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Healthcare personnel (HCP) were recruited to provide serum samples, which were tested for antibodies against Ebola or Lassa virus to evaluate for asymptomatic seroconversion.
From 2014 to 2016, 4 patients with Ebola virus disease (EVD) and 1 patient with Lassa fever (LF) were treated in the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital. Strict infection control and clinical biosafety practices were implemented to prevent nosocomial transmission of EVD or LF to HCP.
All personnel who entered the SCDU who were required to measure their temperatures and complete a symptom questionnaire twice daily were eligible.
No employee developed symptomatic EVD or LF. EVD and LF antibody studies were performed on sera samples from 42 HCP. The 6 participants who had received investigational vaccination with a chimpanzee adenovirus type 3 vectored Ebola glycoprotein vaccine had high antibody titers to Ebola glycoprotein, but none had a response to Ebola nucleoprotein or VP40, or a response to LF antigens.
Patients infected with filoviruses and arenaviruses can be managed successfully without causing occupation-related symptomatic or asymptomatic infections. Meticulous attention to infection control and clinical biosafety practices by highly motivated, trained staff is critical to the safe care of patients with an infection from a special pathogen.
Nearly half of care home residents with advanced dementia have clinically significant agitation. Little is known about costs associated with these symptoms toward the end of life. We calculated monetary costs associated with agitation from UK National Health Service, personal social services, and societal perspectives.
Prospective cohort study.
Thirteen nursing homes in London and the southeast of England.
Seventy-nine people with advanced dementia (Functional Assessment Staging Tool grade 6e and above) residing in nursing homes, and thirty-five of their informal carers.
Data collected at study entry and monthly for up to 9 months, extrapolated for expression per annum. Agitation was assessed using the Cohen-Mansfield Agitation Inventory (CMAI). Health and social care costs of residing in care homes, and costs of contacts with health and social care services were calculated from national unit costs; for a societal perspective, costs of providing informal care were estimated using the resource utilization in dementia (RUD)-Lite scale.
After adjustment, health and social care costs, and costs of providing informal care varied significantly by level of agitation as death approached, from £23,000 over a 1-year period with no agitation symptoms (CMAI agitation score 0–10) to £45,000 at the most severe level (CMAI agitation score >100). On average, agitation accounted for 30% of health and social care costs. Informal care costs were substantial, constituting 29% of total costs.
With the increasing prevalence of dementia, costs of care will impact on healthcare and social services systems, as well as informal carers. Agitation is a key driver of these costs in people with advanced dementia presenting complex challenges for symptom management, service planners, and providers.
Introduction: Elderly patients with comorbid illness have poor meaningful recovery after out of hospital cardiac arrest. Many elderly patients decide that if they have a cardiac arrest, they would want not want resuscitation. In Ontario, prehospital personnel must provide resuscitation to all patients regardless of previously stated wishes or legal documentation unless they are presented a Ministry of Health mandated ‘Do Not Resuscitate’ Confirmation Form (MOH-DNRCF). This study aimed to evaluate the awareness of this form as well as any barriers to its completion. Methods: Patients over 70 years of age presenting to the Emergency Department were approached to complete a short survey about their wishes regarding resuscitation, awareness of the MOH-DNRCF, as well as any barriers to completion. Standard demographic variables were also collected. Patients, with critical illness, with severe dementia, a language barrier or from a nursing home were excluded. The primary outcome was awareness of the MOH-DNRCF. Standard descriptive statistics were summarized using median [IQR] and simple proportions. Results: Preliminary data of 96 patients has been collected. The median [IQR] age of patients recruited was 81 [75-88] years and 54% were female. 49/96 (51%) have wishes to not be resuscitated in the event of cardiac arrest and of those 42 (86%) are not aware of the existence of the MOH-DNRCF. Of the 7 patients who were aware of the form only 1 had completed one. Barriers to completion included the patient being unsure where to access the form and difficulty in discussing the topic. Conclusion: The majority of patients with wishes to be DNR are unaware of the MOH-DNRCF. This has severe repercussions as, in the event of an out of hospital cardiac arrest, these patients would be resuscitated by prehospital care providers. Strategies to increase awareness of the form as well as strategies to increase ease of access should be considered to avoid resuscitation that is against patient wishes.
