Prehospital Noninvasive Ventilation: An NAEMSP Position Statement and Resource Document.

Noninvasive ventilation (NIV), including bilevel positive airway pressure and continuous positive airway pressure, is a safe and important therapeutic option in the management of prehospital respiratory distress. NAEMSP recommends:NIV should be used in the management of prehospital patients with respiratory failure, such as those with chronic obstructive pulmonary disease, asthma, and pulmonary edema.NIV is a safe intervention for use by Emergency Medical Technicians.Medical directors must assure adequate training in NIV, including appropriate patient selection, NIV system operation, administration of adjunctive medications, and assessment of clinical response.Medical directors must implement quality assessment and improvement programs to assure optimal application of and outcomes from NIV.Novel NIV methods such as high-flow nasal cannula and helmet ventilation may have a role in prehospital care.

Cardiac Arrest in Flight: A Retrospective Chart Review of 92 Patients Transported by a Critical Care Air Medical Service.

OBJECTIVE: The purpose of this study was to describe the incidence, characteristics, and outcomes of cardiac arrest in the air medical environment so that we can begin to understand predictors of in-flight cardiac arrest and identify opportunities to improve care. METHODS: This retrospective observational study was undertaken at Airlift Northwest from 2013 to 2017. Descriptive statistics of adult patients with medical and traumatic etiologies of cardiac arrest were analyzed and compared. RESULTS: Of the 13,915 adult patients transported during the study period, fewer than 1% (N = 92) had a cardiac arrest during transport. Of those, 42% in the overall cohort had return of spontaneous circulation on arrival at the destination hospital. Medical etiologies of cardiac arrest were more common than traumatic (65% vs. 35%), more likely to have an initial shockable rhythm (30% vs. 3%, P = .004), and more frequently arrived at the receiving hospital with return of spontaneous circulation (57% vs. 31%, P = .03). Rearrest in transport occurred frequently (39%). Most patients were hypotensive before cardiac arrest, and peri-intubation cardiac arrest occurred in 12% of patients. CONCLUSION: Cardiac arrest during air medical transport is a rare event that requires a high level of critical care to treat refractory cardiac arrests, hemodynamic instability, and airway compromise.

Occupational exposures and programmatic response to COVID-19 pandemic: an emergency medical services experience.

Rigorous assessment of occupational COVID-19 risk and personal protective equipment (PPE) use is not well-described. We evaluated 9-1-1 emergency medical services (EMS) encounters for patients with COVID-19 to assess occupational exposure, programmatic strategies to reduce exposure and PPE use. We conducted a retrospective cohort investigation of laboratory-confirmed patients with COVID-19 in King County, Washington, USA, who received 9-1-1 EMS responses from 14 February 2020 to 26 March 2020. We reviewed dispatch, EMS and public health surveillance records to evaluate the temporal relationship between exposure and programmatic changes to EMS operations designed to identify high-risk patients, protect the workforce and conserve PPE. There were 274 EMS encounters for 220 unique COVID-19 patients involving 700 unique EMS providers with 988 EMS person-encounters. Use of 'full' PPE including mask (surgical or N95), eye protection, gown and gloves (MEGG) was 67%. There were 151 person-exposures among 129 individuals, who required 981 quarantine days. Of the 700 EMS providers, 3 (0.4%) tested positive within 14 days of encounter, though these positive tests were not attributed to occupational exposure from inadequate PPE. Programmatic changes were associated with a temporal reduction in exposures. When stratified at the study encounters midpoint, 94% (142/151) of exposures occurred during the first 137 EMS encounters compared with 6% (9/151) during the second 137 EMS encounters (p<0.01). By the investigation's final week, EMS deployed MEGG PPE in 34% (3579/10 468) of all EMS person-encounters. Less than 0.5% of EMS providers experienced COVID-19 illness within 14 days of occupational encounter. Programmatic strategies were associated with a reduction in exposures, while achieving a measured use of PPE.

Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations.

