Cardiopulmonary Resuscitation Without Aortic Valve Compression Increases the Chances of Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Prospective Observational Cohort Study.

OBJECTIVES: Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA. DESIGN: Prospective observational cohort study. SETTING: Single center. PATIENTS: This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Etco2) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Etco2, post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups. CONCLUSIONS: Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

Characteristic of school injuries in Asia: a cross-national, multi-center observational study.

BACKGROUND: To prevent school injuries, thorough epidemiological data is an essential foundation. We aimed to investigate the characteristics of school injuries in Asia and explore risk factors for major trauma. METHODS: This retrospective study was conducted in the participating centers of the Pan-Asian Trauma Outcome Study from October 2015 to December 2020. Subjects who reported "school" as the site of injury were included. Major trauma was defined as an Injury Severity Score (ISS) value of ≥16. RESULTS: In total, 1305 injury cases (1.0% of 127,715 events) occurred at schools. Among these, 68.2% were children. Unintentional injuries were the leading cause and intentional injuries comprised 7.5% of the cohort. Major trauma accounted for 7.1% of those with documented ISS values. Multivariable regression revealed associations between major trauma and factors, including age, intention of injury (self-harm), type of injury (traffic injuries, falls), and body part injured (head, thorax, and abdomen). Twenty-two (1.7%) died, with six deaths related to self-harm. Females represented 28.4% of injuries but accounted for 40.9% of all deaths. CONCLUSIONS: In Asia, injuries at schools affect a significant number of children. Although the incidence of injuries was higher in males, self-inflicted injuries and mortality cases were relatively higher in females. IMPACT: Epidemiological data and risk factors for major trauma resulting from school injuries in Asia are lacking. This study identified significant risk factors for major trauma occurring at schools, including age, intention of injury (self-harm), injury type (traffic injuries, falls), and body part injured (head, thoracic, and abdominal injuries). Although the incidence of injuries was higher in males, the incidence of self-harm injuries and mortality rates were higher in females. The results of this would make a significant contribution to the development of prevention strategies and relative policies concerning school injuries.

A comparison between intraosseous and intravenous access in patients with out-of-hospital cardiac arrest: A retrospective cohort study.

INTRODUCTION: The optimal vascular access for patients with out-of-hospital cardiac arrest (OHCA) remains controversial. Increasing evidence supports intraosseous (IO) access due to faster medication administration and higher first-attempt success rates compared to intravenous (IV) access. However, the impact on patient outcomes has been inconclusive. METHODS: This retrospective cohort study in Taoyuan City, Taiwan, from January 1, 2019, to December 31, 2022, included patients aged ≥18 years with non-traumatic OHCA resuscitated by emergency medical technician paramedics (EMT-Ps) with either IVs or IOs for final vascular access. The exclusion criteria were cardiac arrest en route to the hospital and resuscitation during the coronavirus pandemic (from May 1, 2022, to October 31, 2022). The primary and secondary outcomes were sustained ROSC (≥2 h) and cerebral performance category (CPC) 1-2, respectively. Univariate logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CI) for the primary analysis. Multivariable logistic regression was employed, with variables selected based on a p-value of <0.05 in the univariate analysis. The survival benefits of different insertion sites and subgroups like general ambulance teams (with a composition that includes fewer EMT-Ps and limited experience in using IO access) were also analyzed. RESULTS: A total of 2003 patients were enrolled; 1602 received IV access and 401 IO access. The median patient age was 70 years, and most were male (66.6%). Compared to patients receiving IV access, the adjusted odds ratios (aORs) for primary and secondary outcomes in patients with IOs were 0.83 (95% confidence interval [CI], 0.61-1.11; p = 0.20) and 0.96 (95% CI, 0.39-2.40; p = 0.93), respectively. Different insertion sites showed no outcome differences. In the subgroups of females and patients resuscitated by general ambulance teams, the aORs for sustained ROSC were 0.55 (95% CI, 0.33-0.92; p = 0.02) and 0.62 (95% CI, 0.41-0.94; p = 0.02), respectively. CONCLUSIONS: For patients with OHCA resuscitated by EMT-Ps, IO access was comparable to IV access regarding patient outcomes. However, in females and patients resuscitated by general ambulance teams, IV access might be favorable.

