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Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate.
Methods:
Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate.
Results:
A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians.
Conclusion:
Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.
Airway management is a controversial topic in modern Emergency Medical Services (EMS) systems. Among many concerns regarding endotracheal intubation (ETI), unrecognized esophageal intubation and observations of unfavorable neurologic outcomes in some studies raise the question of whether alternative airway techniques should be first-line in EMS airway management protocols. Supraglottic airway devices (SADs) are simpler to use, provide reliable oxygenation and ventilation, and may thus be an alternative first-line airway device for paramedics. In 2019, Alachua County Fire Rescue (ACFR; Alachua, Florida USA) introduced a novel protocol for advanced airway management emphasizing first-line use of a second-generation SAD (i-gel) for patients requiring medication-facilitated airway management (referred to as “rapid sequence airway” [RSA] protocol).
Study Objective:
This was a one-year quality assurance review of care provided under the RSA protocol looking at compliance and first-pass success rate of first-line SAD use.
Methods:
Records were obtained from the agency’s electronic medical record (EMR), searching for the use of the RSA protocol, advanced airway devices, or either ketamine or rocuronium. If available, hospital follow-up data regarding patient condition and emergency department (ED) airway exchange were obtained.
Results:
During the first year, 33 advanced airway attempts were made under the protocol by 23 paramedics. Overall, compliance with the airway device sequence as specified in the protocol was 72.7%. When ETI was non-compliantly used as first-line airway device, the first-pass success rate was 44.4% compared to 87.5% with adherence to first-line SAD use. All prehospital SADs were exchanged in the ED in a delayed fashion and almost exclusively per physician preference alone. In no case was the SAD exchanged for suspected dislodgement evidenced by lack of capnography.
Conclusion:
First-line use of a SAD was associated with a high first-pass attempt success rate in a real-life cohort of prehospital advanced airway encounters. No SAD required emergent exchange upon hospital arrival.
On March 15, 2019, Cyclone Idai made landfall near the port city of Beira in central Mozambique causing significant casualties and serious damage to infrastructure. The Emergency Medical Team Type 2 – Italy Regione Piemonte (EMT2-ITA) was deployed approximately two weeks after the disaster to support the country in need, providing essential medical and surgical care.
The EMT2-ITA staff was composed of 77 team members including two rotations and integrating local staff. A total of 1,121 patients (1,183 triage admissions) were treated during the 27 days of field hospital activity; among all the admissions, only few cases (17; 1%) were directly or indirectly attributed to the disaster event. Only three cases of cholera were confirmed and transferred to one of the treatment centers set up in Beira. The EMT2-ITA performed a total of 62 surgical operations (orthopedic, gynecological, general, and plastic surgery), of which more than one-half were elective procedures.
The objective of this manuscript is to report the mission of the EMT2-ITA in Mozambique, raising interesting points of discussion regarding the impact of timing on the mission outcomes, the operational and clinical activities in the field hospital, and the great importance to integrate local staff into the team.
Violence against women (VAW) is a major public health problem and a violation of women’s human rights. The coronavirus disease 2019 (COVID-19) pandemic has worsened gender inequality, resulting in a heightened incidence of VAW. This study aims to assess the characteristics of women who admit to the emergency department (ED), both before the pandemic and during the pandemic. The secondary aim is to compare the frequencies of violence cases between periods.
Methods:
By single-center, retrospective, and cross-sectional design, the periods of April 10 - December 31, 2020 and April 10 - December 31, 2019 were compared. The outcomes of the study were the daily ED admission numbers of both sexes, the prevalence of VAW cases in the ED, as well as sociodemographic and clinical variables of the women who were exposed to violence.
Results:
During the pandemic period, number of VAW cases in the ED increased 13% and the ratio of VAW cases to all ED admissions tripled compared to the pre-pandemic period. Women exposed to VAW were more likely to be without social insurance, injured in the trunk part of their body, and having a life-threatening injury in the pandemic period. In both periods, women were attacked by an intimate partner, dominantly (42.6% and 54.1%, respectively). In addition, among all admissions of adults to the ED, women’s percentage decreased while men’s admission ratios increased during the pandemic period. Admissions to ED declined 47.7% during the COVID-19 pandemic compared to the year before.
Conclusion:
Cases of VAW tend to increase during the pandemic, and health care settings should be well-organized to respond to survivors.
The use of ultrasound in the out-of-hospital environment is increasingly feasible. The potential uses for point-of-care ultrasound (POCUS) by paramedics are many, but have historically been limited to traumatic indications. This study utilized a scoping review methodology to map the evidence for the use of POCUS by paramedics to assess respiratory distress and to gain a broader understanding of the topic.