The majority of paediatric Clostridioides difficile infections (CDI) are community-associated (CA), but few data exist regarding associated risk factors. We conducted a case–control study to evaluate CA-CDI risk factors in young children. Participants were enrolled from eight US sites during October 2014–February 2016. Case-patients were defined as children aged 1–5 years with a positive C. difficile specimen collected as an outpatient or ⩽3 days of hospital admission, who had no healthcare facility admission in the prior 12 weeks and no history of CDI. Each case-patient was matched to one control. Caregivers were interviewed regarding relevant exposures. Multivariable conditional logistic regression was performed. Of 68 pairs, 44.1% were female. More case-patients than controls had a comorbidity (33.3% vs. 12.1%; P = 0.01); recent higher-risk outpatient exposures (34.9% vs. 17.7%; P = 0.03); recent antibiotic use (54.4% vs. 19.4%; P < 0.0001); or recent exposure to a household member with diarrhoea (41.3% vs. 21.5%; P = 0.04). In multivariable analysis, antibiotic exposure in the preceding 12 weeks was significantly associated with CA-CDI (adjusted matched odds ratio, 6.25; 95% CI 2.18–17.96). Improved antibiotic prescribing might reduce CA-CDI in this population. Further evaluation of the potential role of outpatient healthcare and household exposures in C. difficile transmission is needed.
Most studies underline the contribution of heritable factors for psychiatric disorders. However, heritability estimates depend on the population under study, diagnostic instruments, and study designs that each has its inherent assumptions, strengths, and biases. We aim to test the homogeneity in heritability estimates between two powerful, and state of the art study designs for eight psychiatric disorders.
We assessed heritability based on data of Swedish siblings (N = 4 408 646 full and maternal half-siblings), and based on summary data of eight samples with measured genotypes (N = 125 533 cases and 208 215 controls). All data were based on standard diagnostic criteria. Eight psychiatric disorders were studied: (1) alcohol dependence (AD), (2) anorexia nervosa, (3) attention deficit/hyperactivity disorder (ADHD), (4) autism spectrum disorder, (5) bipolar disorder, (6) major depressive disorder, (7) obsessive-compulsive disorder (OCD), and (8) schizophrenia.
Heritability estimates from sibling data varied from 0.30 for Major Depression to 0.80 for ADHD. The estimates based on the measured genotypes were lower, ranging from 0.10 for AD to 0.28 for OCD, but were significant, and correlated positively (0.19) with national sibling-based estimates. When removing OCD from the data the correlation increased to 0.50.
Given the unique character of each study design, the convergent findings for these eight psychiatric conditions suggest that heritability estimates are robust across different methods. The findings also highlight large differences in genetic and environmental influences between psychiatric disorders, providing future directions for etiological psychiatric research.
The development of laser wakefield accelerators (LWFA) over the past several years has led to an interest in very compact sources of X-ray radiation – such as “table-top” free electron lasers. However, the use of conventional undulators using permanent magnets also implies system sizes which are large. In this work, we assess the possibilities for the use of novel mini-undulators in conjunction with a LWFA so that the dimensions of the undulator become comparable with the acceleration distances for LWFA experiments (i.e., centimeters). The use of a prototype undulator using laser machining of permanent magnets for this application is described and the emission characteristics and limitations of such a system are determined. Preliminary electron propagation and X-ray emission measurements are taken with a LWFA electron beam at the University of Michigan.
To ascertain in what proportion the vertical segment of the intratemporal carotid artery on its medial aspect anatomically separates the peri-tubal cells and Eustachian tube from the remainder of the pneumatised spaces of the temporal bone.
A retrospective review was conducted of 222 adult and 29 paediatric consecutive computed tomography scans of petrous temporal bones from a single tertiary referral centre.
In 96 per cent of temporal bones, the carotid artery formed a lateral barrier (with no communication pathway medially) between air spaces anterior and posterior to it. This equated to 94 per cent when chronic otitis media cases were excluded.
The degree of separation of middle-ear air cells from the Eustachian tube or nasopharynx, and the relevant anatomy, are reviewed. This knowledge helps to optimise the outcome of subtotal petrosectomy and blind sac closure. The frequency and process of pneumatisation of the petrous apex, and its connections with the middle ear, have been radiologically confirmed.
