P REHOSPITAL U SE OF A NALGESIA FOR S USPECTED E XTREMITY F RACTURES

Introduction. Pain and its control have been studied extensively in the emergency department. Numerous studies indicate that inadequate treatment of pain is common, despite the availability of myriad analgesics. It has been suggested that oligoanesthesia is also a common practice in the prehospital setting. Objective. To assess the use of prehospital analgesia in patients with suspected extremity fracture. Methods. Emergency medical services (EMS) call reports were reviewed for all patients with suspected extremity fractures treated from June 1997 to July 1998 in a midwestern community with a population base of 223,000. Data collected included demographic information, mechanism of injury, medications given, and field treatment. Standing orders for administration of analgesia were available and permitted paramedics to give either morphine sulfate or nitrous oxide per protocol. Results. The EMS call reports were analyzed for 1,073 patients with suspected extremity fractures. The mean patient age was 47 years. Accidental injuries comprised 86.5% of those reviewed. Suspected leg fractures were most common (20%), followed by hips (18%), arms (11%), knees (10%), ankles (9%), shoulders (7.2%), hands (5.5%), and wrists (5.3%). Multiple trauma and assorted broken digits accounted for the remaining 14%. The most common mechanisms of injury were: fall (43%), motor vehicle collision (21%), and human assault (10%). Intravenous lines were placed in 9.4% of patients; 17% received ice packs; 16% received bandage/dressings; 25% received air splints; and 19% were fully immobilized. Analgesia was administered to 18 patients (1.8%): 16 patients received nitrous oxide and two received morphine. Conclusion. Administration of analgesics to prehospital patients with suspected fractures was rare. Prehospital identification and treatment of pain for patients with musculoskeletal trauma could be improved.     

P REHOSPITAL R APID-SEQUENCE I NTUBATION

Prehospital pain management has become an important emergency medical services (EMS) patient care issue. Objectives. To describe the frequency of EMS andemergency department (ED) analgesic administration to injured children; to describe factors associated with the administration of analgesia by EMS; andto assess whether children with lower-extremity fractures receive analgesia as frequently as do adults with similar injuries. Methods. This was a retrospective study of children (age < 21 years) who were transported by EMS between January 2000 andJune 2002 andhad a final hospital diagnosis of extremity fractures or burns. Secondarily, children with lower-extremity fractures were compared with a cohort of EMS-transported adults with similar injuries andtransported during the same study period. Receipt of andtime of parenteral analgesia were recorded. Results. Seventy-three children met the inclusion criteria. The mean (range) age of this sample was 12.4 (0.9–21) years, with only four patients aged < 5 years. A majority of the patients were male (49/73, 67.1%) andsustained femur (20/73, 27.4%) or tibia/fibula (26/73, 35.6%) fractures. Few pediatric patients received prehospital analgesia (16/73, 21.9%), while a majority received analgesia in the ED (58/73, 79.4%). Prehospital analgesia was associated with earlier patient treatment than that administered in the ED (22.3 ± 5.9 min vs. 88.3 ± 38.2 min). Comparing children (n = 33) with adults (n = 76) with similar lower-extremity fractures, a small insignificant difference was found in the rate of prehospital analgesia between children andadults (7/33, 21.2%, vs. 20/56, 26.3%). Conclusion. Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. Few factors were identified that could be associated with EMS oligoanalgesia. No difference was found between children andadults in the rates of EMS analgesia.     

Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA. PREHOSPITAL EMERGENCY CARE 2002;6:406-410     