PURPOSE: In hospital-based studies, patients intubated by physicians while in an inclined position compared to supine position had a higher rate of first pass success and lower rate of peri-intubation complications. We evaluated the impact of patient positioning on prehospital endotracheal intubation in an EMS system with rapid sequence induction capability. We hypothesized that patients in the inclined position would have a higher first-pass success rate. METHODS: Prehospital endotracheal intubation cases performed by paramedics between 2012 and 2017 were prospectively collected in airway registries maintained by a metropolitan EMS system. We included all adult (age ≥ 18 years) non-traumatic, non-arrest patients who received any attempt at intubation. Patients were categorized according to initial positioning: supine or inclined. The primary outcome measure was first pass success with secondary outcomes of laryngoscopic view and challenges to intubation. RESULTS: Of the 13,353 patients with endotracheal intubation attempted by paramedics during the study period, 4879 were included for analysis. Of these, 1924 (39.4%) were intubated in the inclined position. First pass success was 86.3% among the inclined group versus 82.5% for the supine group (difference 3.8%, 95% CI: 1.5%-6.1%). First attempt laryngeal grade I view was 62.9% in the inclined group versus 57.1% for the supine group (difference 5.8%, 2.0-9.6). Challenges to intubation were more frequent in the supine group (42.3% versus 38.8%, difference 3.5%, 0.6-6.3). CONCLUSION: Inclined positioning was associated with a better grade view and higher rate of first pass success. The technique should be considered as a viable approach for prehospital airway management.

Impact of Building Height and Volume on Cardiac Arrest Response Time.

Emergency medical services (EMS) care may be delayed when out-of-hospital cardiac arrest (OHCA) occurs in tall or large buildings. We hypothesized that larger building height and volume were related to a longer curb-to-defibrillator activation interval. We retrospectively evaluated 3,065 EMS responses to OHCA in a large city between 2003-13 that occurred indoors, prior to EMS arrival, and without prior deployment of a defibrillator. The two-tiered EMS system uses automated external defibrillator-equipped basic life support firefighters followed by paramedics dispatched from a single call center. We calculated three time intervals obtained from the computerized dispatch report and time-synchronized defibrillators: initial 911 call to address curb arrival by first unit (call-to-curb), curb arrival to defibrillator power on (curb-to-defib on), and the combined call-to-defib on interval. Building height and surface area were measured with a validated program based on aerial photography. Buildings were categorized by height as short (<25 ft), medium (26-64 ft) and tall (>64 ft). Volume was categorized as small (<60,000 ft(3)), midsize (60,000-1,202,600 ft(3)) and large (>1,202,600 ft(3)). Intervals were compared using the two-tailed Mann-Whitney test. EMS responded to 1,673 OHCA events in short, 1,134 in medium, and 258 in tall buildings. There was a 1.14 minute increase in median curb-to-defib on interval from 1.97 in short to 3.11 minutes in tall buildings (p < 0.01). Taller buildings, however, had a shorter call-to-curb interval (4.73 for short vs 3.96 minutes for tall, p < 0.01), such that the difference in call-to-defib on interval was only 0.27 minutes: 6.87 for short and 7.14 for tall buildings. A similar relationship was observed for small-volume compared to large-volume building: longer curb-to-AED (1.90 vs. 3.01 minutes, p < 0.01), but shorter call-to-curb (4.87 vs. 4.05, p < 0.01); the difference in call-to-defib on was 0.18 minutes. Both taller and larger-volume buildings had longer curb-to-AED intervals but shorter 911 call-to-curb arrival intervals. As a consequence, building height and volume had a modest overall relationship with interval from call to defibrillator application. These results do not support the hypothesis that either taller or larger-volume buildings need cause poorer outcomes in urban environments.

The complete acute and post-acute care course of children affected by acute flaccid myelitis in Western Pennsylvania: A case series.

Acute flaccid myelitis (AFM) is a "polio-like" neurologic disorder of the spinal cord gray matter characterized by asymmetric, flaccid limb weakness of rapid onset following prodromal viral illness. It has affected the pediatric population of the United States since 2014, but there is a paucity of literature describing the post-acute comprehensive rehabilitation management that maximizes functional outcomes for patients. This case series attempts to mitigate this by describing the complete acute and post-acute care course of six children diagnosed with AFM in Western Pennsylvania. It is critical that pediatric rehabilitation medicine providers be knowledgeable about the complex medical and rehabilitation management for patients with AFM.

A cost-aware framework for the development of AI models for healthcare applications.

