EMS Medical Direction and Prehospital Practices for Acute Cardiovascular Events

Prehospital Emergency Care, Posted online on August 22, 2012.

The purpose of this analysis was to determine whether there is an association between type of emergency medical services (EMS) medical direction and local EMS agency practices and characteristics specifically related to emergency response for acute cardiovascular events.  For each cardiovascular prehospital procedure or practice in the 1,292 EMS agencies in nine US states, the authors compared the proportion of agencies that employed paid (full- or part-time) medical directors with the proportion of agencies that employed volunteer medical directors. The proportion of EMS agencies who reported direct interaction between emergency medical technicians (EMTs) and their medical director within the previous four weeks with the proportion of agencies who reported no direct interaction was also compared.

The study demonstrated that EMS agencies with a paid medical director and agencies with medical director interaction with EMTs in the previous four weeks were more likely to have prehospital cardiovascular procedures in place. Given the strong relationship that both employment status and direct interaction have with the presence of these practices, agencies with limited resources to provide a paid medical director or a medical director that can be actively involved with EMTs should be supported through partnerships and other interventions to ensure that they receive the necessary levels of medical director oversight.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.710718

Ondansetron Oral Dissolving Tablets are Superior to Normal Saline Alone for Prehospital Nausea

Prehospital Emergency Care, Vol. 16, No. 4, Pages 463-468

While simply on a common sense approach this does seem to be a study that would prove beneficial for the argument for antiemetics , the authors state that while antiemetics have been shown to be effective in multiple hospital settings, but few studies have been done in the prehospital environment.

The authors hypotheses was that the amount of normal saline administered during an emergency medical services (EMS) transport was not related to a change in nausea and vomiting and that the addition of the ondansetron orally disintegrating tablet (ODT) would decrease the degree of nausea.

Data were collected from 274 transports in phase 1 (saline only) and 372 transports in phase 2(post introduction of ondansetron). In phase 1 of the study, 178 of 274 patients (65%) received normal saline (mean volume ± standard deviation = 265 ± 192 mL). There was no significant correlation between the nausea visual analog scale change and the amount of fluid administration in either phase of the study. Conversely, during phase 2, patients receiving ondansetron ODT showed significant improvement in both measures of nausea. The difference in nausea improvement between phase 1 and phase 2 was significant (difference in VAS change: 24.6; 95%).

The authors found that there was no improvement in patient nausea related to quantity of saline alone during an EMS transport, but the addition of ondansetron ODT resulted in a significant improvement in degree of nausea.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.695430

Barriers to and Enablers for Prehospital Analgesia for Paediatric Patients

Prehospital Emergency Care, Vol. 16, No. 4, Pages 519-526 

This study aimed to identify and investigate the barriers and enablers perceived by paramedics regarding the administration of analgesia to paediatric emergency medical services (EMS) patients.

Thirteen of 16 paramedics reported success with analgesia in children at least once in their careers. Provider anxiety, unfamiliarity and discomfort with paediatrics, unfamiliarity with the protocol, insufficient didactic and clinical education, and concern for adverse effects from analgesic agents were perceived as barriers to paediatric pain management. The paramedics had differing beliefs about the importance of pain control, the role of parents in medical care for children, and the paramedic’s ability to assess paediatric patients. Having a positive relationship with online medical control and using commercially available assistive guides were viewed as enablers for paediatric pain management.

The response from paramedic supervisors and emergency department staff, unwanted attention from authority figures, perceived superiority of hospital care, difficulty obtaining intravenous access, and overall culture of stinginess in medication administration played important roles in an overall preference to defer paediatric analgesia. Some paramedics mentioned a specific experience or mentoring relationship with a more seasoned provider who taught them the importance of pain management. Paramedics reported various effects of transport distance on their decision to administer analgesia.

The authors identified a number of previously unrecognised barriers to and enablers for prehospital paediatric analgesia, with the majority of these factors leading to an overall preference of paramedics to defer administration of analgesic agents. According to the authors, changes to the educational and EMS system may be required to address these barriers and increase the frequency of appropriate paediatric prehospital analgesia.
http://informahealthcare.com/doi/abs/10.3109/10903127.2012.695436

Feasibility of Continuous Positive Airway Pressure by Primary Care Paramedics

Prehospital Emergency Care, Vol. 16, No. 4, Pages 535-540

Continuous positive airway pressure (CPAP) has been used effectively in the prehospital environment for a wide range of respiratory emergencies but the authors felt that the feasibility of CPAP when used by basic life support level care providers (denoted as primary care paramedics – PCPs) in comparison with advanced care paramedics (ACPs) has not been established.

