Prehospital Stroke Assessment for Large Vessel Occlusions: A Systematic Review.

BACKGROUND AND OBJECTIVE: Stroke is the leading cause of disability in the United States and new evidence shows interventional procedures provide better outcomes for large vessel occlusions (LVO). We performed a systematic review of the literature on prehospital stroke scales used to identify LVOs comparing the scales with analysis of the sensitivity, specificity, and predictive values. The goal was to determine if emergency medical services (EMS) are able to accurately identify LVO in the field. METHODS: In this systematic review, multiple databases were searched for articles that addressed our goal. The identified studies were evaluated for their statistical performance of various stroke scales. In addition, we assessed biases that may explain the varying results reported. RESULTS: Eight studies encompassing 6787 patients were included in our systematic review. Of the 8 studies, 6 were retrospective studies, 1 was a prospective cohort, and 1 was a prospective observational study. Sensitivities of the studies ranged from 49% to 91% while specificity of the studies varied from 40% to 94%. CONCLUSION: At this time, further evaluations must be done in the prehospital setting to determine the ease of use and true sensitivity and specificity of these scales in identifying LVOs.

Supraventricular Tachycardia Cardioverted by an Automated External Debrillator in a 9-year-old Male with a History of Wolff-Parkinson-White Syndrome.

Early defibrillation for cardiac arrest patients is a formidable link in the chain of survival promulgated by the American Heart Association. Automated external defibrillators (AEDs) provide public access defibrillation for out-of-hospital cardiac arrests and improve survivability. AEDs are only approved for use in patients in cardiac arrest; defibrillation may be inadvertently advised if utilized on a patient not experiencing cardiac arrest. We describe a case report of an AED cardioversion of a stable, pediatric patient with acute supraventricular tachycardia secondary to underlying Wolff-Parkinson-White syndrome. We discuss general AED principles, the cardioversion function on the particular AED used in this encounter, and the importance of community and organizational policies to encourage the correct application of AEDs.

The Use of Prehospital Ketamine for Control of Agitation in a Metropolitan Firefighter-based EMS System.

Abstract Introduction. Prehospital personnel frequently encounter agitated, combative, and intoxicated patients in the field. In recent years, ketamine has been described as an effective sedative agent to treat such patients; however, a paucity of research exists describing the use of prehospital ketamine. The objective of this study was to provide a descriptive analysis of the Columbus Division of Fire's experience with utilizing ketamine in the prehospital setting. We hypothesized that ketamine administration improves patient condition, is effective at sedating patients, and does not result in endotracheal intubation in the prehospital setting or in the emergency department (ED). Methods. We conducted a retrospective cohort chart review of Columbus Division of Fire patient care reports and hospital records from destination hospitals in the central Ohio region between October 2010 and October 2012. All patients receiving ketamine administered by Columbus Division of Fire personnel for sedation were included. Patients 17 years and younger were excluded. The primary outcome was the percentage of patients noted to have an "improved" condition recorded in the data field of the patient care report. The secondary outcomes were the effectiveness of sedation and the performance of endotracheal intubation. Results. A total of 36 patients met inclusion criteria over the study period. Data were available on 35 patients for analysis. The mean IV dose of ketamine was 138 mg (SD = 59.5, 100-200). The mean IM dose of ketamine was 324 mg (SD = 120, 100-500). Prehospital records noted an improvement in patient condition after ketamine administration in 32 cases (91%, 95% CI 77-98%). Six patients required sedation post-ketamine administration either by EMS (2) or in the ED (4) (17%, 95% CI 6.5-34%). Endotracheal intubation was performed in eight (23%, 95% CI 10-40%) patients post-ketamine administration. Conclusion. We found that in a cohort of patients administered ketamine, paramedics reported a subjective improvement in patient condition. Endotracheal intubation was performed in 8 patients.

The ultrasound challenge 2.0: introducing interinstitutional competition in medical student ultrasound education.

