Category: EMS
Keywords: refusal, AMA, online medical direction (PubMed Search)
Posted: 10/16/2024 by Jenny Guyther, MD
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EMS may call the hospital to obtain online medical direction when a patient does not wish to come to the hospital. One difficult task faced by the physician at the hospital is determining the decision making capacity of the patient. There is currently no nationally recognized standard protocol for physicians providing EMS oversight in this situation.
The four components involved in the determination of capacity are: understanding, appreciation, reasoning and expression of choice. This study used a modified Delphi approach with 19 physician experts to develop standardized steps to guide best practices for physicians who are called in real time about a patient refusing EMS transport. Consensus was defined as 80% agreement.
The example worksheet with the compilation of recommendations is attached.
Carrillo, E. A., Ignell, S. P., Wulfovich, S., Vernon, M. J., & Sebok-Syer, S. S. (2024). Critical Steps for Determining Capacity to Refuse Emergency Medical Services Transport: A Modified Delphi Study. Prehospital Emergency Care, 1–6. https://doi.org/10.1080/10903127.2024.2403650
Refusal checklist table-670fb6a9192a8.docx (105 Kb)
Category: EMS
Keywords: Cardiac arrest, Sodium Bicarbonate, EMS, Tricyclic Antidepressant (PubMed Search)
Posted: 10/4/2024 by Ben Lawner, MS, DO
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Background:
Despite a lack of reliable evidence, sodium bicarbonate (SB) still appears in various protocols as a potential therapy for patients in cardiac arrest. Local EMS protocols also endorse the use of (SB) in specific scenarios such as: tricyclic overdose and hyperkalemia. EMS systems struggle to articulate best practices with respect to indications for SB administration.
Patients/methods:
Study authors conducted a scoping review of existing literature. The review included in hospital and out of hospital patients with cardiac arrest. Despite multiple studies looking at this question, a total of 12 were included in the final analysis. Criteria for inclusion were as follows: RCT or observational studies looking at patients aged 18 or older who experienced a cardiac arrest. Important outcome metrics incorporated: neurological recovery and survival to discharge.
Results:
The retrospective review failed to demonstrate a reliable association between survival and administration of sodium bicarbonate. Despite significant limitations (different study populations, retrospective designs), there remains insufficient evidence to consider routine administration of bicarb in the setting of cardiac arrest.
Bottom line:
Empiric administration of SB is not linked to a reliable benefit. SB may be considered for specific indications (tricyclic overdose, hyperkalemia) but is unlikely to improve outcomes such as neurologic recovery or hospital discharge. EMS systems should avoid recommending routine SB administration for patients with out of hospital cardiac arrest.
Batarda Sena PM, Rodrigues J, Das Neves Coelho F, Soares Nunes B, Fernandes O, Fernandes N, Nóbrega JJ. Sodium Bicarbonate In In-Hospital and Out-of-Hospital Cardiac Arrest: A Systematic Literature Review. Cureus. 2024 Aug 30;16(8):e68192. doi: 10.7759/cureus.68192. PMID: 39347297; PMCID: PMC11439239.
Category: EMS
Keywords: excited delirium, sedation, intubation (PubMed Search)
Posted: 9/18/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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This study looks at the efficacy of ketamine vs. midazolam for the prehospital sedation of acutely agitated patients, examining the need for repeat sedation (by EMS or in the ED), adverse events and length of stay.
A greater number of patients required repeat sedation within 90 minutes with initial ketamine dosing compared to midazolam. There was no difference in patients receiving repeat sedation within 20 minutes between the two groups.
There were no significant differences in time to repeat sedation, total sedation doses (by EMS or in the ED), use of bag valve mask ventilation or intubation, use of physical restraints, admission location/level of care, or length of stay in the Emergency Department (ED), hospital, or Intensive Care Unit.
Holland D, Glober N, Christopher S, Zahn E, Lardaro T, O'Donnell D. Prehospital sedation with ketamine vs. midazolam: Repeat sedation, intubation, and hospital outcomes. Am J Emerg Med. 2020;38(9):1748-1753. doi:10.1016/j.ajem.2020.05.011
Category: EMS
Keywords: DEI, health equity, CPR (PubMed Search)
Posted: 8/21/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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Previous literature has shown that there is a survival difference between White and Black palpitations with regards to out of hospital cardiac arrest (OHCA) in the US.