Prehospital Analgesia for Pediatric Trauma Patients in Iraq and Afghanistan

Background: Previous studies have evaluated prehospital analgesia during combat operations in Iraq and Afghanistan, but were limited to the adult population. However, a significant portion of the casualties of those conflicts were children. We describe the prehospital analgesia administered to wartime pediatric trauma patients. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients (<18 years of age) admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We divided pediatric patients into 2 groups: those that had documentation of receipt of analgesic drugs in the prehospital setting (n = 618) and those who had not received analgesia before reaching a fixed-facility (n = 2,821). For characterization of drug administration, we grouped patients into those receiving acetaminophen, NSAID, fentanyl, ketamine, morphine, or other analgesics (e.g., hydromorphone, tramadol, etc.). Results: During the study period, there were 3,439 pediatric encounters with documentation of 703 instances of analgesia administrations to 618 patients (17.9% of total pediatric encounters). Of the subjects receiving analgesic agents, 46.2% (n = 325) received morphine, 30.4% (n = 214) received fentanyl, 17.4% (n = 122) received ketamine, 1.8% (n = 13) received acetaminophen, and 2.8% (n = 20) received a non-steroidal anti-inflammatory drug. The remaining 9 administrations consisted of methoxyflourane (1), nalbuphine (2), hydromorphone (3), and tramadol (3). An injury severity score (ISS) >15 increased the odds of receiving an analgesic agent (OR 1.26, 95% CI 1.02–1.56). Additionally, there was an association between analgesia administration and the following prehospital interventions: wound dressing, tourniquet, intravenous (IV) line placement, intraosseous line placement, IV fluids, intubation, and external warming. Conclusions: Overall, a low proportion of pediatric trauma subjects within this population received analgesia in the prehospital environment. The most common analgesic medication administered was morphine. Those receiving analgesic agents had more severe injuries and higher rates of concomitant interventions. These results highlight the potential need for Tactical Combat Casualty Care guidelines specifically providing recommendations for analgesia administration among pediatric patients.     

Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study

Background: The quality of procedural analgesia and sedation among trauma patients has not been studied much in the prehospital setting. The main objective of this study was to characterize the quality of procedural analgesia sedation practices in prehospital settings in trauma patients. Methods: This was an open-label observational prospective multicenter study (January 01, 2012–December 31, 2013). We included all consecutive trauma victims undergoing a potentially painful procedure on the accident scene. The primary endpoint was the procedural pain intensity. Results: Data for 210 patients aged 11 to 98 years were analyzed. The most common lesions were limb fractures or dislocations. The most common procedures were limb realignment and splinting. Overall, 25 different drug combinations [with paracetamol [acetaminophen], non-steroidal anti-inflammatory drugs, nefopam, opioids, loco-regional anesthesia, Equimolar Mixture of Oxygen/Nitrous Oxide (EMONO), sedative drugs] were used by the emergency medical services (EMS). One hundred seventeen patients (55%) received either one or two sedative drugs (among ketamine, propofol, and midazolam), 171 patients (81%) received morphine that was combined with a sedative drug in 54% of cases. During the procedure, 95 patients, 45% [95% Confidence Interval (CI) 39–52] experienced intense to severe pain. Among patients who received sedative drugs, 27% (32/117) had intense to severe pain vs. 68% (63/93) in patients who did not, that is, 40% difference [95% CI 33.8–47.0]. Seventeen patients (8%) experienced 18 adverse events of which 6 were respiratory adverse events. A deep sedation occurred in 17 patients. No center had any specific protocols for procedural sedation analgesia. Conclusion: Procedural sedation-analgesia was inadequate in almost half of the trauma patients in the out-of-hospital setting. The reasons of these failures were probably multiple. The non-administration of a sedative drug despite an indication or non-adapted doses, in the context of a lack of specific protocols, was certainly one of them.     

F EW E MERGENCY M EDICAL S ERVICES P ATIENTS WITH L OWER-EXTREMITY F RACTURES R ECEIVE P REHOSPITAL A NALGESIA

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA.     

Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries

Purpose

The purpose of the study was to document prehospital analgesia (PA) for children with extremity injuries at home or en route to the hospital, as assessed by research personnel at the pediatric emergency department.

Methods

Two parallel groups of patients with fractures or soft-tissue injuries (STIs) were chosen for this prospective observational study. Patients 3 to 18 years of age with a limb or clavicle injury were enrolled. Parents or children were interviewed, pain assessed, and data from the emergency department charts collected.

Results

A total of 310 patients were recruited; their mean age was 10.2 years, and 62% had fractures. The median pain score was 4.0, with no significant difference between fractures and STI. Of the patients, 78% had PA, 73% received first aid (icing, immobilization), and 37% had medication, mostly acetaminophen and ibuprofen. Children with fractures and STI received PA at a similar rate; however, the time to first aid was shorter in those with fractures.

Conclusion

Most patients with moderate or severe pain did not receive prehospital pain medication. Parental education and moderate over-the-counter analgesics are needed for better pain relief.     

