médicos de Emergência , Modelos Organizacionais , Polícia , Crime , Serviços Médicos de Emergência/estatística & dados numéricos , Humanos , North Carolina , Polícia/educação , Fatores de Tempo , Torniquetes , Triagem
9.
Prehosp Emerg Care ; 22(5): 555-564, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29412043

RESUMO

OBJECTIVE: Emergency Departments (ED) are overburdened with patients experiencing acute mental health crises. Pre-hospital transport by Emergency Medical Services (EMS) to community mental health and substance abuse treatment facilities could reduce ED utilization and costs. Our objective was to describe characteristics, treatment, and outcomes of acute mental health crises patients who were transported by EMS to an acute crisis unit at WakeBrook, a North Carolina community mental health center. METHODS: We performed a retrospective cohort study of patients diverted to WakeBrook by EMS from August 2013-July 2014. We abstracted data from WakeBrook medical records and used descriptive statistics to quantify patient characteristics, diagnoses, length of stay (LOS), and 30-day recidivism. RESULTS: A total of 226 EMS patients were triaged at WakeBrook. The median age was 38 years, 55% were male, 58% were white, and 38% were uninsured. The most common chief complaints were suicidal ideation or self-harm (46%) and substance abuse (19%). The most common diagnoses were substance-related and addictive disorders (42%), depressive disorders (32%), and schizophrenia spectrum and other psychotic disorders (22%). Following initial evaluation, 28% of patients were admitted to facilities within WakeBrook, 40% were admitted to external psychiatric facilities, 18% were stabilized and discharged home, 5% were transferred to an ED within 4 hours for further medical evaluation, and 5% refused services. The median LOS at WakeBrook prior to disposition was 12.0 hours (IQR 5.4-21.6). Over a 30-day follow-up period, 60 patients (27%) had a return visit to the ED or WakeBrook for a mental health issue. CONCLUSIONS: A dedicated community mental health center is able to treat patients experiencing acute mental health crises. LOS times were significantly shorter compared to regional EDs. Successful broader programmatic implementation could improve care quality and significantly reduce the volume of patients treated in the ED for acute mental health disorders.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Transtornos Mentais/terapia , Serviços de Saúde Mental/estatística & dados numéricos , Doença Aguda , Adulto , Estudos de Coortes , Serviços de Saúde Comunitária/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Transtornos Mentais/epidemiologia , Saúde Mental , Pessoa de Meia-Idade , North Carolina , Alta do Paciente , Estudos Retrospectivos , Triagem/estatística & dados numéricos
10.
Prehosp Emerg Care ; 22(3): 281-289, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29297739

RESUMO

OBJECTIVE: The United States is currently experiencing a public health crisis of opioid overdoses. To determine where resources may be most needed, many public health officials utilize naloxone administration by EMS as an easily-measured surrogate marker for opioid overdoses in a community. Our objective was to evaluate whether naloxone administration by EMS accurately represents EMS calls for opioid overdose. We hypothesize that naloxone administration underestimates opioid overdose. METHODS: We conducted a chart review of suspected overdose patients and any patients administered naloxone in Wake County, North Carolina, from January 2013 to December 2015. Patient care report narratives and other relevant data were extracted from electronic patient care records and the resultant database was analyzed by two EMS physicians. Cases were divided into categories including "known opioid use," "presumed opioid use," "no known opioid," "altered mental status," "cardiac arrest with known opioid use," "cardiac arrest with no known opioid use," or "suspected alcohol intoxication," and then further separated based on whether naloxone was administered. Patient categories were compared by patient demographics and incident year. Using the chart review classification as the gold standard, we calculated the sensitivity and positive predictive value (PPV) of naloxone administration for opioid overdose. RESULTS: A total of 4,758 overdose cases from years 2013-15 were identified. During the same period, 1,351 patients were administered naloxone. Of the 1,431 patients with known or presumed opioid use, 57% (810 patients) received naloxone and 43% (621 patients) did not. The sensitivity of naloxone administration for the identification of patients with known or presumed opioid use was 57% (95% CI: 54%-59%) and the PPV was 60% (95% CI: 57%-63%). CONCLUSION: Among patients receiving care in this large urban EMS system in the United States, the overall sensitivity and positive predictive value for naloxone administration for identifying opioid overdoses was low. Better methods of identifying opioid overdose trends are needed to accurately characterize the burden of opioid overdose within and among communities.


