The diagnosis and management of seizures and status epilepticus in the prehospital setting

Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed.     

Emergency room management of trauma patients in Greece: Preliminary report of a national study

Aim of the study

The aim of this study was to record and to evaluate the epidemiology of trauma in Greece and to assess the quality of management provided for trauma patients in the emergency department in Greek hospitals.

Methods

The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. The representatives that responded positively, met with the Board of the society in succeeding meetings to establish the reporting form and the inclusion criteria. Inclusion criteria were defined as trauma patients requiring admission, transfer to a higher level center or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic data base and analyzed. The design of the study was prospective and observational.

Results

In total 8862 patients were included in the study in 12 months time. Of them 68.7% (n = 6084) were male, aged 41.8 ± 20.6 (mean ± S.D.) and 31.3% were female (n = 2778), aged 52.7 ± 24.1 (mean ± S.D.). The mean duration of treatment in the emergency room department was 1 h and 28 min. Of the total number of patients, 2312 (26.1%) were initially assessed and managed by a specialist and 6249 (70.5%) were initially assessed and managed by a resident.

Conclusions

Data from this study show that there is substantial room for improvement in the patient care in the emergency department following trauma. Further evaluation will be required to identify particular management patterns that can be readily altered.     

Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study

Objective

We aimed to identify how patient (age, sex, condition) and paramedic factors (sex, role) affected prehospital analgesic administration and pain alleviation.

Definitive airway management after pre-hospital supraglottic airway insertion: Outcomes and a management algorithm for trauma patients

Background

Prehospital airway management increasingly involves supraglottic airway insertion and a paucity of data evaluates outcomes in trauma populations. We aim to describe definitive airway management in traumatically injured patients who necessitated prehospital supraglottic airway insertion.

The effects of interprofessional education – Self-reported professional competence among prehospital emergency care nursing students on the point of graduation – A cross-sectional study

The aim of the study was to investigate whether interprofessional education (IPE) and interprofessional collaboration (IPC) during the educational program had an impact on prehospital emergency care nurses’ (PECN) self-reported competence towards the end of the study program. A cross-sectional study using the Nurse Professional Competence (NPC) Scale was conducted. A comparison was made between PECN students from Finland who experienced IPE and IPC in the clinical setting, and PECN students from Sweden with no IPE and a low level of IPC. Forty-one students participated (Finnish n = 19, Swedish n = 22). The self-reported competence was higher among the Swedish students. A statistically significant difference was found in one competence area; legislation in nursing and safety planning (p < 0.01). The Finnish students scored significantly higher on items related to interprofessional teamwork. Both the Swedish and Finnish students’ self-reported professional competence was relatively low according to the NPC Scale. Increasing IPC and IPE in combination with offering a higher academic degree may be an option when developing the ambulance service and the study program for PECNs.     

Duration of prehospital intubation is not a risk factor for development of early ventilator-associated pneumonia

Purpose

Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality among critically ill patients with trauma. Few VAP prevention strategies have been studied in the prehospital environment. The objectives of this study are to measure the association between duration of prehospital intubation and intubation location with subsequent incidence of early (within 5 days) VAP.

Materials and Methods

Single-center retrospective cohort study of all intubated adult (age ≥ 18 years) patients with trauma presenting to a 711-bed Midwestern Level I trauma center between January 2005 and December 2011 (n = 860).

Results

Thirty-five patients (6.4%) were diagnosed as having early VAP during the study period. Using multivariable logistic regression to adjust for age, injury severity score, and year (corresponding to VAP bundle implementation), the duration of intubation prior to hospital admission was not associated with subsequent diagnosis of VAP (adjusted odds ratio, 0.90 per hour; 95% confidence interval, 0.70-1.15). Location of intubation was similarly not associated with VAP.

Conclusions

Duration of prehospital intubation and intubation location were not different in patients with trauma who developed early VAP. Further prospective analyses should be conducted to better elucidate the effect of prehospital management on the development of traditionally in-hospital complications.     