Modified physiologic criteria for the field triage scheme: Efficacy of major trauma recognition in different age groups in Asia.

BACKGROUND: Major trauma is a leading cause of unexpected death globally, with increasing age-adjusted death rates for unintentional injuries. Field triage schemes (FTSs) assist emergency medical technicians in identifying appropriate medical care facilities for patients. While full FTSs may improve sensitivity, step-by-step field triage is time-consuming. A simplified FTS (sFTS) that uses only physiological and anatomical criteria may offer a more rapid decision-making process. However, evidence for this approach is limited, and its performance in identifying all age groups requiring trauma center resources in Asia remains unclear. METHODS: We conducted a multinational retrospective cohort study involving adult trauma patients admitted to emergency departments in the included countries from 2016 to 2020. Prehospital and hospital data were reviewed from the Pan-Asia Trauma Outcomes Study database. Patients aged ≥18 years transported by emergency medical services were included. Patients lacking data regarding age, sex, physiological criteria, or injury severity scores were excluded. We examined the performance of sFTS in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups. RESULTS: The sensitivity and specificity of the physiological and anatomical criteria for identifying major trauma (injury severity score ≥ 16) were 80.6% and 58.8%, respectively. The modified sFTS showed increased sensitivity and decreased specificity, with more pronounced changes in the young age group. Adding the shock index further increased sensitivity in both age groups. CONCLUSIONS: sFTS using only physiological and anatomical criteria is suboptimal for Asian adult patients with trauma of all age groups. Adjusting the physiological criteria and adding a shock index as a triage tool can improve the sensitivity of severely injured patients, particularly in young age groups. A swift field triage process can maintain acceptable sensitivity and specificity in severely injured patients.

Prehospital neurologic assessment using mobile phones: Comparison between neurologists and emergency physicians.

BACKGROUND: Ambulance-based telestroke may be a promising solution to improving stroke care. We assessed the technical feasibility and reliability of prehospital evaluations using commercial mobile phones with fifth-generation wireless communication technology. METHODS: Six standardized patients portrayed scripted stroke scenarios during ambulance transport in an urban city and were remotely evaluated by independent raters using tablets (three neurologists and three emergency physicians) in a hospital, assisted by paramedics (trained in National Institute of Health Stroke Scale [NIHSS] assessment) in the ambulance; commercial cellular networks were utilized for videoconferencing transmission. The primary outcomes were mean difference (MD) and correlation of NIHSS scores between the face-to-face and remote assessments. We also examined the Bland-Altman plot for itemized NIHSS components, and Kaplan-Meier curves were used to compare the differences in the duration of the two evaluations between neurologists and emergency physicians. RESULTS: We conducted 32 ambulance runs and successfully completed all NIHSS examinations. No significant difference was found between the face-to-face and remote evaluations (MD, 0.782; 95% confidence interval [CI], -0.520-0.395). The correlation of NIHSS scores between the two methods was 0.994 (95% CI, 0.945-1.026), and three items exhibited the highest frequency of runs, with score differences between the two methods. There were no significant differences between neurologists and emergency physicians in the mean evaluation duration and NIHSS scores for the two methods. CONCLUSION: Prehospital evaluation using commercial mobile phones with fifth-generation wireless communication technology is feasible and reliable during ambulance transport in urban areas. Emergency physicians and neurologists performed similarly in stroke evaluations.

Development of a prediction model for emergency medical service witnessed traumatic out-of-hospital cardiac arrest: A multicenter cohort study.

BACKGROUND/PURPOSE: To develop a prediction model for emergency medical technicians (EMTs) to identify trauma patients at high risk of deterioration to emergency medical service (EMS)-witnessed traumatic cardiac arrest (TCA) on the scene or en route. METHODS: We developed a prediction model using the classical cross-validation method from the Pan-Asia Trauma Outcomes Study (PATOS) database from 1 January 2015 to 31 December 2020. Eligible patients aged ≥18 years were transported to the hospital by the EMS. The primary outcome (EMS-witnessed TCA) was defined based on changes in vital signs measured on the scene or en route. We included variables that were immediately measurable as potential predictors when EMTs arrived. An integer point value system was built using multivariable logistic regression. The area under the receiver operating characteristic (AUROC) curve and Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration in the derivation and validation cohorts. RESULTS: In total, 74,844 patients were eligible for database review. The model comprised five prehospital predictors: age <40 years, systolic blood pressure <100 mmHg, respiration rate >20/minute, pulse oximetry <94%, and levels of consciousness to pain or unresponsiveness. The AUROC in the derivation and validation cohorts was 0.767 and 0.782, respectively. The HL test revealed good calibration of the model (p = 0.906). CONCLUSION: We established a prediction model using variables from the PATOS database and measured them immediately after EMS personnel arrived to predict EMS-witnessed TCA. The model allows prehospital medical personnel to focus on high-risk patients and promptly administer optimal treatment.

