Prehospital use of activated charcoal: A pilot study

Activated charcoal (AC) is most effective when administered soon after the ingestion of certain substances. Delays are recognized to occur at times in the administration of AC after arrival of poisoned patients in the emergency department (ED). In addition, it has been recognized that these delays may be avoided if AC administration is begun in selected patients by paramedics while en route to the ED. We present a pilot study evaluating the administration of AC to poisoned patients in the ambulance prior to arrival in the ED. We performed a retrospective review of Emergency Medical System (EMS) run sheets and ED records of poisoned patients during a 6-month period from two area hospitals. Cases were identified that met criteria for the prehospital administration of AC. Cases were divided into two groups: those who received prehospital AC, and those who did not. Groups were compared for ambulance transport time, time from first paramedic contact to AC administration, and whether AC was tolerated by the patient. A total of 14 patients received prehospital AC (group 1). This group was compared to 22 cases that would have qualified under County protocol to receive prehospital AC, but for whatever reason did not (group 2). Group 2 patients all received AC after arriving in the ED. Average ambulance transport times did not statistically differ among groups. The average time from first encounter with paramedics to administration of AC was 5.0 minutes when AC administration was given in the ambulance as compared to 51.4 minutes when delayed until arrival in the ED. Tolerance was similar among the groups. The time to initiate AC administration may be significantly shortened when begun by prehospital personnel. All EMS should consider including AC in protocols addressing the prehospital management of certain poisoned patients.     

Prevalence of Aspirin Use among Patients Calling 9-1-1 for Chest Pain

Abstract. Objective: Early aspirin administration during an acute myocardial infarction (AMI) decreases morbidity and mortality. This investigation examined the extent to which patients with a complaint of chest pain, the symptom most identified with AMI by the general population, self-administer aspirin before the arrival of emergency medical services (EMS) personnel.
Methods: In this prospective, cross-sectional prevalence study, data were derived through the analysis of EMS incident reports for patients with a complaint of chest pain from June 1, 1997, to August 31,1997.
Results: The study included 694 subjects. One hundred two (15%) took aspirin for their chest pain before the arrival of EMS personnel. Of the 322 subjects who reported taking aspirin on a regular basis, 82 (26%) took additional aspirin for their acute chest pain. Only 20 (5%) of the 370 patients who were not using regular aspirin therapy self-administered aspirin acutely (p < 0.001). In addition, patients with lower intensity of chest pain (p = 0.03) were more likely to take aspirin for their chest pain.
Conclusion: Only a relatively small fraction of individuals calling 9-1-1 with acute chest pain take aspirin prior to the arrival of EMS personnel. These individuals are more likely to self-administer aspirin if they are already taking it on a regular basis. It is also possible that they are less likely to take aspirin if their chest pain is more severe.     

A CUTE C ORONARY S YNDROME : P HARMACOTHERAPY

Acute coronary syndrome (ACS) refers to the spectrum of cardiac disease, from unstable angina to ST-segment-elevation myocardial infarction. In the emergency medical services (EMS) setting, ACS may be more broadly thought to include patients with chest pain or other symptoms believed to have a cardiac origin who have evidence of ischemia or acute myocardial infarction on a 12-lead electrocardiogram, or symptomatic patients with a previous cardiac event or known cardiac disease. Pharmacologic management of these patients is based on the use of three primary classes of drugs: those that affect clotting, those that establish and maintain hemodynamic control, and those that relieve pain. Many of these agents have been evaluated in large clinical trials for in-hospital use, and a number of ongoing studies are assessing their efficacy in the prehospital setting. The appropriateness of prehospital use of specific agents within each class depends on proper patient selection, the necessity of immediate intervention, ease of use in the field, expertise of EMS personnel, and cost-effectiveness of therapy. This consensus group reviewed agents from all three classes (including aspirin, GPIIb/IIIa inhibitors, unfractionated and low-molecular-weight heparins, fibrinolytics, beta-adrenergic blockers, calcium antagonists, nitrates, and morphine) for their overall indication, applicability to the prehospital setting, and current prehospital use.     