Assuntos
Analgésicos Opioides/efeitos adversos , Overdose de Drogas/tratamento farmacológico , Serviços Médicos de Emergência , Naloxona/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adolescente , Adulto , Idoso , Intoxicação Alcoólica , Analgésicos Opioides/administração & dosagem , Biomarcadores , Overdose de Drogas/mortalidade , Registros Eletrônicos de Saúde , Serviços Médicos de Emergência/métodos , Feminino , Parada Cardíaca , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , North Carolina/epidemiologia , Estados Unidos , Adulto Jovem
11.
Ann Intern Med ; 168(3): 179-186, 2018 02 06.
Artigo em Inglês | MEDLINE | ID: mdl-29230475

RESUMO

Background: Residents of assisted living facilities who fall may not be seriously ill or injured, but policies often require immediate transport to an emergency department regardless of the patient's condition. Objective: To determine whether unnecessary transport can be avoided. Design: Prospective cohort study. Setting: One large county with a single system of emergency medical services. Participants: Convenience sample of residents in 22 assisted living facilities served by 1 group of primary care physicians. Intervention: Paramedics providing emergency medical services followed a protocol that included consulting with a physician by telephone. Measurements: The number of transports after a fall and the number of time-sensitive conditions in nontransported patients. Results: Of the 1473 eligible residents, 953 consented to participate in the study (mean age, 86 years; 76% female) and 359 had 840 falls in 43 months. The protocol recommended nontransport after 553 falls. Eleven of these patients had a time-sensitive condition. At least 7 of them received appropriate care: 4 requested and received transport despite the protocol recommendation, and 3 had minor injuries that were successfully managed on site. Three additional patients had fractures that were diagnosed by outpatient radiography. The final patient developed vomiting and diarrhea, started palliative care, and died 60 hours after the fall. At least 549 of the 553 patients (99.3% [95% CI, 98.2% to 99.8%]) with a protocol recommendation for nontransport received appropriate care. Limitation: The resources required for this program will preclude use in some locations. Conclusion: Shared decision making between paramedics and primary care physicians can prevent transport to the emergency department for many residents of assisted living facilities who fall. Primary Funding Source: None.


Assuntos
Acidentes por Quedas , Moradias Assistidas , Tomada de Decisões , Serviço Hospitalar de Emergência , Melhoria de Qualidade , Transporte de Pacientes/normas , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , North Carolina , Estudos Prospectivos , Procedimentos Desnecessários
12.
N C Med J ; 76(4): 256-62, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26509521

RESUMO

The North Carolina College of Emergency Physicians (NCCEP) Emergency Medical Services (EMS) Committee uses an evidence-based approach in writing its protocols and procedures. The most recent revision of the NCCEP document, which was started in late 2010, lasted for more than 1 year and utilized committee members from across the state. Four meetings were held at locations across North Carolina. In addition, 2 surveys were sent to get input from EMS providers. Since 2010, the document has been updated on an ongoing basis, aligning it with the latest evidence-based medicine.


Assuntos
Serviços Médicos de Emergência/normas , Medicina Baseada em Evidências , Guias de Prática Clínica como Assunto/normas , Humanos , North Carolina , Sociedades Médicas
13.
Prehosp Emerg Care ; 19(1): 68-78, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25075443