The Ultrasound Challenge was developed at The Ohio State University College of Medicine to introduce focused ultrasound to medical students. The goal was to develop experience in ultrasound through practice and competition. Initially this competition was held between Ohio State University College of Medicine students from years 1 through 4. The Ultrasound Challenge 2.0 was held in 2013. The event expanded on the previous structure by including students from the Wayne State University College of Medicine. The goal of this article is to describe our experiences with expansion of our interinstitutional ultrasound event. The challenge consisted of 6 stations: focused assessment with sonography for trauma, aortic ultrasound, cardiac ultrasound, pelvic ultrasound, musculoskeletal ultrasound, and vascular access. The participants were given a handbook outlining the expectations for each station ahead of time. Vascular access was graded in real time using the Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET) method. The remainder were timed, saved, and graded after the event by 3 independent faculty members using the B-QUIET method. The highest score with the fastest time was the winner. The Ultrasound Challenge 2.0 included 40 participants: 31 from The Ohio State University College of Medicine and 9 from the Wayne State University College of Medicine. The makeup of the winners in all categories consisted of 1 first-year medical student, 7 second-year medical students, 3 third-year medical students, and 10 fourth-year medical students. The Ultrasound Challenge 2.0 was a success for those who participated. It provided the first known interinstitutional medical student ultrasound competition. Students from both institutions were able to practice their image acquisition skills, demonstrate abilities in a competitive environment, and develop collegiality and teamwork.

High-dose insulin and intravenous lipid emulsion therapy for cardiogenic shock induced by intentional calcium-channel blocker and Beta-blocker overdose: a case series.

BACKGROUND: Recently, high-dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe toxicity from calcium-channel blocker (CCB) and beta blocker (BB). OBJECTIVE: Our aim was to describe the use and effectiveness of HDI and ILE for the treatment of CCB and BB overdose. CASE REPORTS: We describe 2 patients presenting to the emergency department after intentional ingestions of CCBs and BBs. A 35-year-old man presented in pulseless electrical activity after ingesting amlodopine, verapamil, and metoprolol. A 59-year-old man presented with cardiogenic shock (CS) after ingesting amlodopine, simvastatin, lisinopril, and metformin. Both patients were initially treated with glucagon, calcium, and vasopressors. Shortly after arrival, HDI (1 unit/kg × 1; 1 unit/kg/h infusion) and ILE 20% (1.5 mL/kg × 1; 0.25 mL/kg/min × 60 min) were initiated. This led to hemodynamic improvement and resolution of shock. At the time of hospital discharge, both patients had achieved full neurologic recovery. CONCLUSIONS: HDI effectively reverses CS induced by CCBs and BBs due to its inotropic effects, uptake of glucose into cardiac muscle, and peripheral vasodilatation. ILE is theorized to sequester agents dependent on lipid solubility from the plasma, preventing further toxicity. To our knowledge, these are the first two successful cases reported using the combination of HDI and ILE for reversing CS induced by intentional ingestions of CCBs and BBs.

Drive-thru continuing education to meet learners' needs.

BACKGROUND: Continuing education is a requirement for emergency medical services practitioners in Ohio, and simulation-based learning has been effective for this purpose. Limitations to providing simulation for emergency medical services practitioners include a lack of simulation resources or equipment and a lack of trained simulationists to adequately use existing equipment, such as high-fidelity manikins. Here, we sought to provide simulation-based learning in the ambulance bays of our local hospitals to meet these needs. METHODS: The OhioHealth simulation team, in conjunction with OhioHealth Emergency Medical Services, conducted simulation-based education sessions in ambulance bays scheduled in 2-h blocks for 3 consecutive days at 3 different hospitals in Columbus, Ohio. The outcomes of the education sessions were evaluated based on the ability to meet the educational objectives and the suitability of the environment for learning. In total, 171 learners completed educational sessions and evaluations. RESULTS: Modified Likert scale surveys were completed by learners to assess their confidence in the learning objectives. For each session, the learners were able to meet the determined learning objectives after the education. Regarding the feasibility of using ambulance bays for education, 90% of learners (155/171) responded that they "Agree" or "Strongly Agree" that the environment was conducive to learning. CONCLUSION: Using care site ambulance bays with simulation staff and content experts, we were able to effectively deliver simulation-based education. Based on learner perception and ability for education to meet its determined objectives, the ambulance bay provides a feasible way to address existing barriers (cost, access to equipment, and trained staff) to simulation-based education for emergency medical services practitioners.

The ultrasound challenge: a novel approach to medical student ultrasound education.