Potential time savings by prehospital administration of activated charcoal

Objective. Activated charcoal (AC) has been proven useful in many toxic ingestions. Theoretically, administration of AC in the prehospital environment could save valuable time in the treatment of patients who have sustained potentially toxic oral ingestions. The purpose of this study was to determine the frequency of prehospital AC administration and to identify time savings that could potentially result from field AC administration.

Methods. Adult patients with a chief complaint of toxic ingestion who had complete emergency medical services (EMS) and emergency department (ED) records and no medical treatment (gastric emptying, AC administration) prior to EMS arrival were eligible for inclusion. Data obtained from EMS and ED records included time of EMS departure from the scene, time of EMS arrival at the ED, and time of administration of AC in the ED. Since most EMS agencies in this system do not insert gastric tubes, patients requiring gastric tube placement for administration of AC were excluded.

Results. Twenty-nine of 117 (24.8%) adult patients received oral AC with no other intervention. None of the 117 patients received AC in the prehospital setting. The EMS transport time for these patients ranged from 5 to 43 minutes (mean 16.2 ± 9.7 minutes). The delay from ED arrival to AC administration ranged from 5 to 94 minutes (mean 48.8 ± 24.1 minutes), and was more than 60 minutes for 14 (48.2%) of the patients. The total time interval from scene departure to ED AC administration ranged from 17 to 111 minutes (mean 65.0 ± 25.9 minutes). Conclusions. In a selected subset of patients who tolerate oral AC, prehospital administration of AC could result in earlier and potentially more efficacious AC therapy. Prospective study of the benefits and feasibility of prehospital AC administration is indicated.     

Community Implementation of a Prehospital Spinal Immobilization Guideline

Objective: The purpose of this study was to qualitatively describe the underpinnings of the successful implementation of a collaborative prehospital spinal immobilization guideline throughout the emergency medical services (EMS) community in two counties in Colorado. We also describe lessons learned that may be beneficial to other communities considering similar initiatives. Methods: Qualitative data were collected from key informants who were directly involved in the implementation of a new prehospital spinal immobilization guideline among four community hospitals in two different hospital systems and the associated EMS providers within the two counties. We interviewed a purposively selected sample of emergency department (ED) physicians and other ED staff, hospital decision makers, EMS educators as well as fire department and EMS medical directors. Data were collected and reviewed until saturation was achieved. We conducted qualitative analysis to summarize and synthesize themes. Results: Ten key informants were interviewed, at which point saturation was achieved and several clear themes emerged. Participants described successful community-wide guideline implementation despite a history of competition, isolation, and conflict between the various EMS organizations and hospitals on past EMS and trauma initiatives. Factors related to success included the nearly universal perception that the initiative was “cutting edge” and thus an important paradigm shift in care for the community, as a whole. Participants reported the ability of community stakeholders to jointly assure a collaborative approach, characterized by intensive education for EMS personnel and others involved, and the ability of the community to together secure the new equipment required for success. Conclusions: Key informants described a convergence of factors as leading to the successful implementation of a prehospital spinal immobilization guideline. Lessons learned regarding how to overcome a tradition of competition and isolation to allow for success may be useful to other communities considering similar initiatives.     