A Novel Assessment Using a Panoramic Video Camera of Resuscitation Quality in Patients following Out-of-Hospital Cardiac Arrest.

The assessment of cardiopulmonary resuscitation and teamwork quality in prehospital settings has always been challenging. Currently, commercialized quality-monitored chest pads and single-angle cameras are being used to monitor prehospital the resuscitation quality in patients following out-of-hospital cardiac arrest (OHCA). However, both these methods have drawbacks. In New Taipei City, we introduced the panoramic video camera as a novel method to assess the resuscitation quality of OHCA patients to monitor both technical skills and teamwork. The panoramic video camera enabled a comprehensive evaluation of prehospital resuscitation, thereby allowing team members to evaluate their performance by reviewing the video after resuscitation. This is the first step toward improving the evaluation of prehospital resuscitation. Using this panoramic video camera and a high-speed internet connection, real-time resuscitation feedback from the dispatch center or medical directors can be provided promptly, thus, making prehospital resuscitation safe and efficient.

Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS).

OBJECTIVE: Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries. METHODS: This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays. RESULTS: Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02-1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04-2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06-5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48-5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40-5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30-7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02-4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23-3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95-22.48, p < 0.001) were significant predictors of hospital mortality. CONCLUSIONS: Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.

Epidemiology and Prehospital Care of Pediatric Unintentional Injuries Among Countries with Different Economic Status in Asia: A Cross-National, Multi-Center Observational Study.

OBJECTIVE: Injury is a major cause of morbidity and mortality in children. However, the epidemiology and prehospital care for pediatric unintentional injuries in Asia are still unclear. METHODS: A total of 9,737 pediatric patients aged <18 years with unintentional injuries cared for at participating centers of the Pan-Asian Trauma Outcome Study (PATOS) from October 2015 to December 2020 were reviewed retrospectively. Patients were divided into two groups: those <8 and those ≥8 years of age. Variables such as patient demographics, injury epidemiology, Injury Severity Score (ISS), and prehospital care were collected. Injury severity and administered prehospital care stratified by gross national income were also analyzed. RESULTS: Pediatric unintentional injuries accounted for 9.4% of EMS-transported trauma cases in the participating Asian centers, and the mortality rate was 0.88%. The leading cause of injury was traffic injuries in older children aged ≥8 years (56.5%), while falls at home were common among young children aged <8 years (43.9%). Compared with younger children, older children with similar ISS tended to receive more prehospital interventions. Uneven disease severity was found in that older children in lower-middle and upper-middle-income countries had higher ISS compared with those in high-income countries. The performance of prehospital interventions also differed among countries with different gross national incomes. Immobilizations were the most performed prehospital intervention followed by oxygen administration, airway management, and pain control; only one patient received prehospital thoracentesis. Procedures were performed more frequently in high-income countries than in upper-middle-income and lower-middle-income countries. CONCLUSIONS: The major cause of injury was road traffic injuries in older children, while falls at home were common among young children. Prehospital care in pediatric unintentional injuries in Asian countries was not standardized and might be insufficient, and the economic status of countries may affect the implementation of prehospital care.

Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route.