Outcomes following out-of-hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity in Victoria,Australia

Background

While internationally reported survival from out-of-hospital cardiac arrest (OHCA) is improving, much of the increase is being observed in patients presenting to emergency medical services (EMS) in shockable rhythms. The purpose of this study was to assess survival and 12-month functional recovery in patients presenting to EMS in asystole or pulseless electrical activity (PEA).

Methods

The Victorian Ambulance Cardiac Arrest Registry was searched for adult OHCA patients presenting in non-shockable rhythms in Victoria, Australia between 1st July 2003 and 30th June 2013. We excluded patients defibrillated prior to EMS arrival and arrests witnessed by EMS. Twelve-month quality-of-life interviews were conducted on survivors who arrested between 1st January 2010 and 31st December 2012. The main outcome measures were survival to hospital discharge and 12-month functional recovery measured by the Extended Glasgow Outcome Scale (GOSE).

Results

A total of 38,378 non-shockable OHCA attended by EMS were included, of which 88.0% were asystole and 11.6% were PEA. Of the patients receiving resuscitation, survival to hospital discharge was 1.1% for asystole and 5.9% for PEA (p < 0.001), with no significant improvement observed over the 10 year study period. In survivors with 12-month follow-up data, the combined rate of death, vegetative state or lower severe disability was 66.7% (95% CI 41.0–80.0%) for asystole and 44.7% (95% CI 30.2–59.9%) for PEA.

Conclusion

Survival outcomes following OHCA with initial rhythms of asystole or PEA did not improve over the 10-year study period. Our findings indicate high rates of death within 12 months, and unfavourable functional recovery for survivors.     

Incidence of cross-border emergency care and outcomes of cardiopulmonary resuscitation in a unique European region

BACKGROUND: Emergency medical service (EMS) systems in Europe have developed differently due to legal, educational and organisational aspects. The aim of the present study was to compare cardiopulmonary resuscitation (CPR) outcomes and characteristics in three differently organised and staffed EMS systems in close vicinity. METHODS: We analysed the charts of patients treated in the EMS systems of the cities of Aachen (Germany), Heerlen (The Netherlands) and Eupen (Belgium), retrospectively. Main outcome measures were the rate of return of spontaneous circulation (ROSC), hospital discharge and cerebral performance after 1 year. Furthermore, factors influencing neurological outcome and the incidence of cross-border emergency assistance were assessed. RESULTS: Of 852 patients found unresponsive with no palpable pulse and/or the absence of breathing, CPR was performed in 322 patients. The overall rate of ROSC was 44.1 and 13.7% of patients were discharged alive. A good neurological outcome was observed in 95.5% of survivors. The rate of ventricular fibrillation was significantly higher (46.9% versus 21.9 and 21.2%, p < 0.05) and the total amount of epinephrine given during CPR significantly lower (4.5+/-5.2 mg versus 9.8+/-10.8 and 8.4+/-6.2 mg, p < 0.05) in the Dutch system. No significant differences in outcome variables were observed between the systems. Neurological outcome was favourable when the arrest was witnessed, occurred in a public place, the initial rhythm was shockable, a low total amount of adrenaline (epinephrine) was given and the call-response interval was short. In 1.2% of the cases cross-border emergency care was provided. CONCLUSIONS: Despite medical and organisational discrepancies, outcomes of CPR in three neighbouring EMS systems are comparable. Neurological outcome is influenced by demographical, organisational and medical factors. Cross-border emergency assistance for CPR is almost undetectable and needs improvement.     

The early chain of care in bacteraemia patients: Early suspicion,treatment and survival in prehospital emergency care

Introduction

Bacteraemia is a first stage for patients risking conditions such as septic shock. The primary aim of this study is to describe factors in the early chain of care in bacteraemia, factors associated with increased chance of survival during the subsequent 28 days after admission to hospital. Furthermore, the long-term outcome was assessed.