Introduction: Patients in ventricular fibrillation (VF) who do not respond to standard Advanced Cardiac Life Support treatments are deemed to be in refractory VF (rVF). The ideal prehospital treatment for patients with rVF remains unknown. Double sequential external defibrillation (DSED) has been proposed as a viable option for patients in rVF. Although the mechanism by which DSED terminates rVF remains unknown, one theory is that the change in defibrillation vector that occurs may contribute. The objective of this study was to describe clinical outcomes for patients presenting in rVF during out-of-hospital cardiac arrest (OOHCA) for those who underwent vector change defibrillation, compared to those who received standard treatment. Methods: This was a retrospective chart review of adult (18 years) patients presenting in rVF during OOHCA over 15 months beginning in March 2016. Patients who underwent vector change defibrillation had a change in pad position (anterior-anterior to anterior-posterior) after 3 or more consecutive shocks. Termination of rVF was defined as the absence of VF after a vector change or standard shock during the next rhythm analysis. Results: There were 372 OOHCA, with 25 (6.7%) patients meeting our definition of rVF. Of these, 16 (64.0%) patients (median age 62 years, 81.3% male) had vector change after a median (IQR) of 3 (3.0-4.0) paramedic defibrillation attempts. Median (IQR) time to vector change defibrillation was 8.8 (7.1-11.1) minutes. Eight (50%) patients had termination of rVF after the first vector change shock, 6 (37.5%) had prehospital return of spontaneous circulation (ROSC) and 5 (31.3%) patients survived to hospital discharge. Of the 9 rVF patients who did not have vector change, median age was 63 years and 88.9% were male. The median (IQR) number of defibrillations within this group was 5 (4.5-7.0). No patients converted after the 4th defibrillation. Prehospital ROSC was achieved in 3 (33.3%) patients and 5 (55.5%) patients were transported while in rVF . Three patients (33.3%) survived to hospital discharge. Conclusion: This is preliminary evidence that vector change defibrillation in patients with rVF may result in VF termination. A randomized controlled trial is warranted to test whether or not vector change has a role in the termination of rVF.
Introduction: In Ontario, Advanced Care Paramedics (ACPs) are required to perform a minimum of 24 educational credits per year of Continuing Medical Education (CME). Of these 24 credits, 12 are chosen by the paramedic, while 12 credits are mandated by the Base Hospital. The combined mandatory and optional CME frame is used so paramedics can target their personal needs appropriately, while ensuring new medical directives and global knowledge deficits identified by Quality Assurance (QA) means can be addressed by the Base Hospital. Objective: To determine if there is a difference between what ACPs identify as their knowledge deficits and what CME they complete. Methods: Methods: Request for participation in a written survey was delivered to all ACPs in an Ontario Base Hospital, prior to the CME cycle for the year. Respondents were asked to identify deficits from a 37-point, organ systems-based list, with free-text option for any deficits not itemized. Following the annual cycle, CME credits were evaluated by the Regional Base Hospital education coordinator, and Base Hospital medical directors for content. The deficits identified prior to the CME cycle were then compared to the CME attended for each respondent. In order to best represent the individual ACP response to their perceived deficits, a percentage of deficits identified and addressed was chosen. Respondents were not aware that their responses would be compared to the credits obtained for the year, to minimize bias in CME selection. Results: Of the 140 ACPs in the region, 42 (30%) completed the survey. From the 37-point list, the median number of perceived deficits identified was 7.00 (IQR 3.00-10.00). The median number of CME events that addressed perceived deficits was 2.00 (IQR 1.00-3.00). The median number of perceived deficits addressed by either paramedic-chosen or mandatory CME were identical at 1.00 (IQR 0.00-2.00). The percentage of perceived deficits identified and addressed via CME was 35.07% (range 0-100%). Paramedic-chosen CME covered 22.48% (range 0-100%) of perceived deficits, while mandatory CME covered 20.14% (range 0-100%) of perceived deficits. Conclusion: In the current system, only 35.07% of perceived deficits were addressed through mandatory and paramedic-chosen CME. Further information regarding barriers to paramedics obtaining CME that meets their perceived deficits needs to be elucidated.
