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Purpose: The purpose of this study was to measure the quality of life of cardiac arrest long-term survivors.
Design: Prospective outcome evaluation.
Setting: The emergency medical system of a mid-sized city.
Type of participants: Prehospital cardiac arrest victims who had a resuscitation attempt from 5/93 through 12/95 and were discharged alive. Patients <18 were excluded.
Measurements: Patients were surveyed by mail. Non-responders were telephoned. The questions assessed Glasgow-Pittsburgh overall performance (GPOP) scores before and after the cardiac arrest. Additional items assessed physical, role, affective, and cognitive functioning, and global health status.
Main Results: 760 cases were collected. 40 had unknown vital status at hospital discharge. The survival rate to hospital discharge for the 270 patients with cardiac etiology and initial rhythm of ventricular fibrillation was 15%, and it was 6% for the other 450 patients. Of 68 survivors, 23 died before a survey was sent; two had unknown addresses. 21 patients (49%) responded, and four refused to participate. The mean interval from cardiac arrest to survey response was 531 days. Ten reported good post-arrest GPOP scores, 5 had moderate disability, 4 severe disability, and 2 were comatose. Cognitive function was improved in 1, unchanged 6, slightly worse 7, markedly worse 4, and none in 3. Eleven patients reported feeling happy. Global healdi was excellent for 2, very good 8, good 5, fair 2, and poor 3.
Purpose: The new Emergency Medical Technician (EMT) basic curriculum includes an optional session on intubation. Unfortunately little data is available regarding retention of endotracheal intubation skills by basic EMTs. The objective of this study was to examine endotracheal intubation skills by basic EMTs, and compare skills retention for a transillumination (TI) versus a direct visualization (DV) technique.
Methods: A prospective, randomized trial was conducted over a five week period during a basic EMT class. EMT classes were randomized to train students to perform endotracheal intubation using either a transillumination or a direct visualization technique. Initial education was performed using an airway mannequin during a modified, accelerated three hour course, consisting of both a didactic and skills session. To assess performance, participants were tested using an airway mannequin and checklist currently implemented by our flight nurse program. Without further education or practice, students were then tested one week and five weeks later to assess short and long term retention.
Purpose: Among pediatric patients, cardiopulmonary arrests account for a small, but important, percentage of responses by emergency medical services (EMS). EMS prehospital assessment of medical and traumatic arrests in the pediatric patient were compared with that of the Office of Medical Investigator (OMI) autopsy reports to assess differences and implications for EMS training and prevention in pediatric arrests.
Methods: Retrospective review of ambulance run forms from an urban EMS system with OMI autopsy correlation. Patients less than fifteen years of age and younger who were treated by prehospital personnel from November 1, 1990, to October 31, 1991, for a medical or traumatic arrest. Proportions were analyzed using chi-square analysis or Fisher's exact test and agreement was assessed using the Kappa statistic.
Results: Ambulance runs were reported for 2,586 pediatric patients. Of these, forty-two (1.6%) suffered arrests, with thirty-two (76%) medical arrests and ten (24%) traumatic arrests. Children one year of age or less accounted for 75% of the medical arrests while children greater that one year of age accounted for 80% of the traumatic arrests (p = 0.003). Overall mortality was 81%. When EMS prehospital assessment of medical and traumatic arrests were compared with OMI reports, there was good agreement (kappa = 0.70) for Sudden Infant Death Syndrome (SIDS), but poor agreement (kappa = 0.37) for child abuse.
Purpose: Headache is a very common complaint in emergency medicine. Its causes are myriad, ranging from benign to life-threatening. Patients who access emergency medical services (EMS), often do so after self-assessment has indicated high acuity. We conducted this study to determine if patients transported by EMS with a chief complaint of headache have a higher rate of serious etiology.