Simplifying prehospital analgesia. Why certain medications should or should not be used for pain management in the field

Prehospital analgesia can be safely provided with only three agents: fentanyl, morphine and the mixed-gas nitrous oxide/oxygen. Of these three, fentanyl is by far the best agent for general EMS analgesic therapy by paramedics. However, to initiate prehospital analgesia earlier in the EMS response time frame, EMT's should administer nitrous oxide/oxygen. This protocol can easily be added to the EMT education program or through a continuing education session. All of the other agents discussed have absolutely no role in modern prehospital care.     

Information Loss in Emergency Medical Services Handover of Trauma Patients

Introduction. Little is known about how effectively information is transferred from emergency medical services (EMS) personnel to clinicians in the emergency department receiving the patient. Information about prehospital events and findings can help ensure expedient and appropriate care. The trauma literature describes 16 prehospital data points that affect outcome and therefore should be included in the EMS report when applicable. Objective. To determine the degree to which information presented in the EMS trauma patient handover is degraded. Methods. At a level I trauma center, patients meeting criteria for the highest level of trauma team activation (“full trauma”) were enrolled. As part of routine performance improvement, the physician leadership of the trauma program watched all available video-recorded full trauma responses, checking off whether the data points appropriate to the case were verbally “transmitted” by the EMS provider. Two EMS physicians then each independently reviewed the trauma team's chart notes for 50% of the sample (and a randomly selected 15% of the charts to assess agreement) and checked off whether the same elements were documented (“received”) by the trauma team. The focus was on data elements that were “transmitted” but not “received.” Results. In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). On the average chart, 72.9% of the transmitted items were received (95% confidence interval 69.0%–76.8%). The most commonly transmitted data elements were mechanism of injury (94 times), anatomic location of injury (81), and age (67). Prehospital hypotension was received in only 10 of the 28 times it was transmitted; prehospital Glasgow Coma Scale [GCS] score 10 of 22 times; and pulse rate 13 of 49 times. Conclusions. Even in the controlled setting of a single-patient handover with direct verbal contact between EMS providers and in-hospital clinicians, only 72.9% of the key prehospital data points that were transmitted by the EMS personnel were documented by the receiving hospital staff. Elements such as prehospital hypotension, GCS score, and other prehospital vital signs were often not recorded. Methods of “transmitting” and “receiving” data in trauma as well as all other patients need further scrutiny.     

Women are less likely than men to receive prehospital analgesia for isolated extremity injuries

Objectives

The goal of this study was to examine the effect of socioeconomic factors, such as ethnicity, income, age, and sex, on the administration of analgesia for isolated extremity injuries in the prehospital setting.

Methods

For this retrospective study, the electronic medical record of a large ground-based emergency medical services agency was reviewed and all isolated extremity injuries occurring during the year 2005 were extracted. A total of 1009 cases met the inclusion criteria. Of these cases, 56 were excluded because of incomplete records, leaving 953 cases for analysis. Basic univariate analysis as well as logistic regression analysis were used to examine the relationship between analgesia administration and patient age, ethnicity, sex, income, subjective pain severity, and time under prehospital care.

Results

A total of 279 patients (29%) received morphine. Both univariate and logistic regression analysis revealed significant differences in analgesia administration based on sex (proportion of men receiving analgesia, 32.8%; women, 26.7%), initial pain severity, and time under prehospital care. Although no category of income was itself significant, a significant trend emerged in which increasing income was associated with increasing likelihood of receiving analgesia. There was no significant difference in analgesia based on patient age or ethnicity.

Conclusion

This study suggests that women are less likely than men to receive prehospital analgesia for isolated extremity injuries. Patients with higher pain severity and longer duration of prehospital care are more likely to receive prehospital analgesia. Increasing levels of income were associated with increased rates of analgesia. The overall rate of prehospital analgesia administration for isolated extremity injuries in this population is higher than has been reported for other emergency medical services systems (29% vs 2%-18% in other recent studies), but there remains considerable room for improvement in the provision of prehospital analgesia. Further inquiry is needed to determine why certain populations such as women receive disproportionately less analgesia.     

Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions

ObjectivesTo compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time.Patients and MethodsA retrospective analysis was performed using data from Florida’s Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks.ResultsIn 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P<.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005).ConclusionThis study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.     

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

Background

The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.