Introduction: Objective: To identify self-perceived knowledge deficits of paramedics, barriers to training and desired methods of self-directed continuing education. Methods: A written 58 question survey was delivered to all 1262 paramedics under the jurisdiction of a single base-hospital in Ontario, Canada. Respondents were asked to select deficit, no deficit or not applicable from a 37-point, anatomic systems-based list. They were then asked to identify from a 15-point list which educational modalities they would choose to address any knowledge deficits. Finally, they were asked which factors they took into consideration when choosing their self-directed continuing education. Results: Seven hundred forty-six of 1262 paramedics (59.11%) completed the surveys. Of these respondents, 82 (10.99%) were advanced care paramedics, while 664 (89.01%) were primary care paramedics. Of the 645 who responded with their primary geographical setting: 136 (21.09%) listed a primary urban practice, 126 (19.53%) listed a primary rural practice and 287 (44.50%) reported a split urban and rural practice. The most common perceived deficits (respondent number, percentage); were electrolyte disturbance (418, 56.03%), neonatal resuscitation (386, 51.74%), pediatric respiratory disorder (381, 51.07%), arrhythmia (377, 50.53%), and pediatric cardiac arrest (317, 42.49%). The top 5 educational opportunities they were most likely to choose included online module (464, 62.20%), in-class lecture (423, 56.70%), web-based review (403, 54.02%), webinar (301, 40.35%) and peer consult (237, 31.77%). The top 3 barriers to choosing continuing education were work scheduling (479, 64.21%), location/ease of attending (382, 51.21%), and cost (305, 40.88%). Conclusion: Paramedics in this base hospital system identified pediatric critical care situations, electrolyte abnormalities and cardiac arrhythmia as self-perceived deficits. The most commonly selected educational opportunities included online learning, in-person training and peer consult. These preferred modalities are consistent with the identified barriers of work scheduling, ease of attending and cost. Targeted educational needs based assessments can help ensure that appropriate topics are delivered in a fashion that help overcome identified barriers to self-directed learning.
Introduction: Correctly identifying pathology in pre-pubertal females is a high-stakes physical examination skill. Currently, learning this skill relies heavily on case-by-case exposure, which is variable, limited and often results in suboptimal skill. Thus, there is a need to develop and evaluate learning platforms that simulate the presentation and diagnosis of this important clinical task. We developed an on-line learning and assessment platform that allowed the deliberate practice of 158 pre-pubertal female genital image interpretations . We examined the quantity of skill acquisition by deriving performance metrics and learning curves. Methods: This was a prospective cross-sectional study administered via an on-line learning and assessment platform. Colposcopic images were acquired from a child abuse clinic. Two child abuse experts interpreted images to determine case solutions and 40% of cases had medical or traumatic pathology. Further, to validate image interpretations, a unique set of five child abuse and pediatric gynaecology experts reviewed the cases. Study participants were recruited from the USA and Canada and were required to complete all 158 cases. For each image, learners designated cases as normal or abnormal and if abnormal indicated the abnormal area on the image. The primary outcome was the change in accuracy, sensitivity and specificity. Results: We enrolled 107 participants, 26 medical students, 31 pediatric residents, 24 pediatric emergency fellows, and 26 pediatric emergency attendings. For all participants, the change in accuracy was +9.6% for accuracy (<0.001), +1.4% for sensitivity (p=0.6) and +15.7% (p<0.001) for specificity. The final score for accuracy, sensitivity and specificity was 79.5%, 66.1%, and 87.8%, respectively. There was no difference between learner types with respect to summary performance metrics (accuracy, p=0.15; sensitivity, p=0.44; specificity, p=0.54). Learning curves show maximal learning gains (inflection point) up until 100 cases. Conclusion: Deliberate practice of pre-pubertal female image interpretation was effective for ensuring predictable skill improvement for normal cases but was less effective for abnormal cases. Future research could examine how to refine the education tool to better serve diagnostic skill of abnormal cases.