The demand for prehospital advanced life support and the appropriateness of dispatch in Taipei

INTRODUCTION: Implementing prehospital advanced life support (ALS) services requires more medical and societal resources in training and equipment. The actual demand for ALS services in our communities was not clear. To ensure good use of expensive resources, it is important to evaluate the demand and appropriateness of ALS services before full-scale implementation takes place. OBJECTIVE: To evaluate the rate and characteristics of demand for ALS, and the appropriateness of ALS dispatch of the emergency medical service (EMS) system in metropolitan Taipei City. METHODS: A retrospective, cross-sectional analysis of the EMS records of Taipei City Fire Department from April 1999 to December 2000 was conducted. Stratified random sampling of all EMS records in the second week of January, April, July and October of 2000 were obtained, along with the corresponding ALS dispatch records. Retrospective ALS demand criteria, including the chief complaints, mechanisms of injury/illness, initial vital signs and types of care rendered, were developed to estimate the rate of ALS demand. ALS demand is expressed as the percentage of cases fulfilling ALS criteria over the total number of EMS cases. Appropriate ALS dispatches were those ALS dispatches determined as fulfilling the ALS demand criteria. RESULTS: Among the sampled 5433 EMS cases, 490 (9.02%) were determined as a demand for ALS care. ALS demands varied from region to region, and were higher during winter months and afternoon rush hours. There were 175 actual ALS dispatches, accounting for 3.22% of the sampled EMS services. The triage performance was suboptimal: the appropriateness of ALS dispatch was 37.14%; the overtriage rate was 72.86%. CONCLUSION: Around nine percent of EMS calls demand ALS services. The current triage performance for proper ALS dispatch was suboptimal. A correct ALS dispatch protocol and more dispatcher training programmes should be established in the communities to ensure best use of valuable ALS resources.     

Characteristics and outcome of prehospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians

Aim

To collect data regarding prehospital paediatric tracheal intubation by emergency physicians skilled in advanced airway management.

Methods

A prospective 8-year observational study of a single emergency physician-staffed emergency medical service. Self-reporting by emergency physicians of all children aged 0–14 years who had prehospital tracheal intubation and were attended by either anaesthesia-trained emergency physicians (group 1) or by a mixture of anaesthesia and non-anaesthesia-trained emergency physicians (group 2).

Results

Eighty-two out of 2040 children (4.0%) had prehospital tracheal intubation (58 in group 1). The most common diagnoses were trauma (50%; in school children, 73.0%), convulsions (13.4%) and SIDS (12.2%; in infants, 58.8%). The overall tracheal intubation success rate was 57 out of 58 attempts (98.3%). Compared to older children, infants had a higher number of Cormack–Lehane scores of 3 or 4, “difficult to intubate” status (both 3 out of 13; 23.1%) and a lower first attempt success rate for tracheal intubation (p = 0.04). Among all 82 children 71 (86.6%) survived to hospital admission and 63 (76.8%) to discharge. Of the 63 survivors, 54 (85.7%) demonstrated a favourable or unchanged neurological outcome (PCPC 1–3). The survival and neurological outcomes of infants were inferior compared to older children (p < 0.001). On average an emergency physician performed one prehospital tracheal intubation in 3 years in a child and one in 13 years in an infant.

Conclusions

Anaesthesia-trained emergency physicians working in our system report high success rates for prehospital tracheal intubation in children. Survival and neurological outcomes were considerably better than reported in previous studies.     

创伤协调护士的发展现状及启示

介绍创伤协调护士的产生背景、定义、任职资格、职责范畴,分析创伤协调护士发展面临的机遇和挑战,提出发展中国创伤协调护士的建议：认为中国应该借鉴创伤协调护士发展的成功经验,建立科学规范的培训模式和资格认证制度,完善岗位设置和运行机制,以提升创伤救治能力,应对创伤救治服务模式改革带来的挑战。     

Beyond the pre-shock pause: the effect of prehospital defibrillation mode on CPR interruptions and return of spontaneous circulation

Aims

The pattern of interruptions to chest compressions in pre-hospital cardiac arrests in Wellington, New Zealand, was examined prospectively to determine whether the mode of defibrillation chosen by paramedics influenced interruptions, shock success and the return of spontaneous circulation (ROSC).