Therapeutic agents utilized in urban/rural prehospital care

INTRODUCTION: Objectives of this study were to determine the number of prehospital emergency patients who were given advanced life support (ALS) drugs and to compare utilization rates for ALS drugs in urban and rural environments. Certified ALS emergency medical technicians (Arizona) have 29 therapeutic agents authorized for prehospital administration. These agents may be administered only under direction of a medical control authority or by following standing orders. METHODS: A retrospective review was made of prehospital emergency encounter records. They were acquired by the Arizona Office of Emergency Medical Services (OEMS) from rural EMS providers who used optically scannable forms and from a metropolitan fire department's medical emergency response records. RESULTS: In 1989 and 1990, 273,611 emergency patient encounter records were entered into the EMS database; 197,260 were urban responses and 76,351 were rural responses. Drugs (ALS) were administered to 16,730 (8.5%) urban emergency patients and to 5,359 (7%) rural emergency patients at the incident site or during transport to a medical care facility. Nitrostat, 0.4 mg sublingual tablet, was the drug most frequently administered to emergency patients in the prehospital setting. Utilization rates found in the urban and the rural data sets were consistent for the individual agents. Variations in use frequency between urban and rural setting were noted for some drugs. Of the 29 approved ALS drugs, seven (24%) were administered to 10% or more urban patients who received drugs. In the rural areas, eight (27.6%) were administered to 10% or more patients who received drugs. There were nine (31%) agents administered to less than 1% of all patients who received drugs. A majority of the approved drugs, 17 (59%) were administered at a rate below 5% of all patients receiving medications. CONCLUSION: Severity of illness or injury prompted administration of ALS drugs to 8.1% of patients receiving prehospital emergency care. The most frequently utilized medication in the urban/rural areas was for treatment of cardiac symptoms. Variations between urban/rural drug utilization reflected the drugs of choice which are compatible with long transport times to a medical facility.     

Valproic acid poisoning: an evidence-based consensus guideline for out-of-hospital management

A review of US poison center data for 2004 showed over 9000 ingestions of valproic acid. A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected ingestion of valproic acid by 1) describing the process by which an ingestion of valproic acid might be managed, 2) identifying the key decision elements in managing cases of valproic acid ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to the acute ingestion and acute-on-chronic ingestion of immediate-release and extended-release dosage forms of valproic acid, divalproex, and valproate sodium alone. Co-ingestion of additional substances could require different referral and management recommendations depending on the combined toxicities of the substances. This review focuses on the ingestion of more than a single therapeutic dose and the effects of an overdose. Although therapeutic doses of valproic acid can cause adverse effects in adults and children, some idiosyncratic and some dose-dependent, these cases are not considered. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions might be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in whom a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) Patients who are symptomatic (more than somnolence or exhibiting coma or seizures) after a valproic acid ingestion should be referred to an emergency department (Grade C). 3) Asymptomatic patients with an unintentional acute ingestion of 50 mg/kg or more or asymptomatic patients who are taking the drug therapeutically and who take an additional single acute ingestion of 50 mg/kg or more of any valproic acid formulation should be referred to an emergency department for evaluation (Grade C). 4) Patients with unintentional ingestions of immediate-release valproic acid formulations, who are asymptomatic, and more than 6 hours has elapsed since the time of ingestion, can be observed at home (Grade C). 5) Patients with unintentional ingestions of delayed-release or extended-release formulations of valproic acid who are asymptomatic, and more than 12 hours has elapsed since the time of ingestion, can be observed at home (Grade C). 6) Pregnant women who ingest below the dose for emergency department referral and do not have other referral conditions should be directed to their primary care obstetrical provider for evaluation of potential maternal and fetal risk. Routine referral to an emergency department for immediate care is not required (Grade D). 7) Do not induce emesis (Grade C). 8) Activated charcoal can be administered to asymptomatic patients who have ingested valproic acid within the preceding hour (Grade C). Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Poison centers should follow local protocols and experience with its use. Do not delay transportation in order to administer activated charcoal (Grades D). 9) In patients who have ingested valproic acid and who are comatose, naloxone can be considered for prehospital administration in the doses used for treatment of opioid overdose, particularly if the patient has respiratory depression (Grade C). 10) A benzodiazepine can be administered by EMS personnel if convulsions are present and if authorized by EMS medical direction, expressed by written treatment protocol or policy, or if there is direct medical oversight (Grade C).     