An observational study of 302 consecutive cases of CPAP use over one year beginning June 25, 2009 was studied. Compliant use was defined as 100% adherence to the provincial CPAP medical directive, including specifics of patient presentation, vital signs, and appropriate documentation by the paramedic, as well as proper use, titration, and discontinuation of CPAP equipment according to protocol.

Using the criteria set out for compliant CPAP use, the highest level of compliance among the ACPs and the PCPs was 98.6% and 98.9%, respectively, for documenting indication for CPAP use. The lowest level of compliance among the ACPs was 84.4% for titration of CPAP during treatment, and the lowest level of compliance among the PCPs was 90% for adherence to criteria for CPAP application according to patients’ vital signs. Overall, the criteria for compliant use of CPAP were met for 76.8% (232/302) of the call reports examined. The rate of compliant use of CPAP was 75.9% for ACP calls and 78.9% for PCP calls.

This study found no significant difference in the compliant use of prehospital CPAP between paramedics trained to the PCP level and those trained to the ACP level. This study suggests that CPAP use by basic life support level paramedics/ care providers may be feasible.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.689930

Prehospital Emergency Care, Vol. 16, No. 4, Pages 513-518 

The purpose of this study was to describe potential adverse effects associated with spinal immobilisation following trauma among children seen at St. Louis Children’s Hospital.  Children were eligible if they underwent spinal immobilisation prior to physician evaluation or if they met the American College of Surgeons (ACS) guidelines for spinal immobilisation but were not immobilised. The children who were immobilised were compared with those who were not immobilised for self-reported pain, use of radiography to evaluate the cervical spine, ED length of stay, and ED disposition.

One hundred seventy-three spine-immobilised children and 112 children who met ACS criteria but were not immobilised were enrolled. There were differences between the two study groups, which included age, mechanism of injury, and proportion transported by emergency medical services. However, the comparison groups had comparable Pediatric Trauma Scores (PTSs) and Glasgow Coma Scale scores (GCSs). Immobilised children had a higher median pain score (3 versus 2) and were more likely to undergo cervical radiography (56.6% versus 13.4%) and be admitted to the hospital (41.6% versus 14.3%).

The authors concluded that despite presenting with comparable PTSs and GCSs, children who underwent spinal immobilisation following trauma had a higher degree of self-reported pain, and were much more likely to undergo radiographic cervical spine clearance and be admitted to the hospital than those who were not immobilised, however, future studies are required to determine whether these differences are related to spinal immobilisation or differences in the mechanisms of injury, injury patterns, or other variables.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.689925

Multivariate Analysis of Successful Intravenous Line Placement in the Prehospital Setting

Prehospital Emergency Care, Posted online on August 22, 2012.

Intravenous (IV) line placement is an important prehospital advanced life support skill, but IV success rates are variable among providers. For those who want to improve their success rates the answer may be simply increasing the size of the IV cannula you are using.

The authors aimed to identify whether first-pass IV success was associated with the number of attempted or successful previous IV attempts – they hypothesized that IV success is associated with the number of successful IV placements in the preceding year. 800 consecutive charts with an IV attempt from 11 suburban and rural emergency medical services (EMS) agencies over a one-month period were analysed, with success of the first IV attempt identified. Potential predictor variables were collected and analysed, including patient age, systolic blood pressure, history of IV drug abuse or renal disease, traumatic event, catheter size, and location of IV attempt, as well as the individual provider’s numbers of total and successful IV attempts in the preceding year.

Of 602 cases meeting the study criteria, 469 (77.9%) had a successful first-pass IV placement. Significantly associated with IV success in the univariate regression were patient age, trauma, IV catheter size, IV location, and the number of previous successful IV attempts. In the multivariate logistic regression model, however, only IV catheter size had a significant association, with a larger-bore IV catheter size associated with higher success.