RESUMO

Abstract Objective. Emergency medical services (EMS) often transports patients who suffer simple falls in assisted-living facilities (ALFs). An EMS "falls protocol" could avoid unnecessary transport for many of these patients, while ensuring that patients with time-sensitive conditions are transported. Our objective was to retrospectively validate an EMS protocol to assist decision making regarding the transport of ALF patients with simple falls. Methods. We conducted a retrospective cohort study of patients transported to the emergency department from July 2010 to June 2011 for a chief complaint of "fall" within a subset of ALFs served by a specific primary care group in our urban EMS system (population 900,000). The primary outcome, "time-sensitive intervention" (TSI), was met by patients who had wound repair or fracture, admission to the ICU, OR, or cardiac cath lab, death during hospitalization, or readmission within 48 hours. EMS and primary care physicians developed an EMS protocol, a priori and by consensus, to require transport for patients needing TSI. The protocol utilizes screening criteria, including history and exam findings, to recommend transport versus nontransport with close primary care follow-up. The EMS protocol was retrospectively applied to determine which patients required transport. Protocol performance was estimated using sensitivity, specificity, and negative predictive value (NPV). Results. Of 653 patients transported across 30 facilities, 644 had sufficient data. Of these, 197 (31%) met the primary outcome. Most patients who required TSI had fracture (73) or wound repair (92). The EMS protocol identified 190 patients requiring TSI, for a sensitivity of 96% (95% CI: 93-98%), specificity of 54% (95% CI: 50-59%), and NPV of 97% (95% CI: 94-99%). Of 7 patients with false negatives, 3 were readmitted (and redischarged) after another fall, 3 sustained hip fractures that were surgically repaired, and 1 had a lumbar compression fracture and was discharged. Conclusions. In this cohort, two-thirds of patients with falls in ALFs did not require TSI. An EMS protocol may have sufficient sensitivity to safely allow for nontransport of these patients with falls in ALFs. Prospective validation of the protocol is necessary to test this hypothesis.

14.
Prehosp Emerg Care ; 19(1): 126-130, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25243771

RESUMO

Abstract Background. Ventricular fibrillation (VF) is considered the out-of-hospital cardiac arrest (OOHCA) rhythm with the highest likelihood of neurologically intact survival. Unfortunately, there are occasions when VF does not respond to standard defibrillatory shocks. Current American Heart Association (AHA) guidelines acknowledge that the data are insufficient in determining the optimal pad placement, waveform, or energy level that produce the best conversion rates from OOHCA with VF. Objective. To describe a technique of double sequential external defibrillation (DSED) for cases of refractory VF (RVF) during OOHCA resuscitation. Methods. A retrospective case series was performed in an urban/suburban emergency medical services (EMS) system with advanced life support care and a population of 900,000. Included were all adult OOHCAs having RVF during resuscitation efforts by EMS providers. RVF was defined as persistent VF following at least 5 unsuccessful single shocks, epinephrine administration, and a dose of antiarrhythmic medication. Once the patient was in RVF, EMS personnel applied a second set of pads and utilized a second defibrillator for single defibrillation with the new monitor/pad placement. If VF continued, EMS personnel then utilized the original and second monitor/defibrillator charged to maximum energy, and shocks were delivered from both machines simultaneously. Data were collected from electronic dispatch and patient care reports for descriptive analysis. Results. From 01/07/2008 to 12/31/2010, a total of 10 patients were treated with DSED. The median age was 76.5 (IQR: 65-82), with median resuscitation time of 51minutes (IQR: 45-62). The median number of single shocks was 6.5 (IQR: 6-11), with a median of 2 (IQR: 1-3) DSED shocks delivered. VF broke after DSED in 7 cases (70%). Only 3 patients (30%) had ROSC in the field, and none survived to discharge. Conclusion. This case series demonstrates that DSED may be a feasible technique as part of an aggressive treatment plan for RVF in the out-of-hospital setting. In this series, RVF was terminated 70% of the time, but no patient survived to discharge. Further research is needed to better understand the characteristics of and treatment strategies for RVF.