The role of EMS systems in public health emergencies

INTRODUCTION: Until now, the public health response to the threat of an epidemic has involved coordination of efforts between federal agencies, local health departments, and individual hospitals, with no defined role for prehospital emergency medical services (EMS) providers. METHODS: Representatives from the local health department, hospital consortium, and prehospital EMS providers developed an interim plan for dealing with an epidemic alert. The plan allowed for the prehospital use of appropriate isolation procedures, prophylaxis of personnel, and predesignation of receiving hospitals for patients suspected of having infection. Additionally, a dual notification system utilizing an EMS physician and a representative from the Office of Infectious Diseases from the hospital group was implemented to ensure that all potential cases were captured. Initially, the plan was employed only for those cases arising from the Centers for Disease Control and Prevention (CDC)/Public Health Service (PHS) quarantine unit at the airport, but its use later was expanded to include all potential cases within the 9-1-1 system. RESULTS: In the two test situations in which it was employed, the plan incorporating the prehospital EMS sector worked well and extended the "surveillance net" further into the community. During the Pneumonic Plague alert, EMS responded to the quarantine facilities at the airport five times and transported two patients to isolation facilities. Two additional patients were identified and transported to isolation facilities from calls within the 9-1-1 system. In all four isolated cases, Pneumonic Plague was ruled out. During the Ebola alert, no potential cases were identified. CONCLUSIONS: The incorporation of the prehospital sector into an already existing framework for public health emergencies (i.e., epidemics), enhances the reach of the public safety surveillance net and ensure that proper isolation is continued from identification of a possible case to arrive at a definitive treatment facility.     

Vital signs records omissions on prehospital patient encounter forms

INTRODUCTION: A reported in-field, prospective evaluation of 227 prehospital patient assessments by advanced life support (ALS) emergency medical technicians (EMTs) found a frequent failure to measure vital signs. The objective of this retrospective review was to report the omission frequency of vital signs found in a centralized emergency medical services (EMS) data collection system. METHODS: The EMS database contained information from 90,480 optically scanned, prehospital patient encounter forms. Each record identified EMT skill levels, response times, dispatch type, vital signs, medical and trauma information, treatment, and patient disposition. Records for 1989 and 1990 were collected from 92 rural EMS providers who responded to emergency medical and trauma events. RESULTS: Of 90,480 emergency responses, 14,129 (15.6%) were false alarms, deceased, or canceled without vital patient contact. Valid encounters were documented for 76,351 (84.4%) patient contacts. Systolic blood pressure measurements were not recorded for 13,262 (17.4%) patients. Diastolic blood pressure was not recorded for 14,272 (18.7%) patients. A pulse record was not recorded for 12,125 (15.9%) patients. A ventilatory rate was absent in 12,958 (17.0%) patient records. CONCLUSION: This study found a frequent failure by non-metropolitan basic life support (BLS) and advanced life support (ALS) EMTs to record vital signs on prehospital emergency patient encounter forms. It supports a previous report of direct in-field observations of ALS EMTs failing to measure vital signs during patient assessment. The impact of vital sign omissions upon individual patient care can be assessed only by receiving medical control physicians. In the absence of effective emergency physician networking, the statewide magnitude of the problem among BLS and ALS EMTs has not been recognized as a system issue.     

An Urban 9-1-1 System’s Experience with Left Ventricular Assist Device Patients

Background: Left ventricular assist devices (LVADs) are used with increasing frequency and left in place for longer periods of time. Prior publications have focused on the mechanics of troubleshooting the device itself. We aim to describe the epidemiology of LVAD patient presentations to emergency medical services (EMS), prehospital assessments and interventions, and hospital outcomes. Methods: This is a retrospective chart review of known LVAD patients that belong to a single academic center’s heart failure program who activated the 9-1-1 system and were transported by an urban EMS system to one of the center’s 2 emergency departments between January 2012 and December 2015. Identifying demographics were used to query the electronic medical record of the responding city fire agency and contracted transporting ambulance service. Two reviewers abstracted prehospital chief complaint, vital signs, assessments, and interventions. Emergency department and hospital outcomes were retrieved separately. Results: From January 2012 to December 2015, 15 LVAD patients were transported 16 times. The most common prehospital chief complaint was weakness (7/16), followed by chest pain (3/16). Of the 7 patients presenting with weakness, one was diagnosed with a stroke in the emergency department. Another patient was diagnosed with subarachnoid hemorrhage and expired during hospital admission. This was the only death in the cohort. The most common hospital diagnosis was GI bleed (3/16). The overall admission rate was 87.5% (14/16). Conclusions: EMS interactions with LVAD patients are infrequent but have high rates of admission and incidence of life-threatening diagnoses. The most common prehospital presenting symptoms were weakness and chest pain, and most prehospital interactions did not require LVAD-specific interventions. In addition to acquiring technical knowledge regarding LVADs, EMS providers should be aware of non-device-related complications including intracranial and GI bleeding and take this into account during their assessment.     