Introduction: To determine trends in identified self-perceived knowledge deficits of paramedics, training barriers and desired methods of self-directed education. Methods: A written survey was delivered to all paramedics in an Ontario base-hospital. Respondents were asked to identify deficits from a 37-point, anatomic systems-based list. Preferred educational modalities to address knowledge deficits and factors taken into consideration when choosing self-directed education were captured. Top 5 perceived deficit topics, number of perceived deficits, top 5 factors associated with training modality chosen and factors taken into consideration for choosing training modalities, were compared against paramedic age, training (Advanced Care Paramedic; ACP, or Primary Care Paramedic; PCP) and primary location of practice (urban, rural, mixed setting). Results: Of 1262 paramedics, 746 (59.11%) completed the survey. PCPs had a higher report of deficit in both neonatal resuscitation and arrhythmia than ACPs (48.3% vs 58.8%, p=0.015; 40.3% vs 58.5%, p<0.001). Paramedics who listed rural as their primary practice location were more likely to report a deficit in pediatric respiratory disorder than those with a mixed urban/rural and primary urban practice (65.9% vs 46.3%, p=0.000; 65.9% vs 45.9%, p=0.001;) as well as a higher median number of listed deficits (9.00 vs 6.00 vs 6.00, p<0.001). ACPs were more likely to consider scheduling, location/ease of attending and cost as barriers than PCPs (85.4% vs 63.8%, p=0.000; 69.5% vs 51.4%, p=0.002; 69.5% vs 39.5%, p=0.000) while reporting an increased desire for webinar material than PCPs (56.1% vs 40.4%, p=0.007). There were no significant differences found by age. Conclusion: Targeted educational needs-based assessments can help ensure appropriate topics are delivered in a fashion that overcomes identified barriers to self-directed learning. From our analysis, increased awareness of ease of attending sessions and preferred modalities, such as webinars may be beneficial; especially for ACPs who require more annual continuing educational hours. Paramedics in rural locations may require increased continuing education, especially for rarely encountered, high risk situations, such as pediatric critical care. These findings can help direct future education in our system and others.
The properties of the acoustic modes are sensitive to magnetic activity. The unprecedented long-term Kepler photometry, thus, allows stellar magnetic cycles to be studied through asteroseismology. We search for signatures of magnetic cycles in the seismic data of Kepler solar-type stars. We find evidence for periodic variations in the acoustic properties of about half of the 87 analysed stars. In these proceedings, we highlight the results obtained for two such stars, namely KIC 8006161 and KIC 5184732.
The late Pleistocene megafaunal extinctions may have been the first extinctions directly related to human activity, but in North America the close temporal proximity of human arrival and the Younger Dryas climate event has hindered efforts to identify the ultimate extinction cause. Previous work evaluating the roles of climate change and human activity in the North American megafaunal extinction has been stymied by a reliance on geographic binning, yielding contradictory results among researchers. We used a fine-scale geospatial approach in combination with 95 megafaunal last-appearance and 75 human first-appearance radiocarbon dates to evaluate the North American megafaunal extinction. We used kriging to create interpolated first- and last-appearance surfaces from calibrated radiocarbon dates in combination with their geographic autocorrelation. We found substantial evidence for overlap between megafaunal and human populations in many but not all areas, in some cases exceeding 3000 years of predicted overlap. We also found that overlap was highly regional: megafauna had last appearances in Alaska before humans first appeared, but did not have last appearances in the Great Lakes region until several thousand years after the first recorded human appearances. Overlap in the Great Lakes region exceeds uncertainty in radiocarbon measurements or methodological uncertainty and would be even greater with sampling-derived confidence intervals. The kriged maps of last megafaunal occurrence are consistent with climate as a primary driver in some areas, but we cannot eliminate human influence from all regions. The late Pleistocene megafaunal extinction was highly variable in timing and duration of human overlap across the continent, and future analyses should take these regional trends into account.