Accurate artificial intelligence (AI) for disease diagnosis could lower healthcare workloads. However, when time or financial resources for gathering input data are limited, as in emergency and critical-care medicine, developing accurate AI models, which typically require inputs for many clinical variables, may be impractical. Here we report a model-agnostic cost-aware AI (CoAI) framework for the development of predictive models that optimize the trade-off between prediction performance and feature cost. By using three datasets, each including thousands of patients, we show that relative to clinical risk scores, CoAI substantially reduces the cost and improves the accuracy of predicting acute traumatic coagulopathy in a pre-hospital setting, mortality in intensive-care patients and mortality in outpatient settings. We also show that CoAI outperforms state-of-the-art cost-aware prediction strategies in terms of predictive performance, model cost, training time and robustness to feature-cost perturbations. CoAI uses axiomatic feature-attribution methods for the estimation of feature importance and decouples feature selection from model training, thus allowing for a faster and more flexible adaptation of AI models to new feature costs and prediction budgets.

Using Motion Analysis in the Evaluation, Treatment & Rehabilitation of Pediatric & Adolescent Knee Injuries: A Review of the Literature.

Three-dimensional motion capture systems may improve evaluation, treatment, and rehabilitation of knee injuries, because quantitative assessment of the knee improves understanding of biomechanical mechanisms. The benefit of using motion analysis in pediatric sports medicine is that it allows closer and more focused evaluation of sports injuries using kinematics, kinetics, and electromyogram with physical and imaging to determine what is happening dynamically during sports. Future research investigating knee injuries should focus on identifying risk factors, assessing the effectiveness of surgical and nonsurgical interventions, and developing return to sport/rehabilitation protocols. The literature is focused on motion capture in adults with knee injuries.

Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine.

BACKGROUND: Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation. METHODS: This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts. RESULTS: During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = -2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = -6.8%, 95% CI = -18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = -46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = -33%, 95% CI = -100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001). CONCLUSIONS: Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.

Ten Steps to Improve Cardiac Arrest Survival in Your Community.

Creating a system of care for out of hospital cardiac arrest (OHCA) is not a simple task. It must be a multifaceted approach that encompasses a variety of teams from call takers, to bystanders, to emergency medical service (EMS) personnel, to hospital personnel. All of these teams must line up and perform their individual task successfully to yield a survivor of OHCA and return a loved one to his or her family. Various best practices have been collected and are highlighted here. Implementation of these concepts in one's system of care for OHCA will not be easy but will result in a greater number of survivors returning to their family in the community.

Emerging and Future Technologies in Out-of-Hospital Cardiac Arrest Care.

The care for victims of out-of-hospital cardiac arrest is evolving and will be influenced by future and emerging technologies that will play a role in the systems of care for these patients. Recent advances in extracorporeal life support and point-of-care ultrasound imaging, both in-hospital and out-of-hospital, may offer a therapeutic solution in some systems for patients with refractory or recurrent cardiac arrest. Drones capable of delivering automated external defibrillators to the scene of an out-of-hospital cardiac arrest, advances in digital and mobile technologies to notify and leverage bystander response, and wearable life detection technologies may improve survival.

Short-Term Perioperative Complications and Mortality After Total Ankle Arthroplasty in the United States.

This study sought to identify patient and operative demographics associated with 30-day perioperative complications in patients undergoing total ankle arthroplasty as recorded in the National Surgical Quality Improvement Project database. Complications were divided into local and systemic and further subcategorized as major and minor. A total of 404 patients underwent total ankle arthroplasty between 2007 and 2014 as captured in the National Surgical Quality Improvement Project database. The overall complication rate was 2.4% with 0.5% mortality and 0.2% infection rate. Length of hospital stay, both as an end point at >5 days and as a continuous variable, was associated with overall complications (odds ratio [OR] = 9.90, P = .002 and OR = 1.52, P = .006, respectively). Patient characteristics that predicted perioperative morbidity included presence of 3 or comorbidities (OR = 8.48, P = 0.038), American Society of Anesthesiologists class III, and history of previous cardiac surgery (OR = 12.22, P = .033). Correct patient selection is imperative in achieving improved outcomes and those that are at risk for complications should be counseled as such. LEVELS OF EVIDENCE: Level III: Database case control study.

Prehospital Lactate Predicts Need for Resuscitative Care in Non-hypotensive Trauma Patients.