INTRODUCTION: The benefits and risks of the intraosseous (IO) route for vascular access in patients with out-of-hospital cardiac arrest (OHCA) remain controversial. This study compares the success rates of establishing the access route, epinephrine administration rates, and time-to-epinephrine between adult patients with OHCA with IO access and those with intravenous (IV) access established by paramedics in the prehospital setting. METHODS: This was a retrospective study conducted by the San-Min station of Taoyuan Fire Department. Data for IV access were collected between January 1, 2020, and December 31, 2020. Data for IO access were collected between January 1, 2021, and March 10, 2021. Inclusion criteria were adult patients with OHCA who received on-scene resuscitation attempts and in whom either IV or IO route access was established by paramedics. Exclusion criteria were missing data, return of spontaneous circulation before establishing vascular access, cardiac arrest en route to hospital, patients not resuscitated, and OHCA unidentified by the dispatcher. Exposure was defined as IV route vs. IO route (EZ-IO®). The outcome measurements were per-patient based success rates of route establishment (successes/attempts), administration rates of epinephrine (epinephrine administered per case/enrolled OHCAs), and odds ratios of IV versus IO on epinephrine administration. We used nonparametric Mann-Whitney rank sum tests for the analysis in continuous variables and Fisher's exact tests for the analysis of categorical variables and the outcomes. Firth logistic regression method was used for sparse data. Factors associated with epinephrine administration other than vascular access were also analyzed. Time-to-epinephrine (defined as time from paramedic arrival to epinephrine injection) was reviewed and calculated by two independent observers and the Kaplan-Meier method was used to compare the two access routes. RESULTS: A total of 112 adult patients were enrolled in the analysis, including 71 men and 41 women, with an average age of 67 years. There were 90 IV access cases and 22 IO access cases. The groups were compared for median success rates of route establishment (33% vs. 100%, P < 0.001) and administration rates of epinephrine (52% vs. 100%, P < 0.001). The adjusted odds ratio of IO versus IV was 32.445, 95% confidence interval (CI) of 1.844-570.861. Time-to-epinephrine was significantly shorter in the cumulative time-event analysis by the Kaplan-Meier method (P < 0.001). CONCLUSION: The IO route was significantly associated with higher success rates of route establishment, epinephrine administration, and shorter time-to-epinephrine in the prehospital resuscitation of adult patients with OHCA.

Development and Validation of a Risk Score for Predicting Ischemic Stroke After Transient Ischemic Attack.

BACKGROUND: A risk stratification scale is essential to identify high-risk patients who had transient ischemic attack (TIA) to prevent subsequent permanent disability caused by ischemic stroke. OBJECTIVE: This study aimed to develop and validate a scoring system to predict acute ischemic stroke within 90 days after TIA in an emergency department (ED). METHODS: We retrospectively analyzed the data of patients with TIA in a stroke registry between January 2011 and September 2018. Characteristics, medication history, electrocardiogram (ECG), and imaging findings were collected. Univariable and multivariable stepwise logistic regression analyses were performed to create an integer point system. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. Youden's Index was also used to determine the best cutoff value. RESULTS: A total of 557 patients were included, and the occurrence rate of acute ischemic stroke within 90 days after TIA was 5.03%. After multivariable analysis, a new integer point system was created-MESH (Medication Electrocardiogram Stenosis Hypodense) score-which contained medication history (antiplatelet medication taken before admission, 1 point), right bundle branch block on electrocardiogram (1 point), intracranial stenosis ≥ 50% (1 point), and size of the hypodense area on computed tomography (diameter ≥ 4 cm, 2 points). The MESH score showed adequate discrimination (AUC = 0.78) and calibration (HL test = 0.78). The best cutoff value was 2 points, with a sensitivity of 60.71% and specificity of 81.66%. CONCLUSIONS: The MESH score indicated improved accuracy for TIA risk stratification in the ED setting.

Comparing the effects of blended learning and traditional instruction on basic life support for laypersons: A randomized controlled trial.

BACKGROUND/PURPOSE: Blended learning offers the advantages of both instructor-led and self-instruction methods in basic life support (BLS). Our study aims to compare the effects of blended learning with those of traditional instructor-led methods on the performance of laypersons taking BLS courses. METHODS: A total of 108 participants were randomly assigned to three groups: traditional instruction (group A, n = 36), blended learning with two rounds of practice (group B, n = 36), and blended learning with three rounds of practice (group C, n = 36). Group A received a 90-min lecture and a 30-min hands-on practice session using a manikin and a metronome. Participants in groups B and C received 18-min standardized online video lessons and performed hands-on practice twice and thrice, respectively. The primary outcome was chest compression at a correct speed (100-120 compressions per min) after the training course. Secondary outcomes included knowledge test scores, attitudes and confidence, and individual skill performance after training. RESULTS: Patient characteristics were similar between the groups. Blended learning with practicing thrice resulted in the highest compressions at a correct speed (group A vs. B vs. C, 68.09 vs 80.03 vs 89.42, p = 0.015) and the shortest average hands-off time (group A vs. B vs. C, 1.12 vs 0.86 vs 0.17 s, p = 0.015). Both blended groups performed better in confirming environmental safety (p < 0.001). No differences in scores of the knowledge test, attitude, or confidence were noted among the three groups. CONCLUSION: Blended learning with three rounds of hands-on practice may be considered an alternative teaching method.