The northern New England region includes the states of Vermont, New Hampshire, and Maine and encompasses a large degree of climate and edaphic variation across a relatively small spatial area, making it ideal for studying climate change impacts on agricultural weed communities. We sampled weed seedbanks and measured soil physical and chemical characteristics on 77 organic farms across the region and analyzed the relationships between weed community parameters and select geographic, climatic, and edaphic variables using multivariate procedures. Temperature-related variables (latitude, longitude, mean maximum and minimum temperature) were the strongest and most consistent correlates with weed seedbank composition. Edaphic variables were, for the most part, relatively weaker and inconsistent correlates with weed seedbanks. Our analyses also indicate that a number of agriculturally important weed species are associated with specific U.S. Department of Agriculture plant hardiness zones, implying that future changes in climate factors that result in geographic shifts in these zones will likely be accompanied by changes in the composition of weed communities and therefore new management challenges for farmers.
Introduction: Paramedics in our region do not perform 15-lead ECGs. As a result, patients experiencing a Right Ventricular Infarct (RVI) may receive nitroglycerin (NTG). In many cases, paramedics do not administer NTG to those with inferior STEMI out of concern that there may be an associated RVI. The purpose of this study is to determine if there is a difference in prehospital adverse events (AEs) associated with NTG administration in patients with unrecognized RVIs compared to those with an inferior STEMI and no RVI. Methods: Ambulance Call Records (ACR) of patients with prehospital STEMI between Jan 1, 2012 and Dec 31, 2015 were analyzed for the incidence of NTG administration. AEs were defined as HR<60 bpm, systolic BP <100 mmHg or drop of 1/3, GCS decrease of >2, syncope, arrest or death. Hospital records were reviewed to determine patients diagnosed with an inferior STEMI without RVI and those with a concurrent or primary RVI as diagnosed on angiography, ECG or discharge diagnosis. Results: Of the 334 ACRs that were filtered and manually reviewed, 144 were excluded (not STEMI, inter-facility transports, duplicate ACR) resulting in 189 patients that had a prehospital STEMI. The mean (SD) age was 66.9 (13.5) years and 70.6% were male. Of 189 STEMI patients, 82 (42.9%) received NTG. Nineteen (41.3%) of these patients were subsequently diagnosed with RVI and 27 (58.7%) had inferior STEMI without RVI. For patients receiving NTG, AEs occurred in 11 (57.9%) within the RVI group, and 10 (37.0%) within the inferior STEMI group (Δ 20.9%, 95% CI -7.8% to 45.4%, p=0.2). Cardiac arrest or death did not occur in either group. A total of 107 did not receive NTG and of these, 93 (86.9%) did not meet conditions or had contraindications for NTG use (22 RVI, 42 inferior STEMI). Three patients had a cardiac arrest and one died while in EMS care, none of which received NTG or had RVIs. Conclusion: Results of this study suggest no difference in the rate of AEs between patients with inferior STEMI and STEMI with RVI when NTG is administered in the prehospital setting. In our EMS system, the conditions and contraindications of NTG administration may be protective against AEs in RVIs, so the potential benefit of a prehospital 15-lead ECG may be limited.
Introduction: When ventricular fibrillation (VF) cannot be terminated with conventional external defibrillation, it is classified as refractory VF (RVF). There is a paucity of information regarding prehospital or patient factors that may be associated with RVF. The objectives of this study were to determine factors that may be associated with RVF, the initial ED rhythm for patients with prehospital RVF, and the incidence of survival in patients who had RVF and were transported to hospital. Methods: Ambulance Call Records (ACRs) of patients with out of hospital cardiac arrest between Mar. 1 2012 and Apr. 1 2016 were reviewed. Cases of RVF (≥5 consecutive shocks delivered) were determined by manual review of the ACR. ED and hospital records were analyzed to determine outcomes of patients who were in RVF and transported to hospital. Descriptive statistics were calculated and all variables were tested for an association with initial ED rhythm, survival to admission, and survival to discharge. Results: Eighty-five cases of RVF were identified. A history of coronary artery disease (47.10%) and hypertension (50.60%) were the most common comorbidities in patients transported to the ED with RVF. Upon arrival to the ED, 24 (28.2%) remained in RVF, 38 (44.7%) had a non-shockable rhythm, and 23 (27.1%) had return of spontaneous circulation. Thirty-four (40%) survived to admission, while only 18 (21.2%) survived to discharge. Pre-existing comorbidities, time to first shock, time on scene, and transport time were not statistically associated with initial ED rhythm, survival to admission or discharge. Patient age was statistically associated with improved rhythm on ED arrival (p=0.013) and survival to discharge (58.24 yrs vs 67.40 yrs, Δ9.17, 95% CI 1.82 to 16.52, p=0.015). Conclusion: The majority of patients with prehospital RVF have a rhythm deterioration by the time care is transferred to the ED. Of these patients with a rhythm deterioration, few survive to hospital discharge. Younger patients are more likely to remain in RVF and survive to discharge. Further research is required to determine prehospital treatment strategies for RVF, as well as patient populations that may benefit from those treatments.