Influence of Sex on the Out-of-hospital Management of Chest Pain

Background: Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out‐of‐hospital (OOH) care for chest pain is protocol‐driven and may be less likely to demonstrate differences between men and women. Objectives: The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex. Methods: A 1‐year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured. Results: A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI). Conclusions: For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk. ACADEMIC EMERGENCY MEDICINE 2010; 17:80–87 © 2010 by the Society for Academic Emergency Medicine     

I S T HERE G ENDER B IAS IN THE P REHOSPITAL M ANAGEMENT OF P ATIENTS WITH A CUTE C HEST P AIN ?

Objective. Prior emergency department (ED) and inpatient studies have found that women with coronary artery disease are more frequently misdiagnosed and undertreated compared with men. This study was performed to determine whether there is a gender bias in the prehospital management of patients with acute chest pain. Methods. This study was performed in a large urban county emergency medical services (EMS) agency with approximately 40,000 patient contacts/year. The study population comprised consecutive patients ≥45 years old with a chief complaint of atraumatic chest pain. Using χ² analysis and the unpaired Student's t-test, male and female patient encounters were compared. This study had >80% power (alpha 0.05) to detect a 3% difference between populations. Results. Data from 2,858 consecutive patient encounters were analyzed, with females comprising 1,508 (53%). Females were significantly older than males (67 ± 13.1 vs. 62.7 ± 12.3 years, p < 0.001). Male patients were more likely to receive aspirin (42.3% vs. 35.4%, p < 0.001) and 12-lead electrocardiograms (ECGs) (46.8% vs. 39.3%, p < 0.001) compared with female patients. The rates of transport refusal, oxygen, nitroglycerin, and narcotic administration did not differ between populations. Conclusion. Although females presenting to this urban EMS system with acute chest pain were older, they received significantly less aspirin and fewer 12-lead ECGs in the field. These results suggest strategies must be developed to ensure that appropriate therapy is provided to women presenting to EMS systems with acute cardiac ischemia.     

Emergency medical services' use of poison control centers for unintentional drug ingestions

Introduction

Every year, emergency medical services (EMS) providers respond to thousands of calls for toxic ingestions. Many systems have begun using poison control centers (PCCs) when unsure of disposition. We sought to determine the type of exposures EMS personnel were using the PCCs for and treatments suggested. Secondary end points included transport rate after consulting the PCC and amount of money saved by avoiding unnecessary transports.

Methods

This study was a qualitative retrospective chart review. Encounters between 2004 and 2006 originating in Austin, TX, were queried and limited to accidental ingestion calls placed by prehospital personnel. Data from charts were then analyzed.

Results

A total of 386 charts met inclusion criteria for this study. Household chemicals were the most frequently encountered agents. The most common recommendation was to observe patients at home for the development of concerning symptoms. In only 6% of cases did the PCC recommend administration of medication. Also of interest was the fact that only 63 patients were transported (16%).

Conclusions

It is unreasonable to expect prehospital providers to know what to do for every toxic exposure. This study suggests that the use of PCCs by EMS systems can be beneficial to patient care. For the time period of this study, EMS crews who contacted the PCC saved the City of Austin more than $205,000 in unnecessary ambulance transport costs. When emergency department expenses are factored in and other regions of the country are included, the savings would likely be much greater. This modality is an important resource for providers in a potentially uncertain realm.     