This study looked at OHCA variables and outcomes among 5 racial/ethnic groups (White, Black, Asian, Hispanic, and Pacific Islander). Data was collected from the CARES registry from 3 racially diverse counties. The adjusted risk ratio for survival to hospital discharge was lower in all 4 other groups compared to patients where data entry identified the patient as White. The risk difference for positive neurologic outcomes was also lower among Black, Asian, Hispanic, and Pacific Islander patients.
When looking at variables associated with the cardiac arrests, there were differences between the groups with regards to response location and bystander CPR.
Bottom line: Cardiac arrest recognition and CPR education needs to be inclusive of all racial/ethnic groups and focus on areas where disparities exist.
Anderson KL, Saxena MR, Matheson LW, et al. Differences in Out-of-Hospital Cardiac Arrest Outcomes Among 5 Racial/Ethnic Groups. Prehosp Emerg Care. Published online April 23, 2024. doi:10.1080/10903127.2024.2335639
Category: EMS
Keywords: EMS, cardiopulmonary resuscitation, CPR, emergency medical services (PubMed Search)
Posted: 8/8/2024 by Ben Lawner, MS, DO
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BACKGROUND:
Cardiac arrest is time sensitive disease. Despite significant advances in resuscitation technology such as eCPR and mechanical compression devices, early basic life support interventions (specifically bystander CPR) are strongly associated with survival. EMS systems must advocate for early initiation of bystander CPR. Dispatch Assisted CPR (DA-CPR) is one of several strategies designed to improve outcomes and encourage early compressions. To optimize survival, EMS systems should achieve a comprehensive understanding about barriers to succesful initiation of DA-CPR.
METHODS AND OUTCOMES:
49,165 patients with out of hospital cardiac arrest were eligible for inclusion the study, and over 36,000 underwent successful DA-CPR. The study's primary outcome was good neurological recovery at hospital discharge. Secondary outcomes included: prehospital return of spontaneous circulation (ROSC)and survival to hospital discharge. The authors defined successful DA-CPR when bystanders initiated compressions and continued resuscitation until the arrival of EMS.
RESULTS:
Quite a few results were consistent with prior studies. Unsuccessful DA-CPR was associated with:
Successful DA-CPR was more likely associated with the presence of family members at the scene and improved neurological recovery. Witnessed arrests were also more likely to receive successful DA-CPR. Not surpringly, patients in the successful DA-CPR group also exhibited improved survival to discharge and prehospital ROSC.
BOTTOM LINE:
Though the study is retrospective and involves a host of confounding variables, EMS systems continue to identify modifiable factors linked to the delivery of DA-CPR. Improved community CPR education and dispatcher training may contribute to higher DA-CPR rates.
BALTIMORE, MD, SPECIFIC PEARL:
Baltimore metropolitan jurisdictions are collaborating with the CPR LifeLinks program to address DA-CPR. The CPR LifeLinks program a national initiative “to help communities save more lives through implementation of telecommunicator and high performance CPR programs." https://www.911.gov/projects/cpr-lifelinks/
Park DH, Park GJ, Kim YM, Chai HS, Kim SC, Kim H, Lee SW. Barriers to successful dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest in Korea. Resusc Plus. 2024 Jul 19;19:100725. doi: 10.1016/j.resplu.2024.100725. PMID: 39091585; PMCID: PMC1129358
Category: EMS
Keywords: intubation, timing, trauma arrest, prehospital (PubMed Search)
Posted: 6/19/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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Several studies have shown that patients who require a resuscitative thoracotomy (RT) have a higher odds of survival if they are transported by police or in private vehicles. This study examined 195 patients who required RT to see if prehospital intubation and out of hospital time (OOHT) affected ROSC rates.
There was no association between OOHT and ROSC and no association of OOHT and survival. The mean OOHT for this study was only 25 minutes which is faster than other studies.
The odds of ROSC were lower in patients who had ANY intubation attempts prior to arrival.
