Use of a limited lights and siren protocol in the prehospital setting vs standard usage.

OBJECTIVE: Our objective was to determine if implementing a standard lights and sirens (L&S) protocol would reduce their use and if this had any effect on patient disposition. METHODS: In a prospective cohort study, we trained emergency medical services (EMS) personnel from 4 towns in an L&S protocol and enrolled control personnel from 4 addition towns that were not using the protocol. We compare the use of L&S between them over a 6-month period. Our protocol restricted the usage of L&S to patients who had maladies requiring expedited transport. Emergency medical services personnel from the control towns had no such restrictions and were not aware that we were tracking their usage of L&S. We also considered if patient disposition was affected by the judicious usage of L&S. RESULTS: Prehospital EMS personnel who were trained in an L&S protocol were 5.6 times less likely to use L&S when compared with those not trained. Of the 808 patients transported by both types of workers, no difference in patient disposition was observed. CONCLUSIONS: Our protocol significantly reduced the use of L&S. Judicious use of L&S has significant implications for transport safety. By allowing for selective transport with L&S usage, we observed no impact in patient disposition.

Comparison of Prehospital Glucose with or without IV Thiamine.

INTRODUCTION: Loading of thiamine prior to glucose administration during hypoglycemia to prevent Wernicke's encephalopathy is routine in the prehospital setting. To date no study has looked at the validity of this therapy. METHODS: We evaluated a retrospective cohort of 242 patients who received intravenous glucose for hypoglycemia comparing those who received thiamine supplementation versus those who did not. Study endpoints were heart rate, blood pressure, Glasgow Coma Scale (GCS), reentry into the 911 system, and emergency department (ED) discharge rates. RESULTS: There were no significant differences between the thiamine, and without-thiamine groups. All patients were discharged neurologically intact or were alert and oriented when refusing transport to the hospital. None of the 242 patients re-called 911 within the immediate 24-hour period or returned to the ED. CONCLUSION: To our knowledge this is the first study in the literature which evaluated the use of thiamine with glucose to prevent Wernicke's encephalopathy in the prehospital setting. We found that routine administration of thiamine with glucose did not result in differences in respiratory rate, systolic blood pressure, GCS or ED hospital discharge rates. Until further research is done to validate our results emergency medical services leadership should consider whether the routine use of thiamine in the prehospital setting is appropriate for their system.

Impact of trauma activation on the ED length of stay for nontraumatic patients.

INTRODUCTION: Trauma activation prioritizes hospital resources for the assessment and treatment of trauma patient over all patients in the emergency department (ED). We hypothesized that length of stay (LOS) is longer for nontrauma patients during a trauma activation. METHODS: A retrospective, case-control chart review was conducted in a level I trauma center. Cases consist of patients who present 1 hour before and after the presentation of the trauma activation. Controls were patients presenting to the ED during the same period exactly 1 week before and after the cases. Confounding variables measured included sex, age, arrivals, and census for the 3 areas. RESULTS: Two hundred ninety-four trauma events occurred from January 1 until September 30, 2009. A significant difference was found between LOS of patients seen during a trauma activation with an average increase of 10.7 minutes in LOS (P =.0082; 95% confidence interval [CI], 2.8-18.7). This difference is attributable to the middle acuity area of the ED, in which the average increase in LOS was 20.3 minutes (P = .0004; 95% CI, 9.1-31.5). Significant LOS difference was not found when a trauma activation had an LOS of less than 60 minutes (P = .30; 95% CI, -7.1-61.7 for trauma LOS <60 minutes vs P = .02; 95% CI, 1.6-18.0 for trauma LOS ≥60 minutes). CONCLUSION: This retrospective case-control chart review identified an increase in ED LOS for patient presenting during trauma activations. Resource prioritization should be accounted for during times when these critical patients enter the ED.

Study of placing a second intravenous line in trauma.

OBJECTIVE: We evaluated the benefit of emergency medical services providers' placing a second intravenous (IV) line in the prehospital trauma setting. Our hypothesis was that the placement of a second IV catheter in trauma does not result in an improvement in heart rate, blood pressure, rehospitalizaton rate, or 30-day mortality. METHODS: A retrospective chart review of 320 trauma patients in a one-year period was conducted at our level I trauma center. All trauma patients who had vascular access obtained prehospitally were included. RESULTS: Patients with two IV lines received an average of 348.4 mL more fluid (95% confidence interval [CI]: 235.6, 461.1; p < 0.0001). No change in heart rate, pulse oximetry, Glasgow Coma Scale score, systolic blood pressure, rehospitalization rate, or 30-day mortality was noted. These effects persisted for patients who were initially tachycardic (heart rate 3.92 bpm; 95% CI ?3.01, 10.82; p = 0.27) or hypotensive (blood pressure 22.00 mmHg; 95% CI ?4.17, 48.16; p = 0.10). CONCLUSIONS: Redundant prehospital IV lines provided no noticeable benefit in physiologic support for trauma patients. When controlling for confounding variables, no significant outcome difference was noted, even in the hypotensive patients. The traditional approach for establishment of a secondary IV line in prehospital trauma patients should not be followed in a dogmatic fashion.