Undergraduate ultrasound education is becoming increasingly important to medical student development; as a result, innovative training methods are being designed and implemented. The Ultrasound Challenge was created to help students learn core ultrasound techniques and apply them in a friendly competition where they showcase their abilities. The Ultrasound Challenge consisted of 6 events: focused assessment with sonography for trauma, cardiac ultrasound, aortic ultrasound, pelvic ultrasound, vascular access, and musculoskeletal ultrasound. Thirty-three students from all 4 years of medical school participated. Medical center residents and faculty served as judges. The Ultrasound Challenge successfully provided medical students with ultrasound experience for future clinical endeavors.

Teaching about the Wild: A Survival Course as a Novel Resident Educational Experience.

Audience: Emergency medicine residents. Introduction: Wilderness medicine (WM) is the practice of resource-limited medicine under austere conditions. Emergency physicians in training should gain additional exposure to wilderness medicine knowledge and outdoor skills to allow for the development of problem solving and improvisation abilities. However, there is limited data on the instruction of general survival skills to residents interested in WM. Educational Objectives: By the end of the session the learner will be able to: 1) differentiate at least three different methods for water purification 2) describe how to erect a temporary survival shelter 3) construct a survival pack for personal use emphasizing multi-use items 4) demonstrate how to make a fire without a direct flame supply. Educational Methods: A small group of resident learners progressed through five survival stations designed to allow for an emphasis on select skills, wilderness medicine knowledge, and improvisation. Resident instructors led the discussion and skills demonstration. Research Methods: Participants completed a six item before and after questionnaire. Each item was ranked from 0 for "strongly disagree" to 10 for "strongly agree." Total mean scores before and after were compared. Results: Twelve individuals participated. The total mean score for the six-item analysis increased following the workshop (39.1 before versus 51.0 after, p = 0.0008). Discussion: General survival skills are traditionally acquired through time-intensive experiences; however, this is often unfeasible during residency training. We developed an alternative, more efficient mechanism for incorporating wilderness medicine skills into residency training that appears to improve understanding and confidence of participants, as well as to provide a teaching opportunity for new resident educators. Topics: Wilderness medicine, survival skills, emergency medicine, graduate medical education.

A Step in the Right Direction: Point-of-Care Ultrasound as an Evaluation Tool of Achilles Tendon Injuries in the Emergency Department.

This report describes the diagnosis of an Achilles tendon tear in a female patient with an inconclusive physical exam, which was limited by the patient's body habitus. Expedient use of point-of-care ultrasound supported the diagnosis of an Achilles tear with findings of a tendinous defect, fibrous stranding, and surrounding anechoic fluid, suggestive of localized hemorrhage. The patient was splinted in plantar flexion and had prompt orthopedic referral with MRI that verified Achilles tear.

Sex, Drugs, and Seizures: Subarachnoid Hemorrhage in a Young Patient.

A 17-year-old male patient presented to the emergency department (ED) with seizures after sexual intercourse. The patient was found to have an intracerebral hemorrhage (ICH) likely secondary to sexual intercourse and concomitant amphetamine use, an extremely rare finding in this patient population. In this case review, we will discuss the presentation, management, and disposition of subarachnoid hemorrhage (SAH), a well-known emergency diagnosis within the ED, while highlighting a case that is clearly uncommon. In addition, we discuss the etiology of ICH in the setting of intercourse and amphetamine use with the ultimate goal of understanding the interdisciplinary care of a complex subject.

Administration of Naloxone by Prehospital Personnel: A Retrospective Analysis.

Introduction Patient-specific discrepancies in prehospital naloxone administration have been documented. As the opioid epidemic continues to evolve, further evaluation of prehospital naloxone administration practices is needed. The objective of this study was to compare patients who received prehospital naloxone and received an emergency department (ED) diagnosis of opioid overdose with patients who received prehospital naloxone and received an alternative ED diagnosis.  Methods This was a retrospective, multicenter chart review of patients who received naloxone by prehospital personnel for suspected opioid overdose between October 1, 2016, and October 31, 2017. Patients were excluded if age was less than 18 years, naloxone was administered by non-emergency medical service (EMS) personnel, not transported, or if prehospital records could not be linked with ED records. Demographic information and several prehospital clinical findings, including unresponsiveness, apnea, and miosis, were compared between patients diagnosed with opioid overdoses versus an alternative ED diagnosis. Descriptive statistics were utilized. Results A total of 837 patients had complete data available and were included in the analysis. Overall, 402 (48%) of patients received an ED diagnosis of opioid overdose, and 435 (52%) of patients received an alternative ED diagnosis. Patients in the alternative diagnosis group were older, had less known drug use, were more likely to be admitted, and had lower incidences of apnea, unresponsiveness, and miosis. In the opioid overdose group, there was a higher proportion of previous drug use, apnea, unresponsiveness, and miosis in the EMS setting, whereas there was a higher proportion of previous overdose, previous suicide attempts, and neurological deficits in the ED setting. Conclusions In this retrospective review evaluating patients who received prehospital naloxone, several demographic and clinical differences were noted between the two groups. Further elucidation of the safety and efficacy of prehospital naloxone in alternative diagnoses is needed.