Bottom line: BLS airway management (or supraglottic placement) may be more beneficial for the trauma arrest patient in the prehospital setting.
Radulovic N, Hillier M, Nisenbaum R, Turner L, Nolan B. The impact of out-of-hospital time and prehospital intubation on return of spontaneous circulation following resuscitative thoracotomy in traumatic cardiac arrest. Prehosp Emerg Care. 2023 Nov 28:1-14. doi: 10.1080/10903127.2023.2285390. Epub ahead of print. PMID: 38015060.
Category: EMS
Keywords: delivery, neonatal, OB, contractions (PubMed Search)
Posted: 5/15/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births. There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena. This study aimed to quantify the complications encountered by EMS clinicians.
In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.
1% of the out of hospital deliveries had a documented complication for the mother. Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.
Few patients had medications given, including 0.4% receiving oxytocin. no patients received prehospital blood transfusion or TXA. Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.
Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications. Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available). EMS clinicians should be educated on up to date management of OB emergencies.
Rebecca E. Cash, Anjali J. Kaimal, Margaret E. Samuels-Kalow, Krislyn M. Boggs, Maeve F. Swanton & Carlos A. Camargo Jr (2023) Epidemiology of Emergency Medical Services-Attended out-of-Hospital Deliveries and Complications in the United States, Prehospital Emergency Care, DOI: 10.1080/10903127.2023.2283892
Category: EMS
Keywords: pediatric trauma, vital signs, blood pressure (PubMed Search)
Posted: 4/17/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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The short answer is yes, pediatric trauma patients without blood pressures recorded from EMS had a higher mortality (4.3%) compared to pediatric patients that did have a recorded blood pressure (1.1%). This is based off of a prehospital study conducted in Japan.
Prehospital vital signs are left out more often in pediatric patients compared to adults. Of those vital signs that are recorded, blood pressure is the most common one left off.
There can be several barriers to obtaining a blood pressure on the pediatric patient in the prehospital setting: lack of properly sized equipment, an uncooperative child, and lack of education. However, the inability to obtain a blood pressure can also be due to the patient being more severely injured and having other skills performed or was unable to be obtained due to poor perfusion. In this study, those who did not have a recorded blood pressure also had a lower GCS score and a higher injury severity score.
Shinohara et al. Association between blood pressure recording in prehospital setting and patient outcome in pediatric trauma patients: A prospective matching study. Journal of Trauma and Acute Care Surgery. July 2023. Epub ahead of print.
Category: EMS
Keywords: cardiac arrest, ECMO, E-CPR, mechanical ventilation (PubMed Search)
Posted: 4/3/2024 by Ben Lawner, MS, DO
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BACKGROUND:
The ideal strategy for out of hospital ventilation is a matter of long standing debate and clinical controversy. To date, improved out of hospital outcomes have been associated with non invasive (BVM) and supraglottic airway (SGA) management strategies. A recent, prospective trial featured in Resuscitation offers a slightly different perspective. The trial enrolled 420 adult patients with refractory out of hospital cardiac arrest due to a shockable rhythm. The study looked at outcomes for patients who received endotracheal intubation (ETI) or supraglottic airway placement. Importantly, the study involved a high volume cannulation center and codified screening criteria for eCPR including: a) ongoing arrest despite 3 shocks, b) treatment with amiodarone, c) mechanical CPR and d) anticipated time to arrival at ECMO cannulation center of <30 minutes.
OUTCOMES:
Compared to patients in the SGA group, patients receiving ETI demonstrated:
In accordance with the study institution's cannulation criteria, more patients in the SGA group were deemed ineligible for ECMO.
BOTTOM LINE:
In this single center study, patients who received ETI as a primary strategy for out of hospital airway management were more likely to meet ECMO eligibility critera and exhibit improved oxygenation and ventilation.
While this is not necessarily a practice changing article, it illustrates the complexities inherent in out of hospital cardiac arrest management. EMS has largely transitioned from a “scoop and run” cardiac arrest strategy to a plan that emphasizes treat in place. For patients who may benefit from E-CPR, additional research is indicated to shed light on best out of hospital resuscitation (and airway management) practices.