Effect of crew ratio of advanced life support-trained personnel on patients with out-of-hospital cardiac arrest: A systematic review and meta-analysis.

BACKGROUND/PURPOSE: This review aimed to investigate the effect of crew ratios of on-scene advanced life support (ALS)-trained personnel on patients with out-of-hospital cardiac arrest (OHCA). METHODS: We systematically searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials databases from the inception date until September 30, 2022, for eligible studies. Two reviewers independently screened the studies for relevance, extracted data, and quality. We compared the effect of the ratio of on-scene ALS-trained personnel >50 % to those with a ratio ≤50 % among prehospital personnel on the clinical outcomes of OHCA patients. The primary outcome was survival-to-discharge and secondary outcomes were any return of spontaneous circulation (ROSC), sustained ROSC (≥2 h), and favourable neurological outcome at discharge (cerebral performance category scores: 1 or 2). Pooled odds ratios (ORs) were calculated, and the certainty of evidence was assessed. RESULTS: From 10,864 references, we identified four non-randomised studies, including 16,475 patients. Two studies were performed in Japan and two in Taiwan. There were significant differences in survival-to-discharge (OR: 1.24, 95 % confidence interval [CI]: 1.07-1.44, I2: 7 %), any ROSC (OR:1.22, 95 % CI: 1.04-1.43, I2: 74 %) and sustained ROSC (OR: 1.39, 95 % CI: 1.16-1.65, I2: 40 %), but insignificant differences in favourable neurological outcome at discharge. The overall certainty of evidence was rated as very low for all outcomes. CONCLUSION: Prehospital ALS care with a ratio of on-scene ALS-trained personnel >50 % could improve OHCA patient outcomes than crew ratios ≤50 %. Further studies are required to reach a robust conclusion.

Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience.

BACKGROUND/PURPOSE: A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community. METHODS: Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time. RESULTS: We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001). CONCLUSION: The prehospital bypass strategy with G-FAST showed benefits for stroke patients.

Effect of Nighttime on Prehospital Care and Outcomes of Road Traffic Injuries in Asia: A Cross-Sectional Study of Data from the Pan-Asian Trauma Outcomes Study (PATOS).

Introduction: Emergency response to a road traffic injury (RTI) plays a crucial role in patient survival, and the quality of the emergency response should be consistent regardless of the time of day. The aim of this study was to investigate prehospital care and survival outcomes compared between emergency response to RTI during the day and emergency response to RTI at night in Asia.Method: This cross-sectional study used data from the Pan-Asian Trauma Outcome Study (PATOS) that was conducted during 2015-2018. We included RTI patients who were transported to the emergency department (ED) by ground ambulance. That group was then categorized according to the time that the ambulance arrived on-scene. On-scene arrival during 8:00 am to 7:59 pm was defined as the daytime group, and arrival during 8:00 pm to 7:59 am was defined as the nighttime group. Multiple logistic regression was employed to identify factors associated with nighttime prehospital interventions and survival outcomes after adjustment for age, alcohol consumption, and injury severity score (ISS).Results: The final analysis included 20,105 RTI patients. Of those, 12,043 (60%) accidents occurred during the daytime, and 8,062 (40%) occurred at night. RTI patients at night were younger (mean age: 35.7 ± 17.3 vs. 39.5 ± 20.7; p < 0.001), had more alcohol consumption (15.0% vs. 4.2%; p < 0.001), and had more severe injuries (mean ISS: 6.5 ± 7.5 vs. 5.8 ± 7.0; p < 0.001) compared to the daytime group. The nighttime group had increased prehospital immobilization (adjusted odds ratio [aOR]: 1.22, 95% confidence interval [CI]: 1.14-1.31) and more prehospital intravenous (IV) access (aOR 1.36, 95%CI: 1.22-1.51). There was no significant difference in either basic or advanced airway management between the daytime and nighttime groups. The nighttime group had decreased survival in the ED (aOR: 0.80, 95%CI: 0.65-0.98); however, nighttime on-scene arrival did not impact survival to discharge (aOR: 1.10, 95%CI: 0.91-1.33).Conclusion: In the PATOS community, RTI patients that sustained their injuries at night received significantly more prehospital immobilization and IV access, and they had significantly decreased survival in the ED. The results of this study can be used to develop and enhance strategies to improve the care and outcomes of nighttime RTI in Asia.