Adrenaline upregulates monocyte L-selectin in vitro

OBJECTIVE: To determine the efficacy of atropine therapy in patients with hemodynamically compromising bradycardia or atrioventricular block (AVB) in the prehospital and emergency department settings. METHODS: DESIGN: Retrospective review of prehospital, emergency department, and hospital records. PARTICIPANTS: Prehospital patients with hemodynamically compromising bradycardia or AVB with evidence of spontaneous circulation who received atropine as delivered by emergency medical services personnel (advanced life support level). SETTING: Urban/suburban fire department-based emergency medical service system with on-line medical control serving a population of approximately 1.6 million persons. DEFINITIONS: Hemodynamic instability was defined as the presence of any of the following: ischemic chest pain, dyspnea, syncope, altered mental status, and systolic blood pressure less than 90 mmHg. Bradycardia was defined as sinus bradycardia, junctional bradycardia, or idioventricular bradycardia (grouped as bradycardia) while AVB included first-, second- (types I and II), or third-degree (grouped as AVB). The response that occurred within one minute following each dose of atropine was defined as none, partial, complete, or adverse. MAIN RESULTS: Of 172 patients meeting entry criterion complete data was available for 131 (76.1%) and constitutes the study population. The mean age was 71 years. Fifty-one percent were female. Forty-five patients had AVB and 86 bradycardia. Patients with AVB were more likely to have a presenting systolic blood pressure less than 90 mmHg than those with bradycardia. In the 131 patients, responses to atropine were as follows: 26 (19.8%) = partial, 36 (27.5%) = complete, 65 (49.6%) = none, and 4 (2.3%) = adverse. Patients presenting with bradycardia (compared to AVB) more commonly: (1) received a single dose of atropine; (2) a lower total dose of atropine in the prehospital interval; (3) were more likely to arrive in the ED with a normal sinus rhythm; and (4) were less likely to receive additional atropine or isoproterenol in the ED. Those patients who achieved normal sinus rhythm over the total course of care were likely to have achieved that rhythm during the prehospital interval. There was no difference between groups in the likelihood of leaving the ED with a normal sinus rhythm achieved during the ED interval. Acute myocardial infarction was more common in patients presenting with AVB (55.5%) than with bradycardia (23.2%, P = 0.001). CONCLUSIONS: Approximately one-half of patients who received atropine in the prehospital setting for compromising rhythms had either a partial or complete response to therapy. Adverse responses were uncommon. Those patients who presented with hemodynamically unstable bradycardia to EMS personnel responded more commonly to a single dose and a lower total dose of atropine compared to similar patients with AVB. Those patients who achieve normal sinus rhythm by ED discharge were likely to have achieved it during the prehospital interval.     

The prehospital 12-lead electrocardiogram: impact on management of the out-of-hospital acute coronary syndrome patient

The electrocardiogram (ECG), when applied in the prehospital setting, has a significant effect on the patient with chest pain. The potential effect on the patient includes both diagnostic and therapeutic issues, including the diagnosis of acute myocardial infarction (AMI) and the indication for thrombolysis. The prehospital ECG may also detect an ischemic change that has resolved with treatment delivered by emergency medical services (EMS) prior to the patient's arrival in the emergency department (ED). Perhaps the most significant issue in the management of chest-pain patients involves the effect of the out-of-hospital ECG on the ED-based delivery of reperfusion therapy, such as thrombolysis. In AMI patients with ST-segment elevations, it has been conclusively demonstrated that information obtained from the prehospital ECG reduces the time to hospital-based reperfusion treatment. Importantly, these benefits are encountered with little increase in EMS resource use or on-scene time.     

Lessons learned from chlorine intoxications in swimming pools: the challenge of pediatric mass toxicological events