Bartos JA, Clare Agdamag A, Kalra R, Nutting L, Frascone RJ, Burnett A, Vuljaj N, Lick C, Tanghe P, Quinn R, Simpson N, Peterson B, Haley K, Sipprell K, Yannopoulos D. Supraglottic airway devices are associated with asphyxial physiology after prolonged CPR in patients with refractory Out-of-Hospital cardiac arrest presenting for extracorporeal cardiopulmonary resuscitation. Resuscitation. 2023 May;186:109769. doi: 10.1016/j.resuscitation.2023.109769. Epub 2023 Mar 17. PMID: 36933882.
Category: EMS
Keywords: Suicide, EMS, prevention, causes (PubMed Search)
Posted: 3/20/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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7,365 suicide related cardiac arrests were included in this study that included a several year study period in Queensland Australia. Cardiac arrests where resuscitation was attempted by EMS and where circumstances were concerning for suicide were included. ROSC rates were 28.6% with survival at 30 days being only 8%. 30-day survival for medical cardiac arrests in this jurisdiction was 16.4%. Overdose and poisoning had the best survival rate (19.9%), while hanging and chemical asphyxia were the worst (7.3 and 1.1% respectively).
Bottom line: Survival rates for suicide related out of hospital cardiac arrest were worse compared to other causes of medical arrest. Suicide prevention should become a focus with emphasis on early identification and treatment of people at high risk of suicide. While EMS is well trained on the management of cardiac arrest, training should also emphasize suicide risk assessment and identification.
Doan et al. Suicide related out-of-hospital cardiac arrests in Queensland, Australia: temporal trends of characteristics and outcomes over 14 years. Prehospital Emergency Care. 2023.
Category: EMS
Keywords: vital signs, age, pediatric, prehospital intervention (PubMed Search)
Posted: 2/21/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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Vital signs in children can be difficult to remember since they vary with age. Using a standardized card or app (such as PALS) can help EMS clinicians remember the values. Most pediatric vital sign reference ranges were derived from samples of healthy children in the outpatient setting (ie PALS). This study attempted to validate a range of pediatric vital signs that were more accurate in predicting the need for prehospital interventions compared to the standard PALS vital sign ranges. The thought was that by using EMS data, these vital sign ranges could better alert EMS to patients in need of acute intervention.
The authors used a large EMS database to determine the vital signs for the patients age and correlated that to prehospital interventions (including IV, medication, EKG, advanced airway management, ect). They used the <10% and >90% for the age values (termed "extreme" vitals signs) as a cut off to be considered abnormal. Using the EMS derived values, 17.8% of the encounters with an extreme vital sign received medication. If the PALS abnormal vital sign range was used, only 15.2% of those patients were given medications. Overall, encounters with an extreme vital sign had a higher proportion of any intervention being performed compared to other vital sign criteria (i.e. only 33.7% with PALS).
These extreme vital signs also had a greater accuracy in predicting mortality.
Bottom line: While vital signs are based on physiology that does not change based on location, using a seperate criteria for the EMS population, can improve discrimination between sick and sicker patients and hopefully allow EMS to recognize and intervene on sicker patients sooner.
Ramgopal S, Sepanski RJ, Crowe RP, Martin-Gill C. External validation of empirically derived vital signs in children and comparison to other vital signs classification criteria [published online ahead of print, 2023 Apr 27]. Prehosp Emerg Care. 2023;1-15. doi:10.1080/10903127.2023.2206473
Category: EMS
Keywords: ACS, PE, risk stratification (PubMed Search)
Posted: 1/17/2024 by Jenny Guyther, MD
(Updated: 10/29/2024)
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The 2nd most common reason for EMS activation is chest pain. In this study, paramedics were asked to complete the HEAR (history, EKG, age, risk factor) score, EDACS (ED Assessment of chest pain score), the Revised Geneva Score and the PERC (Pulmonary embolism rule-out criteria) for all patients older than 21 who presented with chest pain. The positive and negative likelihood ratios (LR) of the risk scores in relation to 30 day MACE and PE risk were calculated.