Curated Collections for Clinician Educators: Five Key Papers on Graduated Responsibility in Residency Education.

Introduction The Accreditation Council for Graduate Medical Education calls graduated responsibility "one of the core tenets of American graduate medical education." However, there is no clear set of resources for programs to implement a system of progressively increasing responsibilities for trainees. This project aimed to identify a set of high-yield papers on graduated responsibility for junior faculty members. Methods A study group of Academic Life in Emergency Medicine Faculty Incubator participants identified relevant literature on graduated responsibility via a comprehensive literature search and a call to the online medical education community; 59 total papers were identified. The most relevant and applicable were selected by the study group via a three-round modified Delphi process. Results Five key articles for junior faculty interested in implementing more robust graduated responsibility at their residency training program were selected and described here. Summaries of key points, along with considerations for faculty developers and relevance to junior faculty, are presented for each article. Conclusions The articles presented here provide a solid theoretical and practical basis for junior faculty to explore graduated responsibility. The five articles presented here provide the junior faculty with a toolkit to examine and improve their systems for assigning responsibilities in a graded fashion at their own institutions.

The Effect of Ambulance Staffing Models in a Metropolitan, Fire-Based EMS System.

Introduction The staffing of ambulances with different levels of Emergency Medical Service (EMS) providers is a difficult decision with evidence being mixed on the benefit of each model. Hypothesis/Problem The objective of this study was to describe a pilot program evaluating alternative staffing on two ambulances utilizing the paramedic-basic (PB) model (staffed with one paramedic and one emergency medical technician[EMT]). METHODS: This was a retrospective study conducted from September 17, 2013 through December 31, 2013. The PB ambulances were compared to geographically matched ambulances staffed with paramedic-paramedic (PP ambulances). One PP and one PB ambulance were based at Station A; one PP and one PB ambulance were based at Station B. The primary outcome was total on-scene time. Secondary outcomes included time-to-electrocardiogram (EKG), time-to-intravenous (IV) line insertion, IV-line success rate, and percentage of protocol violations. Inclusion criteria were all patients requesting prehospital services that were attended to by these teams. Patients were excluded if they were not attended to by the study ambulance vehicles. Descriptive statistics were reported as medians and interquartile ranges (IQR). Proportions were reported with 95% confidence intervals (CI). The Mann-Whitley U test was used for significance testing (P<.05). RESULTS: Median on-scene times at Station A for the PP ambulance were shorter than the PB ambulance team (PP: 10.1 minutes, IQR 6.0-15; PB: 13.0 minutes, IQR 8.1-18; P=.01). This finding also was noted at Station B (PP: 13.5 minutes, IQR 8.5-19; PB: 14.3 minutes, IQR 9.9-20; P=.01). There were no differences between PP and PB ambulance teams at Station A or Station B in time-to-EKG, time-to-IV insertion, IV success rate, and protocol violation rates. CONCLUSION: In the setting of a well-developed EMS system utilizing an all-Advanced Life Support (ALS) response, this study suggests that PB ambulance teams may function well when compared to PP ambulances. Though longer scene times were observed, differences in time to ALS interventions and protocol violation rates were not different. Hybrid ambulance teams may be an effective staffing alternative, but decisions to use this model must address clinical and operational concerns. Cortez EJ , Panchal AR , Davis JE , Keseg DP . The effect of ambulance staffing models in a metropolitan, fire-based EMS system. Prehosp Disaster Med. 2017;32(2):175-179.

Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest.