INTRODUCTION: The prehospital decision of whether to triage a patient to a trauma center can be difficult. Traditional decision rules are based heavily on vital sign abnormalities, which are insensitive in predicting severe injury. Prehospital lactate (PLac) measurement could better inform the triage decision. PLac's predictive value has previously been demonstrated in hypotensive trauma patients but not in a broader population of normotensive trauma patients transported by an advanced life support (ALS) unit. METHODS: This was a secondary analysis from a prospective cohort study of all trauma patients transported by ALS units over a 14-month period. We included patients who received intravenous access and were transported to a Level I trauma center. Patients with a prehospital systolic blood pressure ≤ 100 mmHg were excluded. We measured PLac's ability to predict the need for resuscitative care (RC) and compared it to that of the shock index (SI). The need for RC was defined as either death in the emergency department (ED), disposition to surgical intervention within six hours of ED arrival, or receipt of five units of blood within six hours. We calculated the risk associated with categories of PLac. RESULTS: Among 314 normotensive trauma patients, the area under the receiver operator characteristic curve for PLac predicting need for RC was 0.716, which did not differ from that for SI (0.631) (p=0.125). PLac ≥ 2.5 mmol/L had a sensitivity of 74.6% and a specificity of 53.4%. The odds ratio for need for RC associated with a 1-mmol/L increase in PLac was 1.29 (95% confidence interval [CI] [0.40 - 4.12]) for PLac < 2.5 mmol/L; 2.27 (1.10 - 4.68) for PLac from 2.5 to 4.0 mmol/L; and 1.26 (1.05 - 1.50) for PLac ≥ 4 mmol/L. CONCLUSION: PLac was predictive of need for RC among normotensive trauma patients. It was no more predictive than SI, but it has certain advantages and disadvantages compared to SI and could still be useful. Prospective validation of existing triage decision rules augmented by PLac should be investigated.

Lower-dose epinephrine administration and out-of-hospital cardiac arrest outcomes.

BACKGROUND: International guidelines recommend administration of 1 mg of intravenous epinephrine every 3-5 min during cardiac arrest. The optimal dose of epinephrine is not known. We evaluated the association of reduced frequency and dose of epinephrine with survival after out-of-hospital cardiac arrest (OHCA). METHODS: Included were patients with non-traumatic OHCA treated by advanced life support (ALS) providers from January 1, 2008 to June 30, 2016. During the before period, providers were instructed to give epinephrine 1 mg intravenously at 4 min followed by additional 1 mg doses every eight minutes to patients with OHCA with a shockable rhythm and 1 mg doses every two minutes to patients with a non-shockable rhythm (higher dose). On October 1, 2012, providers were instructed to reduce the dose of epinephrine treatment during out-of-hospital cardiac arrest (OHCA): 0.5 mg at 4 and 8 min followed by additional doses of 0.5 mg every 8 min for shockable rhythms and 0.5 mg every 2 min for non-shockable rhythms (lower dose). Patients with shockable initial rhythms were analyzed separately from those with non-shockable initial rhythms. The primary outcome was survival to hospital discharge with a secondary outcome of favorable neurological status (Cerebral Performance Category [CPC] 1 or 2) at hospital discharge. Multiple logistic regression modeling was used to adjust for age, sex, presence of a witness, bystander CPR, and response interval. RESULTS: 2255 patients with OHCA were eligible for analysis. Of these, 24.6% had an initially shockable rhythm. Total epinephrine dose per patient decreased from a mean ±â€¯standard deviation of 3.4 ±â€¯2.3 mg-2.6 ±â€¯1.9 mg (p < 0.001) in the shockable group and 3.5 ±â€¯1.9 mg-2.8 ±â€¯1.7 mg (p < 0.001) in the non-shockable group. Among those with a shockable rhythm, survival to hospital discharge was 35.0% in the higher dose group vs. 34.2% in the lower dose group. Among those with a non-shockable rhythm, survival was 4.2% in the higher dose group vs. 5.1% in the lower dose group. Lower dose vs. higher dose was not significantly associated with survival: adjusted odds ratio, aOR 0.91 (95% CI 0.62-1.32, p = 0.61) if shockable and aOR 1.26 (95% CI 0.79-2.01, p = 0.33) if non-shockable. Lower dose vs. higher dose was not significantly associated with favorable neurological status at discharge: aOR 0.84 (95% CI 0.57-1.24, p = 0.377) if shockable and aOR 1.17 (95% CI 0.68-2.02, p = 0.577) if non-shockable. CONCLUSION: Reducing the dose of epinephrine administered during out-of-hospital cardiac arrest was not associated with a change in survival to hospital discharge or favorable neurological outcomes after OHCA.