Introduction: Paramedics are often required to manage violent or combative patients. In order to do so safely, chemical sedation may be required. There are a number of pharmacologic agents which may be used. However, there is a paucity of evidence as to the optimal agent. Objective: To provide a descriptive analysis of a single base hospital’s experience with combative patients and to determine the efficacy and any adverse events (AEs) in the prehospital setting, associated with midazolam use in these patients. Methods: A retrospective chart review of ambulance calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were filtered and manually examined. Patients were excluded if they were 17 or younger. A priori data points were abstracted by trained research personnel from the ambulance call record. Results: Of approximately 350,000 calls over the study period, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam for sedation. Multiple doses were required in 33.3% of patients. Depending on route of administration, the average total dose administered was 6.27 mg (SD 3.98 mg) intramuscular, 10.7 mg (SD 4.00 mg) intranasal and 4.95 mg (SD 3.81 mg) intravenous. Midazolam was documented as effective in treating the combativeness in 133 (71.6%), ineffective in 28 (15.1%), and not documented in 25 (13.4%) calls. AEs post midazolam administration, defined as hypotension, bradypnea, bradycardia, or need for airway intervention, were encountered in 3 (1.61%) calls (respiratory rate of 8, hypotension of 88/59 that responded to intravenous fluid and asymptomatic bradycardia of 59). There was a trend of increasing number of combative patients each year over the study period, with a significant difference in the number of combative calls requiring midazolam administration between 2012 and 2015 (50.0% vs 72.8%, p=0.007). Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with minimal AEs. However, midazolam was ineffective in 15.1% and a third of all patients required multiple doses, prolonging the combative period and compromising paramedic and patient safety. Further research is warranted for this cohort’s emergency department (ED) sedation needs and any associated AEs within 1 hour of ED arrival.
Introduction: Paramedics are required to manage combative patients. In order to do so safely, chemical sedation may be required. Advanced Care Paramedics in our EMS system utilize midazolam for chemical restraint. Our previous research has shown that midazolam appears to have few prehospital adverse events (AEs) associated with its use. However, it required multiple dosages in 33.3% of patients and was deemed ineffective in 15.1% of patients that received it in the prehospital setting. Objective: To determine Emergency Department (ED) AEs associated with the prehospital use of midazolam in combative patients and determine the efficacy of this agent as a chemical restraint during the first hour of the ED stay. Methods: A retrospective chart review of paramedic calls from 2 urban centers, from January 2012 to December 2015 was completed. All cases of combative patients were examined. Patients were excluded if they were 17 or younger. Ambulance call records were linked to the patient’s ED chart. ED charts were reviewed and a priori endpoints were extracted. Results: Of approximately 350,000 calls, there were 269 patients that were combative. Of these, 186 (69.1%) received midazolam in the prehospital setting. During the first hour of their ED stay, 68 (36.5%) required further sedation, while 118 (63.4%) patients did not. Of the 186 patients who received midazolam in the prehospital setting there was one death and one AE in the ED (defined as hypotension, bradypnea, or need for airway intervention). After further review of the charts, both AEs were deemed likely resulting from underlying pathology and not related to the use of midazolam. The average ED Length of stay (LOS) was 7.6 hours for all patients. A total of 82 (44.1%) were admitted to hospital with a mean in hospital LOS of 13.1 days. Conclusion: Prehospital use of midazolam for combative patients appears to be safe, with no reported delayed AEs. 36.5% of this cohort required further sedation within 1 hour of their ED arrival. This supports previous findings that midazolam was ineffective in 15.1 % of prehospital combative patients. Further study is required to determine midazolam’s efficacy and AE profile compared to other prehospital agents in order to ensure optimal safety of both patients and paramedics.