Methods

A prospective observational cohort study of 44 adult cardiac arrests in which 203 shocks were administered by Wellington Free Ambulance (WFA) paramedics was undertaken to compare Code-stat^® electronic records from Medtronic^® Lifepak 12 and Lifepak 15 defibrillators used in semi-automated (AED) or manual mode. Interruptions during the 30 s prior to shock delivery as well as pre-shock and post-shock pauses were calculated. Shock success and ROSC were the outcome measures.

Results

Pre-shock pauses were shorter in manual mode (median 3 s, IQR 2–5) versus AED mode (median 4 s, IQR 3–6; p = 0.003). Interruptions of CPR in the 30 s prior to shock delivery were also shorter in manual mode (median 7 s, IQR 4–11) versus AED mode (median 14 s, IQR 12–16; p = <0.001). Shock success rates and post-shock pauses were not statistically different between modes. ROSC was significantly higher in manual mode (18.49%) versus AED mode (8.33%, p = 0.042).

Conclusion

When paramedics used the defibrillator in manual mode as compared to AED mode, interruptions to CPR during the 30 s prior to shock delivery were significantly reduced and pre-shock pauses were also shorter. This was associated with increased ROSC. Manual defibrillation should be the preferred option for appropriately trained paramedics. Training in this locality has been changed accordingly.     

The Toronto prehospital hypertonic resuscitation--head injury and multiorgan dysfunction trial: feasibility study of a randomized controlled trial

Objective

The aim of the study was to evaluate the feasibility of a prehospital trial comparing hypertonic saline and dextran (HSD) with normal saline (NS) in blunt head injury patients.

Design

The study used a double blind randomized trial.

Setting

The study was conducted in air and land emergency medical services and 2 trauma centers serving a population of 4 million people.

Patients

The study population consisted of head injured, blunt trauma adult patients with a Glasgow Coma Scale of lower than 9.

Interventions

We used 250 mL of HSD vs NS given within 4 hours of the accident.

Measurements

The specific objectives were to assess protocol-related logistical issues, randomization, HSD safety, and follow up rates and to obtain survival and neurocognitive end point estimates.

Main Results

Of 132 eligible patients, 113 were randomized. Nineteen eligible patients were missed because of lack of time (9 [22%]), paramedic discretion (3 [7%]), the paramedic forgot (6 [15%]), and the paramedic refused (1 [2%]). Randomization compliance was 96% (109/113). Four randomized cases met exclusion criteria: penetrating trauma (1), cardiac arrest (2), and fall from standing (1). Three randomized patients were excluded from the final analysis: 2 patients received less than 50 mL of study solution due to an interstitial intravenous line and 1 lost randomization identification. Fifty patients (47%) were randomized to HSD and 56 (53%) to NS. Mean injury severity score was 32.7 for HSD and 32.6 for NS. There was no difference in length of stay, Sequential Organ Failure Assessment maximum, Multiple Organ Dysfunction Score maximum, delta Multiple Organ Dysfunction Score, or Apache scores. Initial head scans scored 3 or higher by Marshall classification for 12 HSD and 11 NS patients. Zero adverse events occurred, and follow-up for the primary outcome was 100%. Alive at 30 days for HSD and NS, respectively, was 70% (35/50) and 75% (42/56) and at discharge was 68% (34/50) and 73% (41/56). Only 49.3% (37/77) of surviving patients consented to follow-up at 4 months and 89% (33/37) completed the assessment. Disability rating scale (median, interquartile range) was 3 (0, 6) for HSD and was 0 (0, 6) for NS. Glasgow Outcome Scale Evaluation was higher than 4 for HSD (12/12 [100%]) and NS (15/21 [72%]). Functional Independence Measure (mean, SD) was 62 (37) for HSD and 80 (32) for NS.

Conclusions

It is feasible to conduct a prehospital randomized controlled trial with HSD for treatment of blunt trauma patients with head injuries; however, consent for neurofunctional outcomes in this cohort is problematic and threatens the feasibility of definitive trials using these potentially meaningful end points.