Methods:
Databases Ovid MEDLINE, EMBASE, CINAHL Plus, and PUBMED were searched from January 1, 1990 through April 14, 2021. Google Scholar was searched, and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital POCUS performed by non-physicians for non-traumatic respiratory distress.
Results:
A total of 591 unique articles were identified, of which seven articles met the inclusion criteria. The articles reported various different scan protocols and, with one exception, suffered from low enrolments and low participation. Most articles reported that non-physician-performed ultrasound was feasible. Articles reported moderate to high levels of agreement between paramedics and expert reviewers for scan interpretation in most studies.
Conclusion:
Paramedics and emergency medical technicians (EMTs) have demonstrated the feasibility of lung ultrasound in the out-of-hospital environment. Further research should investigate the utility of standardized education and scanning protocols in paramedic-performed lung ultrasound for the differentiation of respiratory distress and the implications for patient outcomes.
Bangladesh is repeatedly threatened by tropical storms and cyclones, exposing one-third of the total population of the country. As a preparedness measure, several cyclone shelters have been constructed, yet a large proportion of the coastal population, especially women, are unwilling to use them. Existing studies have demonstrated a range of concerns that discourage women from evacuating and have explored the limitations of the shelters, but the experiences of female evacuees have not been apparent in these stories. This study explores the lived-experiences of women in the cyclone shelters of Bangladesh and discusses their health and well-being as evacuees in the shelters. Nineteen women from three extremely vulnerable districts of coastal Bangladesh were interviewed. Seven research themes were identified from the participants’ narratives using van Manen’s thematic analysis process. The most salient theme, being understood (as a woman), portrayed the quintessential image of these women, which subsequently influenced their vulnerability as evacuees. The next themes–being a woman during crisis, being in a hostile situation, being fearful, being uncertain, being faithful, and being against the odds–focused on the incidents they lived through which affected their physical and mental health and the emotions they felt as evacuees. The paper offers a deep inquiry into women’s experiences of well-being in the shelters and recognizes the significance of women’s voices to improve their experiences as evacuees.
The European Society of Cardiology (ESC) 2020 guidelines propose an algorithm for in-hospital management of non-ST-elevation myocardial infarction (NSTEMI) based on risk stratification according to clinical, electrocardiographic, and biological data. However, out-of-hospital management is not codified.
Study Objective:
The objective of the present study was to evaluate the role of high-sensitivity cardiac troponin-I in out-of-hospital management of NSTEMI by Emergency Medical Services (EMS).
Methods:
This monocentric, retrospective, observational study analyzed the files of all patients having received a troponin assay in the EMS of Beaujon University Hospital, AP-HP (Paris region, France) from January 1, 2020 through December 31, 2020. Patients were classified as low risk, high risk, or very high risk according to the ESC 2020 algorithm at the time of their hospital treatment. The relationship between troponin in point-of-care and risk level according to time to onset of pain was analyzed using logistic regression. A search for predictors of risk level was performed using multivariate analysis. A P value <.05 was considered significant.
Results:
Out of 309 patients in the file, 233 were included. Men were 61% and the median age was 63 years. A positive troponin assay was associated with high-risk or very high-risk stratification regardless of the time to onset of pain (P <.0001). Predictive factors for being classified as high or very high risk in hospital were: a history of atrial fibrillation (P = .03), electrocardiogram (ECG) modifications such as negative T wave or ST-segment depression (P <.0001), and positive troponin (P <.0001).
Conclusion:
The use of point-of-care troponin in EMS, combined with clinical and electrical criteria, allows risk stratification of NSTEMI patients from the prehospital management stage and optimization of referral to an appropriate care pathway. Patients classified as low risk should be referred to the emergency department (ED) and patients classified as high risk or very high risk to the cardiac intensive care unit or percutaneous coronary intervention (PCI) center.
In March 2021, a series of explosions shook a military base in Bata, Equatorial Guinea. As a response to government officials’ request, the Israel Defense Forces Medical Corps (IDF-MC) deployed an emergency aid team that faced two major challenges: (1) understanding the scenario, the injury patterns, and the needs of the local medical system; and (2) minimizing the coronavirus disease 2019 (COVID-19) outbreak threats. This report describes the team design, the activities performed before and during the deployment, analyzes the pathology encountered, and shares lessons learned from the mission.
Sources:
Data were collected from the delegation protocols and IDF medical records. All activities of the Israeli delegation were coordinated with the local government.