INTRODUCTION: Survival from out of hospital cardiac arrest (OHCA) is highest in victims with shockable rhythms when early CPR and rapid defibrillation are provided. However, a subset of individuals present with ventricular fibrillation (VF) that does not respond to defibrillation (refractory VF). One intervention that may be a possible option in refractory VF is double sequential external defibrillation (DSD). The objective of this case series was to describe the outcome of prehospital victims with refractory VF treated with DSD in the out-of-hospital setting. METHODS: This evaluation is a retrospective chart review of VF patients treated with DSD in the prehospital setting from August 1st, 2010 through June 30th, 2014. Patients were excluded if less than 17 years of age. The outcomes we evaluated were the number of patients with return of spontaneous circulation, conversion from VF, survival-to-hospital discharge, and Cerebral Performance Category score. RESULTS: Total of 2428 OHCA events were reviewed with twelve patients treated with DSD. Median DSD and prehospital resuscitation times were 27min (IQR 22-33) and 32 (IQR 24-38), respectively. Of the 12 patients treated, return of spontaneous circulation was achieved in three patients, nine patients were converted out of ventricular fibrillation, three patients survived to hospital discharge, and two patients (2/12, 17%) were discharged with Cerebral Performance Category scores of 1 (good cerebral performance). CONCLUSIONS: Double sequential defibrillation may be another tool to improve neurologically intact survival from OHCA. Further studies are needed to demonstrate direct benefits to patient outcomes.

Clinical Outcomes in Cardiac Arrest Patients Following Prehospital Treatment with Therapeutic Hypothermia.

INTRODUCTION: Recent studies have brought to question the efficacy of the use of prehospital therapeutic hypothermia for victims of out-of-hospital cardiac arrest (OHCA). Though guidelines recommend therapeutic hypothermia as a critical link in the chain of survival, the safety of this intervention, with the possibility of minimal treatment benefit, becomes important. Hypothesis/Problem This study examined prehospital therapeutic hypothermia for OHCA, its association with survival, and its complication profile in a large, metropolitan, fire-based Emergency Medical Services (EMS) system, where bystander cardiopulmonary resuscitation (CPR) and post-arrest care are in the process of being optimized. METHODS: This evaluation was a retrospective chart review of all OHCA patients with return of spontaneous circulation (ROSC) treated with therapeutic hypothermia, from January 1, 2013 through November 30, 2013. The primary outcomes were the proportion of patients with initiation of prehospital therapeutic hypothermia with survival to hospital admission, the proportion of patients with initiation of prehospital therapeutic hypothermia with survival to hospital discharge, and the complication profile of therapeutic hypothermia in this population. The complication profile included several clinical, radiographic, and laboratory parameters. Exclusion criteria included: no prehospital therapeutic hypothermia initiation; no ROSC; and age of 17 year old or younger. RESULTS: Fifty-one post-cardiac arrest patients were identified that met inclusion criteria. The mean age was 61 years (SD=14.7 years), and 33 (72%) were male. The initial rhythm was ventricular fibrillation or pulseless ventricular tachycardia in 17 (37%) patients, and bystander CPR was performed in 28 (61%) patients with ROSC. Thirty-nine (85%) patients survived to hospital admission. Twenty-one patients (48%; 95% CI, 33-64) were administered vasopressors, 10 patients (24%; 95% CI, 10-37) were administered diuretics, and 19 patients (44%; 95% CI, 29-60) were administered antibiotics. Initial chest radiograph (CXR) findings were normal in 12 (29%) patients. Overall, 13 (28%; 95% CI, 15-42) study patients survived to hospital discharge. CONCLUSION: Recent reports have questioned the efficacy and safety of prehospital therapeutic hypothermia. In this evaluation, in the setting of unstandardized post-arrest care, 85% of the patients survived to hospital admission and 28% survived to hospital discharge, with a complication profile which was similar to that noted in other studies. This suggests that further evidence may be needed before EMS systems stop administering therapeutic hypothermia to appropriately selected patients. In less-optimized systems, therapeutic hypothermia may still be an essential link in the chain of survival.

Ban Tu Wan hepatotoxicity.

Medications are thought to contribute to approximately 50% of the cases of acute liver failure in the USA. This number includes some herbal medications and supplements. However, little regulatory oversight of these later substances occurs. This report describes a case of fulminant hepatic failure secondary to Ban Tu Wan (a Chinese herb). We discuss the use of this herbal supplement and the relationship to drug-induced hepatitis.