Methods: This observational, retrospective study, was conducted by consecutive review of charts on all patients presenting to the emergency department (ED) from December 1994 through May 1995 with a chief complaint of headache. Patients presenting with other manifestations of intracranial pathology (ICP), such as altered mental status or seizures, were excluded. Mode of arrival was determined to be either via emergency medical services (EMS) or other means. Patients were categorized as having serious (meningitis, hemorrhage, tumor) or benign (migraine, etc.) ICP, based final diagnosis. It was noted whether or not diagnostic studies (DS), such as CT scan and lumbar puncture, were performed. Statistical analysis was performed using the Yates corrected chi-square test.
Purpose: To determine whether melatonin (N-acetyl-5-methoxytryptamine) is effective in helping prehospital personnel working consecutive night shifts reset their biological clock and minimize circadian rhythm disruption.
Methods: A double-blinded, randomized, cross-over study was performed using 12 paramedic volunteers. Paramedics were working a span of consecutive night (2300-0700) shifts and received either a melatonin capsule (6 mg) or placebo to be taken prior to each of the consecutive day sleeps. Each participants completed a total of four spans of consecutive night shifts (2-melatonin, 2-placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and possible drug side-effects. Assessment of job performance, mood and alertness were measured every day using 10-cm visual analog scales (VAS).
Results: Analysis of sleep diaries demonstrated no significant difference (p >0.05) between the two treatments in respect to mean sleep latency (melatonin = 15.4 min. vs. placebo = 14.6 min), mean sleep duration (melatonin = 6.7 hrs. vs. placebo = 6.9 hrs), or subjectively rated sleep quality (melatonin = 5.8 VAS vs placebo = 5.6 VAS). Similarly, no significant benefits were noted between the mean VAS scores for daily job performance, mood and alertness. Adverse effects were rare, one patient taking melatonin reported a prolonged sedative effect.
Conclusion: Despite widespread belief in the benefits of melatonin as a hypnotic agent, no clinical benefits were noted in terms of daytime sleep or job performance in paramedics working consecutive night shifts.
Purpose: Because overall EMS system response depends on ambulance availability, we conducted a prospective study of the EMS turnaround interval. This interval consists of the delivery and recovery intervals as defined in Spaite's EMS time-interval model.
Methods: An on-site observer, while monitoring EMS radio traffic, recorded the delivery and recovery activities of personnel from a large urban EMS system at a university hospital ED. System policy permits a maximum 30 minute turnaround interval. Prospectively defined subintervals were analyzed.
Results: A convenience sample of 122 patient deliveries was collected. Observed and radio-reported arrival at the hospital differed by -1′24″; to +11′8″. Time from arrival to removal of the patient from the ambulance averaged 59″ (range 13″-2′53″), and time from patient removal to ED entry averaged 42″ (10″ - 5′22″). While the mean time for the verbal report to ED staff was 33″ (2″-5′20″), it was 0 = 15″ in 36% of cases. Time from ED entry to placement of the patient on an ED bed averaged 2′11″ (33″-9′35″). Writing the report averaged 17′12″ (5′20″-52′11″). The mean time off radio was 29′51″ (ll′43″-53′37″) and the mean time the ambulance was at the ED was 30′01″ (11′25″-1°17′53″). Observed and radio-reported ambulance departures differed by -4′31″ to +23′32″. In 22% of cases, departure was reported on radio more than 5′after actual departure.
Purpose: The use of automatic external defibrillators (AED) by emergency medical service (EMS) first responders (FR) is widely advocated based largely on reports from one metropolitan area, but widespread impact on survival remains unproven. We hypothesized that the addition of AEDs to an EMS system with short FR and prolonged paramedic response times (4 vs. 10 minutes) would improve survival from sudden cardiac death.
Methods: Prospective, controlled, crossover study (AED vs. no AED) of consecutive cardiac arrests managed by 24 FR fire companies from 1992–1995 in a city of 440,000. Patients were stratified by the Utstein criteria. Primary end-point was survival to hospital discharge among patients with bystander witnessed arrests of cardiac etiology. Power was set at 0.8 to detect a 10% difference in survival.