837 patients were included in this study with 687 patients having all 4 scores completed. The combination of HEAR/PERC had the best negative LR (0.25) for ruling our MACE and PE at 30 days. However, these scores, alone or in combination, were not sufficient to exclusively guide treatment or destination decisions. Adding biomarkers (ie troponin or Ddimer to the prehospital setting) could improve the usefulness of these scores.
Stopyra JP, Snavely AC, Ashburn NP, et al. Performance of Prehospital Use of Chest Pain Risk Stratification Tools: The RESCUE Study. Prehosp Emerg Care. 2023;27(4):482-487. doi:10.1080/10903127.2022.2036883
Category: EMS
Posted: 1/7/2024 by Ben Lawner, MS, DO
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BACKGROUND:
Critical care transport teams are tasked with extending specialized care to the bedside. Given the uptick in COVID and ARDS cases, there are increasing demands for the transport of patients proned for respiratory compromise. An air medical service in British Columbia (BC) published their experience with transporting intubated patients in the proned position. The BC service utilizes 2 trained flight paramedics and conducts transports via pressurized fixed wing and non pressurized rotor wing aircraft. The small, retrospective study of 10 patients demonstrated feasibility of this practice. No extubations were recorded in the study population. 6/10 patients experienced >6% increase in oxygen saturation and no medical lines were disconnected during transport.
BOTTOM LINE:
BALTIMORE, MD SPECIFIC PEARL:
BONUS AVIATION ENTHUSIASTC SPECIFIC PEARL:
Naples C, Micalos PS, Johnston T, Schlamp R, Besserer F, Vu E. Prone Positioning of Ventilated Patients During Air Medical Evacuation: A Case Series. Air Med J. 2024 Jan-Feb;43(1):55-59. doi: 10.1016/j.amj.2023.10.004. Epub 2023 Nov 8. PMID: 38154841.
1402JEMSbc-p07 BCHEMS-659aec1e4a6bf.jpeg (186 Kb)
Category: EMS
Keywords: EMS, red, yellow, divert, capacity (PubMed Search)
Posted: 12/20/2023 by Jenny Guyther, MD
(Updated: 10/29/2024)
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US hospitals have traditionally been concerned that without an ambulance diversion protocol that they would be overrun with EMS arrivals. EMS had been concerned that without diversion there would be extended wait times at the hospital. This study looked at EMS arrivals one year (2021) before the elimination of diversion and compared the number to one year after diversion elimination (2022).
This study of a single level 1 trauma center showed that there was NO difference between the number of EMS arrivals per day (84 vs 83, p = 0.08), time to room for ESI 2 patients, time to head CT in acute stroke patients OR ambulance turn around time (16 min vs 17 min, p = 0.15).
Aaron M. Burnett, Kari B. Haley, Matthew F. Milder, Bjorn K. Peterson, Joey Duren, Andrew Stevens, Danielle M. Hermes, Paul Nystrom, Joseph Lippert, Jennifer L. Moberg & Kurt M. Isenberger (2023) Elimination of Emergency Department Ambulance Divert during the COVID-19 Pandemic Was Not Associated with an Increase in the Average Number of Ambulance Arrivals per Day, Prehospital Emergency Care, DOI: 10.1080/10903127.2023.2271567
Category: EMS
Keywords: EMS, trauma, emergency medical services, (PubMed Search)
Posted: 12/6/2023 by Ben Lawner, MS, DO
(Updated: 10/29/2024)
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BACKGROUND
EMS systems differ in staffing and composition. The Japanese model utilizes “doctor cars” which bring a physician and nurse to the scene of a critical patient encounter. Personnel on the “doctor cars” are able to perform advanced therapies such as REBOA, finger thoracostomy, and chest tube thoracostomy. As physician EMS fellowships continue to expand in the United States, it is helpful to examine the utility of physician response incorporated into prehospital emergency care.
THE STUDY
A nationwide retrospective cohort study including over 370,000 patients examined the impact of Japan “doctor cars” upon in hospital survival. Doctor cars responded to 2361 trauma patients, and traditional Ground Emergency Medical Services (GEMS) units cared for 46,783 trauma patients. The study’s primary outcome was survival to discharge.