The impact of first responder turnout and curb-to-care intervals on survival from out-of-hospital cardiac arrest.

PURPOSE: Patients with out-of-hospital cardiac arrest (OHCA) more likely survive when emergency medical services (EMS) arrive quickly. We studied time response elements in OHCA with attention to EMS intervals before wheels roll and after wheels stop to understand their contribution to total time response and clinical outcome. METHODS: We analyzed EMS responses to OHCA from 2009-2014 in an urban, fire department based system. The Call-to-Care Interval, from call receipt to hands-on EMS care, was comprised of four time intervals: 1) call received to EMS notification (Activation), 2) EMS notification to vehicle wheels rolling (Turnout), 3) wheels rolling to arrival at scene (Travel), and 4) arrival at scene to hands-on EMS care (Curb-to-Care). We created a new time interval (On-Feet) comprised of the turnout and curb-to-care intervals. Using logistic regression, we evaluated whether the total EMS response interval and discrete time intervals were related to survival to discharge. RESULTS: Of 1,831 cases, 1,806 (98.6%) had complete information. The mean lengths for the intervals were 7.2±3.6min. (call-to-care), 58±39s (activation), 63±29s (turnout), 2.5±1.3min (travel), 2.4±1.6min (curb-to-care), and 3.5±1.7min (on-feet). After adjustment, "On Feet" interval was associated with OHCA survival (OR=0.91 [95% CI=0.83-1.00] for each additional minute). CONCLUSIONS: Turnout and curb-to-care intervals were half of the total response interval in our EMS system. Measurement should incorporate these two intervals to accurately characterize and possibly reduce the professional response interval.

Stakeholder Perceptions of Risk in Construction.

Safety management in construction is an integral effort and its success requires inputs from all stakeholders across design and construction phases. Effective risk mitigation relies on the concordance of all stakeholders' risk perceptions. Many researchers have noticed the discordance of risk perceptions among critical stakeholders in safe construction work, however few have provided quantifiable evidence describing them. In an effort to fill this perception gap, this research performs an experiment that investigates stakeholder perceptions of risk in construction. Data analysis confirms the existence of such discordance, and indicates a trend in risk likelihood estimation. With risk perceptions from low to high, the stakeholders are architects, contractors/safety professionals, and engineers. Including prior studies, results also suggest that designers have improved their knowledge in building construction safety, but compared to builders they present more difficultly in reaching a consensus of perception. Findings of this research are intended to be used by risk management and decision makers to reassess stakeholders' varying judgments when considering injury prevention and hazard assessment.

Measuring static seated pressure distributions and risk for skin pressure ulceration in ice sledge hockey players.

PURPOSE: To determine whether sledge hockey players with physical disability have higher average seated pressures compared to non-disabled controls. METHOD: Fifteen age-matched controls without physical disability and 15 experimental participants with physical disability were studied using a pressure mapping device to determine risk for skin pressure ulceration and the impact of cushioning and knee angle positioning on seated pressure distributions. RESULTS: Regardless of participant group, cushioning, or knee angle, average seated pressures exceeded clinically acceptable seated pressures. Controls had significantly higher average seated pressures than the disability group when knees were flexed, both with the cushion (p = 0.013) and without (p = 0.015). Knee extension showed significantly lower average pressures in controls, both with the cushion (p < 0.001) and without (p < 0.001). Placement of the cushion resulted in significantly lower average pressure in controls when knees were extended (p = 0.024) but not when flexed (p = 0.248). Placement of the cushion resulted in no difference in pressure (p = 0.443) in the disability group. CONCLUSIONS: Pressures recorded indicate high risk for skin ulceration. Cushioning was effective only in the control group with knees extended. That knee extension significantly lowered average seated pressures is important, as many sledge hockey players utilize positioning with larger knee flexion angles. Implications for Rehabilitation Ice sledge hockey is a fast growing adaptive sport. Adaptive sports have been associated with several positive improvements in overall health and quality of life, though may be putting players at risk for skin ulceration. Measured static seated pressure in sledges greatly exceeds current clinically accepted clinical guidelines. With modern improvements in wheelchair pressure relief/cushioning there are potential methods for improvement of elevated seated pressure in ice hockey sledges.