Results: A total of 627 patients were studied. Groups were comparable for age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and ventricular fibrillation (VF) as initial rhythm.
Introduction: Previous studies of motorcycle injuries show that helmet use is associated with a decrease in head trauma. Understanding patterns of helmet use is important in selecting and assessing injury prevention strategies.
Methods: All 470 motorcyclists presenting to either of two regional Level I trauma centers from 7/93 through 12/95 comprise this case series. Thirty-three patients were excluded due to unknown helmet use or outcome, and 50 due to age under 18 years (for whom helmet use was required by state law).
Results: Of 386 patients, 42% wore helmets, and 58% did not, with no difference in the mean ages of the groups. 13% of patients were women (n = 50), and 10% were passengers (n = 38). Women were 25 times more likely than men to be passengers (95% CI: 11 to 50), and passengers were 5 times more likely than drivers to not wear a helmet (95% CI: 2 to 16). Helmet use was not related to sex, even when the data were controlled for driver vs. passenger. Of 265 patients assayed for ethanol, 30% had >100 mg/dL, 7% had <100 mg/dL, and 63% had none. Non-helmeted patients were 3.6 more likely than helmeted ones to have detectable ethanol (95% CI: 2.0 to 6.5), but there was no association with sex or age. The mean ethanol level was 80 mg/dL in non-helmet users, and 24 mg/dL in helmet users (p <0.001). 39% of non-helmeted patients were legally intoxicated (ethanol > 100 mg/dL), compared to 11% of helmeted ones.
Hypothesis: Do paramedics influence the outcome of out of hospital cardiac arrests in a rural setting?
Methods: Retrospective analysis of cardio-respiratory arrests of ALS-EMS system in rural Southeastern Alaska for 9 years. There were two patient groups treated by EMT-III or paramedics. EMT-III vs. paramedics differ in training/experience but not technical skills. Statistical analyses were done by chi square.
Results: Thirty-seven patients (52%) were treated by paramedics, thirty-four (48%) by EMT-III. Demographics/CPR variables for the groups were not significantly different. Comparing paramedics vs. EMT-III: successful ET placement (87% vs. 62%, p <0.02), successful IV placement (87% vs. 62%, p <0.02), return of spontaneous circulation (ROSC) 46% (17/37 pts.) vs. 18% (6/34 pts.) (p = 0.01), ICU admission 38% (14/37) vs. 15% (5/34) (p = 0.03), hospital discharge 20% (7/35) vs. 9% (3/34) (p = NS). There was no correlation between successful ET placement or IV insertion and outcome.
Introduction: Prior studies have documented less than 3% survival for out-of-hospital cardiac arrest (CA) in D.C. EMS intubation has failed to improve extremely poor survival rates for out of hospital CA. This study will investigate whether the addition of automatic external defibrillator (AED) use will improve the negligible survival rate experienced in a system that transports 80,000 pts/yr; Thus replicating success with AED for CA in other centers.
Methods: Retrospective review of all CA data from D.C. EMS system from 1-12/91 (no AED) vs. 1-12/93 (AED in use). Supporting data from run sheets and hospital records was compared for years with and without the AED using student's t test, chi-square with p <0.05.
Results: In 1991 there were 414 out of hospital CAs arrests with an overall survival rate of 2.3% with a mean EMS arrival time of 10 minutes. There were no significant differences with respect to CA patients’ age, bystander CPR or BLS/ALS response times between two years (1991 and 1993) p = NS. In VF patients who comprised 26% and 24% of presenting rhythms for ’91 and ’93 respectively, the use of AEDs improved survival 3.8% vs. 29% with AEDs in ’93 (p <0.05). There was no difference in percentage of non-VF presenting rhythms or patient outcomes between the two groups.
Purpose: To determine the reasons why patients with potentially serious complaints present to the Emergency Department by a non-EMS mode of transportation.