Observations:
The local authorities reported that a total of 107 people were killed and more than 700 people were wounded. The team was the first international team to arrive at the scene and assisted the local medical teams to treat 231 patients in the three local hospitals and 213 patients in field clinics in the villages surrounding Bata. The COVID-19 pandemic influenced the operation of this mission, and caution measures were activated.
Analysis:
Unplanned explosions at munitions sites (UEMS) are a growing problem causing the medical teams to face unique challenges. By understanding the expected challenges, the team was reinforced with a plastic surgeon, portable ultrasound devices, a large amount and a variety of antibiotics, whole blood units, and freeze-dried plasma. Rehabilitation experts were needed in some cases in the week following the injury. An important key for the success of this kind of medical aid delegation is the collaboration with the local medical teams, which enhances patient care.
Trauma is the leading cause of death in the Western world. Trauma systems have been paramount in opposing this problem. Commonly, Level 1 Trauma Centers are staffed by in-house (IH) attending trauma surgeons available 24/7, whereas other institutions function on an on-call (OC) basis with defined response times. There is on-going debate about the value of an IH attending trauma surgeon compared to OC trauma surgeons regarding clinical outcome.
Methods:
This study was performed at a tertiary care facility complying with all requirements to be a designated Level 1 Trauma Center as defined by the American College of Surgeons Committee on Trauma (ACSCOT). Inclusion occurred from January 1, 2012 through December 31, 2013. Patients were assigned an identifier for IH trauma surgeon attendance versus OC attendance. The primary outcome variable studied was overall mortality in relation to IH or OC attending trauma surgeons. Additionally, time to operating theater, hospital length-of-stay (HLOS), and intensive care unit (ICU) admittance were investigated.
Results:
A total of 1,287 unique trauma cases in 1,285 patients were presented to the trauma team. Of all cases, 712 (55.3%) occurred between 1700h and 0800h. These 712 cases were treated by an IH attending in 66.3% (n = 472) and an OC attending in 33.7% (n = 240). In the group of patients treated by an IH attending trauma surgeon, the overall mortality rate was 5.5% (n = 26); in the group treated by an OC attending, the overall mortality rate was 4.6% (n = 11; P = .599). Cause of death was traumatic brain injury (TBI) in 57.6%. No significant difference was found in the time between initial presentation at the trauma room and arrival in the operating theater.
Conclusion:
In terms of trauma-related mortality during non-office hours, no benefit was demonstrated through IH trauma surgeons compared to OC trauma surgeons.
To date, there is limited evidence for health care providers regarding the determinants of early assessment of poor outcomes of adult in-patients due to earthquakes. This study aimed to explore factors related to early assessment of adult earthquake trauma patients (AETPs).
Methods:
The data on 29,933 AETPs in the West China Earthquake Patients Database (WCEPD) were analyzed retrospectively. Then, 37 simple variables that could be obtained rapidly upon arrival at the hospital were collected. The least absolute shrinkage and selection operator (LASSO) regression analyses were performed. A nomogram was then constructed.
Results:
Nine independent mortality-related factors that contributed to AETP in-patient mortality were identified. The variables included age (OR:1.035; 95%CI, 1.027-1.044), respiratory rate ([RR]; OR:1.091; 95%CI, 1.050-1.133), pulse rate ([PR]; OR:1.028; 95%CI, 1.020-1.036), diastolic blood pressure ([DBP]; OR:0.96; 95%CI, 0.950-0.970), Glasgow Coma Scale ([GCS]; OR:0.666; 95%CI, 0.643-0.691), crush injury (OR:3.707; 95%CI, 2.166-6.115), coronary heart disease ([CHD]; OR:4.025; 95%CI, 1.869-7.859), malignant tumor (OR:4.915; 95%CI, 2.850-8.098), and chronic kidney disease ([CKD]; OR:5.735; 95%CI, 3.209-10.019).
Conclusions:
The nine mortality-related factors for ATEPs, including age, RR, PR, DBP, GCS, crush injury, CHD, malignant tumor, and CKD, could be quickly obtained on hospital arrival and should be the focal point of future earthquake response strategies for AETPs. Based on these factors, a nomogram was constructed to screen for AETPs with a higher risk of in-patient mortality.
Many triage algorithms exist for use in mass-casualty incidents (MCIs) involving pediatric patients. Most of these algorithms have not been validated for reliability across users.
Study Objective:
Investigators sought to compare inter-rater reliability (IRR) and agreement among five MCI algorithms used in the pediatric population.