The authors concluded that in this retrospective study, larger IV catheter size, but not the prehospital providers’ previous years’ experience, was associated with successful IV placement in adult patients and that the data fail to support requirements for a minimum number of yearly IV placements by full-time paramedics to improve success rates.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.710717

The Emergency Department Experience with Prehospital Ketamine: A Case Series of 13 Patients

Prehospital Emergency Care, Vol. 16, No. 4, Pages 553-559

In order to better understand the risk–benefit ratio for the prehospital use of ketamine, the authors examined the emergency department (ED) courses of 13 patients to whom emergency medical services (EMS) had administered ketamine for chemical restraint.  Time from ketamine administration to peak sedation was <5 minutes in 11 patients and 20 minutes for two patients.

On emergency physician examination, five of 12 patients had Richmond Agitation Sedation Scale (RASS) scores of –5 (unarousable), one of 12 had a RASS score of –4 (deep sedation), four of 12 had RASS scores of –3 (moderate sedation), and two of 12 had RASS scores of –2 (light sedation). Three patients developed hypoxia, two in the ED and one prior to hospital arrival. Two of these patients required intubation and one was treated with jaw thrust. Indications for intubation were recurrent laryngospasm and intracranial bleeding. One additional patient experienced a single episode of hypersalivation, which was successfully treated with suctioning of the oropharynx. Of the nonintubated patients, three of 10 were diagnosed with an emergence reaction and five of 10 required additional sedation. The primary diagnosis on ED disposition was drug/ethanol intoxication (3), psychosis (4), intracranial bleeding (1), seizure (1), suicidal ideation (1), agitation (1), and altered mental status (1).

In these 13 patients, ketamine produced moderate or deeper sedation and respiratory complications included hypoxia, laryngospasm, and hypersalivation. Emergence reactions occurred in 30% of nonintubated patients, but they were successfully treated with small doses of benzodiazepines.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.695434

Prehospital Emergency Care, Vol. 16, No. 4, Pages 571-571 

The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) believe that emergency medical services (EMS) systems should have protocols that allow EMS providers to terminate resuscitative efforts for certain adult patients in traumatic cardiopulmonary arrest. The guidelines suggest key points that should be contained in a termination of resuscitation protocol or guideline including emphasis on evacuation to definitive care; a specific period of time resuscitation should be attempted, support services available for the patient’s family and exception requirements for when termination is not appropriate.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.695857

Prehospital Emergency Care, Vol. 16, No. 4, Pages 451-455

Despite accepted termination-of-resuscitation criteria existing, many patients are transported to hospitals without achieving field return of spontaneous circulation (ROSC) which opens the suggestion to whether emergency medical services (EMS) should convey patients without ROSC.

The researchers examined field ROSC influence on OHCA survival to hospital discharge in two large urban EMS systems – San Antonio Fire Department and Cincinnati Fire Department.  A retrospective analysis of prospectively collected data was conducted for all attempted resuscitations of medical OHCA and cardiac OHCA for San Antonio and Cincinnati, respectively, from 2008 to 2010. A total of 2,483 resuscitation attempts were evaluated and while age and gender distributions were similar between cities, ethnic profiles differed. Cincinnati had 17% more patients with an initial shockable rhythm and was more likely to initiate transport before field ROSC. Overall survival to hospital discharge was 165 of 2,483 (6.6%). More than one-third (894 of 2,483, 36%) achieved field ROSC. Survival with field ROSC was 17.2% (154 of 894) and without field ROSC was 0.69% (11 of 1,589). Of the 11 survivors transported prior to field ROSC, nine received defibrillation by EMS. No asystolic patient survived to hospital discharge without field ROSC and the researchers concluded that survival to hospital discharge after OHCA is rare without field ROSC.

The article suggests that resuscitation efforts should focus on achieving field ROSC and transport should be reserved for patients with field ROSC or a shockable rhythm, however, the authors recognise that both of the datasets fail to include some or part of important time intervals, including response time, time spent on scene, and time from dispatch to hospital arrival and that response times may be a reason for the differing rates of VF/VT rhythms. While this article provides evidence to termination of resuscitation procedures, it is also suggests that compliance with such a procedure should not be mandatory but that transportation decision should always be made on the whole clinical picture.

http://informahealthcare.com/doi/abs/10.3109/10903127.2012.695435