Methods: Prospective patient survey distributed during a one-month period to patients presenting to a military emergency department. Surveys were entered into a data base program and descriptive, parametric and non-parametric statistical tests utilized to examine characteristics of the two groups.
Results: The only significant difference between the ambulance and non-ambulance groups of the 158 participants was patient sex.
Purpose: To determine the degree of concordance between thrombolytic checklists completed by emergency medical technicians (EMTs) in the field and corresponding checklists completed by emergency physicians in the emergency department (ED).
Methods: This was a comparative analysis of matched pairs of thrombolytic checklists. Subjects included patients 35 years or older with clinical signs or symptoms of cardiac origin who were transported to the ED by ambulance. The checklist contained 12 items and was completed by EMTs during transport of eligible patients. An identical checklist was completed in the ED by an emergency physician upon arrival of the patient. The main outcome measurement was concordance between the matched pairs.
Objective: The objective of this study is to identify potential problems associated with prehospital advanced airways by assessing the utilization, complications, and education associated with the use of portable suction equipment.
Methods: Fifty-one paramedics serving a university medical center were anonymously surveyed. The survey consisted of questions regarding: utilization, difficulties, bad outcomes, and training associated with portable suction equipment.
Results: Six of the paramedics set up and check suction equip ment for every airway procedure. The rest perform daily checks or rarely test equipment. Twenty-three medics reported equipment malfunctions: dead battery (12), improper set-up (5), clogged tubing (6). Twenty-six of the paramedics reported having at least one bad outcome due to malfunction of suction equipment. These were cases of failed intubation following at least one attempt. Seven bad outcomes were attributed to lack of suction equipment at scene. Paramedics carry suction equipment to the scene for less than twenty-five percent of calls. Three suction units were in use: S-SCORT (32), S-SCORT Jr. (11), and Impact (8). There was no difference in utilization or bad outcomes by unit type. Ninety-eight percent of the paramedics reported some type of formal training on use of suction equipment during airway procedures.
To compare the efficacy of high-dose epinephrine (HDE) with standard-dose epinephrine (SDE) in the management of cardiac arrest in adults in the prehospital setting.
Hypothesis:
The use of HDE will improve the outcome of adult patients in cardiac arrest.
Methods:
In a general population of 700,000 persons, in a mixed geographical area of 2,200 square miles, a 12-month retrospective study of SDE and a 12-month prospective trial of HDE were conducted involving adult patients in cardiac arrest in the prehospital setting. Treatment was provided by paramedic-level clinicians. In the control group, patients were treated according to existing American Heart Association cardiac resuscitation guidelines using SDE (defined as 1.0 mg boluses to a maximum dose of 4 mg). In the test group, the same guidelines were revised to use HDE (defined as a rapid sequence of 5, 10, and 15 mg boluses to a total dose of 30 mg).
Results:
The control group included 594 patients; the test group consisted of 580 patients. The overall survival rate to hospital admission in the control group was 14.5% (84 patients) and in the test group 15.3% (89 patients). The survival rate to hospital discharge in the control group was 4.9% (29 patients) versus 4.8% (28 patients) in the test group. For patients whose initial rhythms were ventricular fibrillation, survival to admission in the control group was 20.4% (39 patients) versus 24.4% (43 patients) in the test group. Survival to discharge for patients with ventricular fibrillation in the control group was 8.9% (17 patients) versus 10.8% (19 patients) in the test group.
Conclusion:
There was no statistically significant difference in overall rate of survival to hospital admission or discharge between patients treated with SDE and those treated with HDE, regardless of the initial rhythm.
Purpose: To determine the most frequent sources of injuries from the interior of motor vehicles involved in crashes.
Methods: We searched the National Highway Traffic Safety Administration's National Accident Sampling System to determine the most frequent sources of injuries. This database includes sources of injuries resulting from crashes from January 1, 1991 to December 31, 1992.