The adjusted odds ratio for survival was significantly higher in the exposure group served by the doctor cars. The study suggests that there may be a role for augmenting ground EMS personnel in the response to critical injuries. Via logistic regression, the study controlled for multiple other variables such as age, sex, prehospital vital signs, out of hospital time, and injury severity score (ISS).
BOTTOM LINE
This study is far from definitive but contributes to a growing body of literature addressing how EMS physicians integrate into prehospital systems.
Hayashi T, Matsuo K, Furuya S, Nakajima Y, Hitomi S, Ogawa K, Suzuki H, Yamamoto D, Asami M, Sakamoto S, Kamiyama J, Okuda Y, Minami K, Teshigahara K, Gokita M, Yasaka K, Taguchi S, Kiyota K. Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan. Eur J Trauma Emerg Surg. 2023 Nov 24. doi: 10.1007/s00068-023-02383-w. Epub ahead of print. PMID: 37999771.
Category: EMS
Keywords: mental health, excited delirium, agitation, sedation, ketamine (PubMed Search)
Posted: 11/15/2023 by Jenny Guyther, MD
(Updated: 10/29/2024)
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Bourke et al. Acute Severe Behavioral Disturbance Requiring Parenteral Sedation in Pediatric Mental Health Presentations to Emergency Medical Services: A Retrospective Chart Review. Annals of Emergency Medicine. 2023; 1-13. epub ahead of print.
Category: EMS
Keywords: Stroke, EMS, medical record linkage, prehospital (PubMed Search)
Posted: 11/3/2023 by Ben Lawner, MS, DO
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BACKGROUND: Prehospital (EMS) clinicians are positioned on the front lines of health care. With respect to stroke identification and treatment, early recognition is essential to positive outcomes. Considerable variability exists within EMS documentation. Despite considerable variability in documentation, the establishment and tracking of core stroke metrics serves as a benchmark to gauge performance and outline strategies for improvement.
METHODS: Authors conducted a retrospective, observational analysis of EMS encounters (2018-2019) which ultimately received a diagnosis of an "acute cerebrovascular event." Hospital based diagnoses included: hemorrhagic stroke, ischemic stroke, or transient ischemic attack. The data set was comprised of a statewide EMS documentation and a state wide acute stroke registry. Authors examined compliance with six core performance metrics which included measurement of blood glucose, documentation of last known well time, and on-scene time < 15 mins for patients with suspected stroke. During the 18 month study, almost 6000 encounters met criteria for inclusion.
RESULTS: EMS documentation remains a significant source of variability. EMS crews were largely compliant with blood glucose measurement. However, last known well time had the lowest (24%) documentation rate. Patients diagnosed with subarachnoid hemorrhage had the lowest rate of compliance with metrics.
BOTTOM LINE: Accurate prehospital stroke diagnosis remains a challenge. Consistent data collection and benchmarking remains an important first step in the evaluation of performance. Higher NIHSS scores and ischemic strokes are linked to higher rates of metric compliance.
Oostema JA, Nickles A, Luo Z, Reeves MJ. Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry. J Am Heart Assoc. 2023 Jan 3;12(1):e026834. doi: 10.1161/JAHA.122.026834. Epub 2022 Dec 20. PMID: 36537345; PMCID: PMC9973590.
Category: EMS
Keywords: BVM, tidal volume, TV, ALS, BLS (PubMed Search)
Posted: 10/18/2023 by Jenny Guyther, MD
(Updated: 10/29/2024)
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The typical bag valve mask ventilator (BVM) for adults has a reservoir volume between 1500-2000 mL depending on the manufacturer while the volume is between 500-1000 mL for a pediatric BVM. When trying to obtain the recommended tidal volume of 6-8 mL/kg (500-600 mL for the typical adult), one thought was that a pediatric BVM could be used with adult patients so as to avoid iatrogenic barotrauma. This has been studied on manakins using an oral pharyngeal airway, supraglottic airway and endotracheal tubes (ETT) and has been successful. This study attempted to obtain the same results in the back of a moving ambulance. Paramedics and EMTs, squeezing pediatric and adult BVMs with one hand, bagged adult manakins in the back of a moving ambulance (without lights and sirens). The average tidal volume was recorded using various types of airways (i-gel, King airway and ETT).