15.
Open Heart ; 1(1): e000150, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25332830

RESUMO

OBJECTIVES: This paper describes the methodology for a prospective, community-based study of sudden unexpected death in Wake County, North Carolina. METHODS: From 1 March to 29 June 2013, data of presumed cardiac arrest cases were captured from Wake County Emergency Medical Services. Participants were screened into the presumed sudden unexpected death group based on specific and sequential screening criteria, and medical and public records were collected for each participant in this group. A committee of independent cardiologists reviewed all data to determine final inclusion/exclusion of each participant into registry. RESULTS: We received 398 presumed cardiac arrest referrals. Of these, 105 participants, age 18-65 years old, were identified as presumed sudden unexpected deaths. The primary reason for exclusion was survival to hospital (38%). Ninety-five per cent of participants in the presumed sudden unexpected death group experienced an unwitnessed death. Hypertension was present in almost 50%, while dyslipidaemia and diabetes mellitus were present in almost 25% of the same group. In addition, the presumed sudden unexpected death group includes 67.6% males (95% CI 58 to 76) whereas the control group only included 58.9% (95% CI 46 to 55) males. CONCLUSIONS: Participant identification and data collection processes identify presumed sudden unexpected death cases and secure medical and public data for screening and final adjudication. The study infrastructure developed in Wake County will allow its expansion to other counties in North Carolina. Preliminary data indicate the study presently focuses on a population demographically representative of North Carolina.

16.
Emerg Med Clin North Am ; 31(1): 59-86, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23200329

RESUMO

The venous and/or arterial vasculature may be accessed for fluid resuscitation, testing and monitoring, administration of blood product or medication, or procedural reasons, such as the implantation of cardiac pacemaker wires. Accessing the vascular system is a common and often critically important step in emergency patient care. This article reviews methods for peripheral, central venous, and arterial access and discusses adjunct skills for vascular access such as the use of ultrasound guidance, and other forms of vascular access such as intraosseus and umbilical cannulation, and peripheral venous cut-down. Mastery of these skills is critical for the emergency medicine provider.


Assuntos
Cateterismo/métodos , Cateterismo/efeitos adversos , Cateterismo/instrumentação , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/métodos , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Cateterismo Periférico/métodos , Cateteres de Demora/efeitos adversos , Emergências , Humanos , Infusões Intraósseas/efeitos adversos , Infusões Intraósseas/instrumentação , Infusões Intraósseas/métodos , Ultrassonografia de Intervenção/instrumentação , Ultrassonografia de Intervenção/métodos , Artérias Umbilicais , Venostomia/efeitos adversos , Venostomia/instrumentação , Venostomia/métodos
17.
Prehosp Emerg Care ; 15(4): 533-6, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21806468

RESUMO

Emergency medical services (EMS) encountered an alert patient with sustained ventricular fibrillation with preserved hemodynamics via a left ventricular assist device (LVAD). Multiple firings of the patient's implantable defibrillator were the only sign that this patient was experiencing the usually fatal ventricular arrhythmia. Initial attempts at rhythm conversion with amiodarone and 200-J biphasic shocks were unsuccessful. The patient was finally defibrillated to normal sinus rhythm after a 360-J biphasic shock. This case conference highlights the increasing prevalence of LVADs. These devices are used not only as a bridge to cardiac transplantation, but also as definitive therapy for patients in end-stage cardiac failure. Ventricular fibrillation has been shown to be well tolerated in patients with LVADs, and we discuss a standard of care for these patients. The occurrence of sustained ventricular fibrillation in patients with ventricular assist devices represents a challenging situation for EMS and emergency department providers and one that will be increasingly encountered in the future.


Assuntos
Amiodarona/administração & dosagem , Desfibriladores Implantáveis , Cardioversão Elétrica , Fibrilação Ventricular/terapia , Idoso , Amiodarona/uso terapêutico , Antiarrítmicos/administração & dosagem , Antiarrítmicos/uso terapêutico , Eletrocardiografia , Serviços Médicos de Emergência/métodos , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Coração Auxiliar , Hemodinâmica/fisiologia , Humanos , Fibrilação Ventricular/fisiopatologia
18.
Prehosp Emerg Care ; 10(2): 247-53, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-16531384