Methods:
A dataset of 253 pediatric (<14 years of age) trauma activations from a Level I trauma center was used to obtain prehospital information and demographics. Three raters were trained on five MCI triage algorithms: Simple Triage and Rapid Treatment (START) and JumpSTART, as appropriate for age (combined as J-START); Sort Assess Life-Saving Intervention Treatment (SALT); Pediatric Triage Tape (PTT); CareFlight (CF); and Sacco Triage Method (STM). Patient outcomes were collected but not available to raters. Each rater triaged the full set of patients into Green, Yellow, Red, or Black categories with each of the five MCI algorithms. The IRR was reported as weighted kappa scores with 95% confidence intervals (CI). Descriptive statistics were used to describe inter-rater and inter-MCI algorithm agreement.
Results:
Of the 253 patients, 247 had complete triage assignments among the five algorithms and were included in the study. The IRR was excellent for a majority of the algorithms; however, J-START and CF had the highest reliability with a kappa 0.94 or higher (0.9-1.0, 95% CI for overall weighted kappa). The greatest variability was in SALT among Green and Yellow patients. Overall, J-START and CF had the highest inter-rater and inter-MCI algorithm agreements.
Conclusion:
The IRR was excellent for a majority of the algorithms. The SALT algorithm, which contains subjective components, had the lowest IRR when applied to this dataset of pediatric trauma patients. Both J-START and CF demonstrated the best overall reliability and agreement.
Tourniquets are the standard of care for civilian and military prehospital treatment of massive extremity hemorrhages. Over the past 17 years, multiple military studies have demonstrated rare complications related to tourniquet usage. These studies may not translate well to civilian populations due to differences in baseline health. Experimental studies have demonstrated increased rates of post-traumatic acute kidney injuries (AKIs) in rats with obesity and increased oxidative stress, suggesting that comorbidities may affect AKI incidence with tourniquet usage. Two recently published retrospective studies, focused on the safety of tourniquets deployed within civilian sectors, documented increased incidence of AKI in patients with a prehospital tourniquet as compared to previously published military results. This study aimed to provide descriptive data concerning the association between the use of prehospital tourniquets and AKIs amongst civilian patient populations as AKIs increase mortality in hospitalized patients.
Methods:
This was a single-center, observational, cross-sectional, pilot study involving chart review of participants presenting to a tertiary Level 1 trauma center. Patient data were extracted from prehospital and hospital electronic medical records. For this study, AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.
Results:
A total of 255 participants were included. Participants with a history of diabetes mellitus had a significantly higher incidence of AKI as compared to those without. Analysis revealed an increased odds of AKI with diabetes in association to the use of a prehospital tourniquet. Participants with diabetes had an increased relative risk of AKI in association to the use of a prehospital tourniquet. The incidence of AKI was statistically higher than what was previous reported in the military population in association with the use of a prehospital tourniquet.
Conclusion:
The incidence of AKIs was higher than previously reported. Patients with diabetes had an associated higher risk and incidence of sustaining an AKI after the use of a prehospital tourniquet in association with the use of a prehospital tourniquet. This may be due to the known deleterious effects of diabetes mellitus on renal function. This study provides clinically relevant data that warrant further multi-site investigations to further investigate this study’s associated findings and potential causation. It also stresses the need to assess whether renally-impacting environmental and nutritional stressors affect AKI rates amongst military personnel and others in which prehospital tourniquets are used.
The first priority of the primary survey of trauma care is airway management. For patients who have a known or suspected cervical spine injury, using the jaw-thrust maneuver is critical. It was hypothesized that the jaw-thrust maneuver would ease the insertion of the laryngeal mask airway (LMA) by moving the tongue forward from the palate and posterior pharyngeal wall.
Study Objectives:
The aim of the study was to evaluate the effect of jaw-thrust maneuver on LMA insertion times of the paramedics with or without chest compression and with or without cervical stabilization in a manikin.
Methods:
Eleven experienced paramedics inserted LMA in jaw-thrust position and standard position in chest compression without cervical stabilization scenario, chest compression with cervical stabilization scenario, cervical stabilization without chest compression scenario, and the scenario where neither cervical stabilization nor chest compression were performed. The primary outcome of the study was the comparison of LMA insertion times for each method. The secondary outcome measures were first-pass success rates and the comparison of the difficulty level of each method.
Results:
During the LMA placement, performing the jaw-thrust maneuver instead of the standard method did not shorten the LMA insertion times. Adding chest compression and/or cervical stabilization did not complicate the LMA insertion. All of the LMA insertion attempts during the jaw-thrust maneuver and standard method were successful.
Conclusion:
The findings of this study suggest that LMA insertion might be attempted both during the jaw-thrust maneuver and standard position in patients with or without chest compression and with or without cervical stabilization.