INTRODUCTION: The classical doctrine of mass toxicological events provides general guidelines for the management of a wide range of "chemical" events. The guidelines include provisions for the: (1) protection of medical staff with personal protective equipment; (2) simple triage of casualties; (3) airway protection and early intubation; (4) undressing and decontamination at the hospital gates; and (5) medical treatment with antidotes, as necessary. A number of toxicological incidents in Israel during the summer of 2005 involved chlorine exposure in swimming pools. In the largest event, 40 children were affected. This study analyzes its medical management, in view of the Israeli Guidelines for Mass Toxicological Events. METHODS: Data were collected from debriefings by the Israeli Home Front Command, emergency medical services (EMS), participating hospitals, and hospital chart reviews. The timetable of the event, the number and severity of casualties evacuated to each hospital, and the major medical and logistical problems encountered were analyzed according to the recently described methodology of Disastrous Incident Systematic Analysis Through-Components, Interactions, Results (DISAST-CIR). RESULTS: The first ambulance arrived on-scene seven minutes after the first call. Emergency medical services personnel provided supplemental oxygen to the victims at the scene and en route when required. Forty casualties were evacuated to four nearby hospitals. Emergency medical services classified 26 patients as mildly injured, 13 as mild-moderate, and one as moderate, suffering from pulmonary edema. Most children received bronchodilators and steroids in the emergency room; 20 were hospitalized. All were treated in pediatric emergency rooms. None of the hospitals deployed their decontamination sites. CONCLUSIONS: Event management differed from the standard Israeli toxicological doctrine. It involved EMS triage of casualties to a number of medical centers, treatment in pediatric emergency departments, lack of use of protective gear, and omission of decontamination prior to emergency department entrance. Guidelines for mass toxicological events must be tailored to unique scenarios, such as chlorine intoxications at swimming pools, and for specific patient populations, such as children. All adult emergency departments always should be prepared and equipped for taking care of pediatric patients.     

Treatment of acute myocardial infarction in Scottish emergency departments: survey of current practice.

INTRODUCTION: Thrombolysis was rarely given in emergency departments in Scotland when last studied in 1996. This study aimed to review the current practice of Scottish emergency departments with respect to thrombolysis for acute myocardial infarction. METHODS: Postal questionnaires were sent to all emergency departments in Scotland staffed by at least one consultant in emergency medicine, assessing the processes used for thrombolysis of acute myocardial infarction in the emergency department. A reminder letter was sent to non-responders after 1 month. All results were anonymized. RESULTS: The response rate was 77% (23 questionnaires from 30 hospitals). Twenty (87%) emergency departments performed thrombolysis according to protocol. In 13 emergency departments, thrombolysis was initiated by the emergency department staff, in six by on-call physicians and one emergency department had nurse-led thrombolysis. Twelve emergency departments occasionally received patients who had been given prehospital thrombolysis. Six hospitals had on-site primary angioplasty but only two hospitals had a 24-h service. Thirteen respondents thought the emergency department was the most appropriate place for thrombolysis, four felt that prehospital thrombolysis was best and one thought that coronary care was optimal. Four respondents felt that prehospital or the emergency department were the best options. CONCLUSION: Most emergency departments in Scotland are now administering thrombolysis for patients with acute myocardial infarction. Thrombolysis, delivered either in the prehospital arena or in the emergency department, is likely to be the primary option for patients with acute myocardial infarction in Scotland in the foreseeable future.     

Emergency department at the cutting edge.

OBJECTIVE: This paper reviews the experience of penetrating chest trauma over a 3-year period in one UK emergency department. METHODS: A retrospective review was performed of patients assessed in the emergency department resuscitation room between 1 January 2002 and 31 December 2005. Patients with penetrating chest trauma, either isolated or in combination with other injuries, were included. A Medline search was performed using the terms 'chest', 'trauma' and 'penetrating'. RESULTS: A total of 120 patients presented with penetrating chest trauma. Ninety-two percent were male. Ninety-six percent (115) of the patients survived to hospital discharge. Seventy-eight percent of the patients presented at night (20.00 and 8.00 h). A single wound accounted for 52% (63) of patients, multiple wounds 43% (52) with 2% (two) gun-shot wounds and 3% (three) impalings. The mean prehospital time of patients in cardiac arrest was 42 min with a mean on-scene time of 24 min. The mean prehospital time for patients undergoing formal emergency surgery was 39 min with a mean on-scene time of 16 min. Twenty-three patients required one or more tube thoracostomies to be performed in the emergency department and six underwent emergency department thoracotomy. Sixteen patients required immediate formal emergency surgery for haemorrhage control. CONCLUSION: Penetrating chest trauma contributes significantly to our trauma workload with a high proportion of patients sustaining life-threatening injuries requiring immediate intervention. Significant prehospital delays occur. Overall mortality of 4.2% is comparable with that of a major American case series. Further education and protocol development is required to ensure that prehospital and emergency department management of these patients reflects the latest evidence-based guidelines.