Prehospital management of acute respiratory distress in suspected COVID-19 patients

BackgroundIn December 2019, coronavirus disease (COVID-19) emerged in China and became a world-wide pandemic in March 2020. Emergency services and intensive care units (ICUs) were faced with a novel disease with unknown clinical characteristics and presentations. Acute respiratory distress (ARD) was often the chief complaint for an EMS call. This retrospective study evaluated prehospital ARD management and identified factors associated with the need of prehospital mechanical ventilation (PMV) for suspected COVID-19 patients.MethodsWe included 256 consecutive patients with suspected COVID-19-related ARD that received prehospital care from a Paris Fire Brigade BLS or ALS team, from March 08 to April 18, 2020. We performed multivariate regression to identify factors predisposing to PMV.ResultsOf 256 patients (mean age 60 ± 18 years; 82 (32%) males), 77 (30%) had previous hypertension, 31 (12%) were obese, and 49 (19%) had diabetes mellitus. Nineteen patients (7%) required PMV. Logistic regression observed that a low initial pulse oximetry was associated with prehospital PMV (ORa = 0.86, 95%CI: 0.73–0.92; p = 0.004).ConclusionsThis study showed that pulse oximetry might be a valuable marker for rapidly determining suspected COVID-19-patients requiring prehospital mechanical ventilation. Nevertheless, the impact of prehospital mechanical ventilation on COVID-19 patients outcome require further investigations.     

Patient Characteristics and Temporal Trends in Police Transport of Blunt Trauma Patients: A Multicenter Retrospective Cohort Study

Background: Police transport (PT) of penetrating trauma patients has the potential to decrease prehospital times for patients with life-threatening hemorrhage and is part of official policy in Philadelphia, Pennsylvania. We hypothesized that rates of PT of bluntly injured patients have increased over the past decade. Methods: We used Pennsylvania Trauma Outcomes Study registry data from 2006–15 to identify bluntly injured adult patients transported to all 8 trauma centers in Philadelphia. PT was compared to ambulance transport, excluding transfers, burn patients, and private transport. We compared demographics, mechanism, and injury outcomes between PT and ambulance transport patients and used multivariable logistic regression to identify independent predictors of PT. We also identified physiological indicators and injury patterns that might have benefitted from prehospital intervention by EMS. Results: Of 28 897 bluntly injured patients, 339 (1.2%) were transported by police and 28 558 (98.8%) by ambulance. Blunt trauma accounted for 11% of PT and penetrating trauma for 89%. PT patients were younger, more likely to be male, and more likely to be African American or Asian and were more often injured by assault or motor vehicle crash. There were no significant differences presenting physiology between PT and EMS patients. In multivariable logistic regression analysis, male sex (OR 1.89, 95%CI 1.40–2.55), African American race (OR 1.71 95%CI 1.34–2.18), and Asian race (OR 2.25, 95%CI 1.22–4.14) were independently associated with PT. Controlling for injury severity and physiology, there was no significant difference in mortality between PT and EMS. Overall, 64% of PT patients had a condition that might have benefited from prehospital intervention such as supplemental oxygen for brain injury or spine stabilization for vertebral fractures. Conclusions: PT affects a small minority of blunt trauma patients, and did not appear associated with higher mortality. However, PT patients included many who might have benefited from proven, prehospital intervention. Clinicians, EMS providers, and law enforcement should collaborate to optimize use of PT within the trauma system.     

Evaluation of prehospital hydroxocobalamin use in the setting of smoke inhalation

BackgroundThe indications for prehospital hydroxocobalamin are not well defined. The aim of this study was to evaluate prehospital signs and symptoms in patients who received hydroxocobalamin to improve future use.MethodsIn this retrospective study, all patients who received prehospital Hydroxocobalamin at a tertiary care burn center from December 2012 to March 2018 were reviewed. Each case was evaluated for evidence of suspected cyanide toxicity: hypotension, syncope, CNS depression/altered mentation, seizures, respiratory or cardiac arrest. A determination was made whether or not hydroxocobalamin was indicated.ResultsIn this study, EMS providers administered hydroxocobalamin to 42 patients between December 2012 and March 2018. The majority (71%) of suspected cyanide exposures were from house fires. The most common prehospital findings were coma or depressed CNS (36%), followed by hypotension (16%) and cardiac arrest (12%). Sixty percent of patients treated with hydroxocobalamin had none of the six clinical indicators for potential cyanide toxicity. Carboxyhemoglobin and serum lactate were significantly different in patients that had a clinical indication for hydroxocobalamin compared to those who did not.ConclusionsPrehospital hydroxocobalamin was used empirically however, indications are unclear. Using defined clinical indications may provide greater clarity for providers and reduce unnecessary use of hydroxocobalamin.