RESUMO

OBJECTIVES: Growing evidence indicates that it may not be essential to deliver ventilations in the first few minutes of CPR. We compared time to delivery of first compression in traditional CPR with ventilations and compressions to compression-only CPR performed by untrained laypersons assisted by a mock 911 dispatcher. METHODS: This randomized-controlled simulation study included a convenience sample of English-speaking emergency department visitors during a 6-month period. Exclusion criteria were prior CPR training or physical incapacity. A cardiac arrest scenario was presented to subjects who were then provided with one of two sets of telephone CPR instructions by a mock 911 dispatcher. One group received traditional CPR instructions (TCPR) and the second group received compression only CPR instructions (COCPR). Subjects performed CPR on a Laerdal Resusci-Anne CPR manikin and recording strips were analyzed for frequency and quality measures. Pre-and post-test questionnaires assessed subject fatigue and telephone instruction understanding. The primary outcome was the time interval from 911 call to initiation of chest compressions. Analysis included Student t-test, Chi-square, and Wilcoxon Rank Sum. RESULTS: Of 377 potential subjects, 54 consented to randomization. The data from 50 subjects were analyzed. Compared to group TCPR, group COCPR initiated chest compressions faster (72 vs 117 sec, p < 0.0001), completed four cycles of CPR faster (168 vs. 250 sec, p < 0.0001), and paused for a smaller percentage of the resuscitation (13% vs. 36%, p < 0.0001). Only 9% of ventilation opportunities in the TCPR group yielded ventilations of the correct volume. There were no differences between groups in perceived understanding of CPR instruction or fatigue. CONCLUSIONS: We have identified the potential timesavings that may occur during compressions-only CPR. Bystander resuscitation may be more efficient when ventilations are excluded from the CPR sequence.


Assuntos
Reanimação Cardiopulmonar/métodos , Sistemas de Comunicação entre Serviços de Emergência , Massagem Cardíaca , Respiração , Adulto , Serviços Médicos de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
19.
J Neurosci ; 23(23): 8204-11, 2003 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-12967981

RESUMO

Electrophysiological recording procedures were used to examine basolateral amygdala (BLA) cell firing during cocaine self-administration and relative to response-independent presentations of cocaine-associated stimuli. Of 72 neurons (n = 10 rats), 31 cells (43%) were classified as phasically active, exhibiting one of three types of patterned discharges relative to the drug-reinforced response, similar to that previously described for nucleus accumbens (Acb) neurons (Carelli, 2002). Briefly, neurons exhibited increased firing rates within seconds preceding the response [termed preresponse (PR)], increased activity within seconds after the response [termed reinforcement excitation (RFe)] or an inhibition in cell firing before and/or after the response for intravenous cocaine [termed reinforcement inhibition (RFi)]. To examine the responsiveness of these same neurons to cocaine-associated stimuli, the stimulus "probe" procedure was used. Specifically, probe trials (18-20) were presented in which the audiovisual (tone-house light) stimulus associated with intravenous cocaine delivery during self-administration was randomly presented by the computer, interspersed between reinforced lever press responses. Neurons classified as type PR or type RFi were not activated by the stimulus. In contrast, neurons that exhibited increased firing immediately after the response (type RFe neurons) were significantly activated by the audiovisual cue. These findings are discussed with respect to the role of the BLA in cocaine addiction as well as previous studies characterizing Acb cell firing during cocaine self-administration.


Assuntos
Tonsila do Cerebelo/fisiologia , Transtornos Relacionados ao Uso de Cocaína/fisiopatologia , Cocaína/administração & dosagem , Sinais (Psicologia) , Neurônios/fisiologia , Estimulação Acústica , Tonsila do Cerebelo/citologia , Tonsila do Cerebelo/efeitos dos fármacos , Animais , Comportamento Animal/efeitos dos fármacos , Condicionamento Operante , Eletrodos Implantados , Eletrofisiologia , Neurônios/citologia , Neurônios/efeitos dos fármacos , Estimulação Luminosa , Ratos , Reforço Psicológico , Autoadministração
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