Machine Learning-Based Text Analysis to Predict Severely Injured Patients in Emergency Medical Dispatch: Model Development and Validation.

BACKGROUND: Early recognition of severely injured patients in prehospital settings is of paramount importance for timely treatment and transportation of patients to further treatment facilities. The dispatching accuracy has seldom been addressed in previous studies. OBJECTIVE: In this study, we aimed to build a machine learning-based model through text mining of emergency calls for the automated identification of severely injured patients after a road accident. METHODS: Audio recordings of road accidents in Taipei City, Taiwan, in 2018 were obtained and randomly sampled. Data on call transfers or non-Mandarin speeches were excluded. To predict cases of severe trauma identified on-site by emergency medical technicians, all included cases were evaluated by both humans (6 dispatchers) and a machine learning model, that is, a prehospital-activated major trauma (PAMT) model. The PAMT model was developed using term frequency-inverse document frequency, rule-based classification, and a Bernoulli naïve Bayes classifier. Repeated random subsampling cross-validation was applied to evaluate the robustness of the model. The prediction performance of dispatchers and the PAMT model, in severe cases, was compared. Performance was indicated by sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. RESULTS: Although the mean sensitivity and negative predictive value obtained by the PAMT model were higher than those of dispatchers, they obtained higher mean specificity, positive predictive value, and accuracy. The mean accuracy of the PAMT model, from certainty level 0 (lowest certainty) to level 6 (highest certainty), was higher except for levels 5 and 6. The overall performances of the dispatchers and the PAMT model were similar; however, the PAMT model had higher accuracy in cases where the dispatchers were less certain of their judgments. CONCLUSIONS: A machine learning-based model, called the PAMT model, was developed to predict severe road accident trauma. The results of our study suggest that the accuracy of the PAMT model is not superior to that of the participating dispatchers; however, it may assist dispatchers when they lack confidence while making a judgment.

Expanding resources of endovascular thrombectomy: An optimization model.

BACKGROUND/PURPOSE: Recently optimized models for selecting the locations of hospitals capable of providing endovascular thrombectomy (EVT) did not consider the accuracy of the prehospital stroke scale assessment and possibility of secondary transport. Our study aimed to propose a new model for selecting existing hospitals with intravenous thrombolysis capability to become EVT-capable hospitals. METHODS: A sequential order was provided to upgrade hospitals providing intravenous thrombolysis, using a mixed integer programming model based on current medical resource allocation. In addition, we drafted a centralized plan to redistribute existing EVT resources by redetermining locations of EVT-capable hospitals. Using historical data of 7679 on-scene patients with suspected stroke, the model was implemented to determine the hospital that maximizes the number of patients receiving EVT treatment within call-to-definitive-treatment time. RESULTS: All suspected stroke patients were sent to EVT-capable hospitals directly under the current medical resource allocation model. After upgrading one additional hospital to become an EVT-capable hospital, the percentage of patients receiving definitive treatment within the standard call-to-definitive-treatment time was elevated from 68.82% to 72.97%. In the model, assuming that there is no hospital providing EVT, all patients suspected of stroke will be sent to EVT-capable hospitals directly after upgrading three or more hospitals to be able to provide treatment. CONCLUSION: All patients eligible for acute stroke treatment are sent to EVT-capable hospitals in the simulation under the current medical resource allocation model. This model can be utilized to provide insights for capacity redistribution in other regions.

External validation of prehospital stroke scales for emergent large vessel occlusion.