Volumes delivered with the pediatric BVM were significantly lower than the tidal volumes with adult BVMs across all airway types suggesting that in the moving ambulance, using pediatric BVMs on an adult patient would not be appropriate.
The I-Gel and King airway provided similar tidal volumes which were not statistically different than volume delivered through the ETT.
EMTs consistently delivered 50% less tidal volumes compared to paramedics. The authors suggested that perhaps the additional training and pathophysiology knowledge that paramedics have could also be important with a skill that is considered basic.
Sun et al. Are Pediatric Manual Resuscitators Only Fit for Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance. Prehospital Emergency Care 2023, 27:4, 501-505.
Category: EMS
Keywords: Emergency medical services, harm reduction, buprenorphine, overdose (PubMed Search)
Posted: 10/5/2023 by Ben Lawner, MS, DO
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BACKGROUND:
Emergency Medical Services (EMS) systems, especially those within urban jurisdictions, struggle to effectively meet the needs of patients experiencing complications of substance use. The exceedingly high burden of disease, coupled with potentially life-threatening sequelae of substance use stresses EMS systems beyond capacity. The current paradigm of naloxone administration and subsequent refusal of care places patients at an increased risk of death and other complications such as aspiration. EMS agencies, in collaboration with area hospitals, public health experts, and addiction medicine specialists are devising novel mitigation strategies to reduce morbidity and mortality. “Leave behind” naloxone, peer outreach, and 911 diversion programs are part of a more over-arching strategy that links patients to longer term, definitive health care resources within the community. EMS-administered buprenorphine has emerged as a novel treatment modality for prehospital patients. This study examined outcomes of patients who were a) experiencing symptoms of opiate withdrawal and b) given buprenorphine by a credentialed EMS paramedic. Patients included in the buprenorphine cohort scored >5 on the clinical opiate withdrawal scale (COWS), regained “full decisional capacity” after being resuscitated from an overdose, and were > 18 years of age. The study excluded pregnant patients and those who took methadone within 48 hours prior to an EMS encounter. After consultation with an EMS physician, patients received 16 mg of sublingual buprenorphine. Paramedics could administer ondansetron and an additional 8 mg of buprenorphine for continued symptoms. Finally, the study cohort was matched to a similar group of patients who were treated by “non buprenorphine equipped” ambulance. Outcomes of interest included: rates of repeat overdose, likelihood of transport, and follow up with addiction medicine/substance use resources. The study was conducted in an urban EMS system with robust EMS physician oversight and advanced life support transport units.
RESULTS:
Patients receiving buprenorphine did not experience a reduction in repeat overdose. However, they were less likely to be transported. The buprenorphine cohort, predictably, was much more likely to be enrolled in a substance use treatment program within 30 days of the initial encounter. Paramedics spent more time on scene with the buprenorphine cohort. Though far from a conclusive study, the manuscript adds to a growing body of literature that attests to the feasibility of paramedic administered buprenorphine.
BOTTOM LINE:
Though far from a conclusive study, buprenorphine administration by EMS paramedics is feasible. The increased linkage to care and decreased rates of transport will hopefully motivate EMS systems to consider novel strategies for harm reduction. The study authors opine that buprenorphine may “be a promising…link to long term recovery.”
Carroll G, Solomon KT, Heil J, Saloner B, Stuart EA, Patel EY, Greifer N, Salzman M, Murphy E, Baston K, Haroz R. Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services. Ann Emerg Med. 2023 Feb;81(2):165-175. doi: 10.1016/j.annemergmed.2022.07.006. Epub 2022 Oct 1. PMID: 36192278.
Category: EMS
Keywords: cardiac arrest, CPR, bystander (PubMed Search)
Posted: 9/20/2023 by Jenny Guyther, MD
(Updated: 10/29/2024)
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Ko YC, Hsieh MJ, Schnaubelt S, Matsuyama T, Cheng A, Greif R. Disparities in layperson resuscitation education: A scoping review [published online ahead of print, 2023 Jul 25]. Am J Emerg Med. 2023;72:137-146. doi:10.1016/j.ajem.2023.07.033