BACKGROUND: It is suggested that a prehospital scale should be utilized to identify patients with emergent large vessel occlusion (ELVO). We aimed to perform external validation of nine ELVO scales. METHODS: This single center retrospective observational study included patients with ischemic stroke visiting the emergency department (ED) within 6 h of symptom onset. Participants were excluded if individual items of the National Institute of Health Stroke Scale scores were not recorded or they did not receive brain computed tomography angiography or magnetic resonance imaging before intravenous thrombolysis or endovascular thrombectomy, and within 24 h of ED admission. The first definition of ELVO was emergent occlusion of the internal carotid artery (ICA) and middle cerebral artery segment 1 (M1). The second definition was emergent occlusion of ICA, M1, basilar artery, middle cerebral artery segment 2, anterior cerebral artery segment 1, and posterior cerebral artery segment 1. Area under the receiver operating characteristic curve (AUROC) was constructed to examine discrimination. The sensitivity, specificity, positive predictive value, and negative predictive value of the nine scales under the two ELVO definitions were calculated. RESULTS: A total of 1231 patients were included in the study. No significant differences were observed in the AUROC under the two ELVO definitions. However, sensitivity values of these scales were largely different, ranging from 44.56% to 93.68% under the first ELVO definition. The sensitivity values among scales were also different under the second ELVO definition. CONCLUSION: Stakeholders in the community should choose suitable scales according to their own system conditions.

Strategies on locations of public access defibrillator: A systematic review.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a critical condition with poor outcomes. Although the survival rate increases in those who undergo defibrillation, the utility of on-time defibrillation among bystanders remained low. An evaluation of the deployment strategy for public access defibrillators (PADs) is necessary to increase their use and accessibility. This study was to conduct a systematic review for deployment strategies of PADs. METHODS: Two authors independently searched for articles published before October 2019 from PubMed, Embase, Web of Science, and Cochrane Library. An independent librarian provided the search strategy and assisted the literature research. We included articles that were focused on the main topic, but excluded those which were missing results or that used an unclear definition. The qualitative outcomes were the utility and OHCA coverage of PADs. We performed a qualitative analysis across the studies, but a quantitative analysis was not available due to the studies' heterogeneity in design and variety of outcomes. RESULTS: We eventually included 15 studies. Three strategies were presented: guidelines-based, grid-based, and landmark-based. The guidelines-based deployment was common fit for OHCA events. The grid-based method increased the use of bystander defibrillation 3-fold, and 30-day survival doubled. The top 3 landmarks in the landmark-based strategy were offices (18.6%), schools (13.3%), and sports facilities (12.9%). Utility of PADs might increase if we optimize PAD location by mathematical modeling and evaluation feedback. CONCLUSION: Three deployment strategies were presented. Although the optimal method could not be fully identified, a more efficient PAD deployment could benefit the population in terms of OHCA coverage and survival among patients with OHCA.

A prediction model for patients with emergency medical service witnessed out-of-hospital cardiac arrest.

BACKGROUND/PURPOSE: The study aim was to develop a model for predicting patients with emergency medical service (EMS) witnessed out-of-hospital cardiac arrest (OHCA). METHODS: We used fire-based EMS data from Taipei city to develop the prediction model. Patients included in this study were those who were initially alive, non-traumatic, and age ≧20 years. Data were extracted from electronic records of ambulance run sheets and an Utstein-style OHCA registry. The primary outcome (EMS-witnessed OHCA) was defined as cardiac arrest occurring during the service of emergency medical technicians before arrival at a receiving hospital. Area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. The point value system with Youden's J Index was used to find the optimal cut-off value. RESULTS: From 2011 to 2015, a total of 252,771 patients were included. Of them, 660 (0.26%) were EMS-witnessed OHCA. The model, including the predictors of male gender, respiratory rate≦10 cycles/min, heart rate <60 or ≧120 beats/min, systolic blood pressure <100 mmHg, level of consciousness, and oxygen saturation <94%, reached excellent discrimination with an AUROC of 0.94 [95% confidence interval (CI), 0.93-0.95] and excellent calibration (p = 0.42 for HL test) in a randomly selected derivation cohort. The results were comparable to those found in a validation cohort. The optimal cut-off value (≧13) of the tool demonstrated high sensitivity (87.84%) and specificity (86.20%). CONCLUSION: This newly developed prediction model will help identify high-risk patients with EMS-witnessed OHCA.