Older age and risk for delayed abdominal pain care in the emergency department.

BACKGROUND AND IMPORTANCE: Suboptimal acute pain care has been previously reported to be associated with demographic characteristics. OBJECTIVES: The aim of this study was to assess a healthcare system's multi-facility database of emergency attendances for abdominal pain, to assess for an association between demographics (age, sex, and ethnicity) and two endpoints: time delay to initial analgesia (primary endpoint) and selection of an opioid as the initial analgesic (secondary endpoint). DESIGN, SETTING, AND PARTICIPANTS: This retrospective observational study assessed four consecutive months' visits by adults (≥18 years) with a chief complaint of abdominal pain, in a UK National Health Service Trust's emergency department (ED). Data collected included demographics, pain scores, and analgesia variables. OUTCOME MEASURES AND ANALYSIS: Categorical data were described with proportions and binomial exact 95% confidence intervals (CIs). Continuous data were described using median (with 95% CIs) and interquartile range (IQR). Multivariable associations between demographics and endpoints were executed with quantile median regression (National Health Service primary endpoint) and logistic regression (secondary endpoint). MAIN RESULTS: In 4231 patients, 1457 (34.4%) receiving analgesia had a median time to initial analgesia of 110 min (95% CI, 104-120, IQR, 55-229). The univariate assessment identified only one demographic variable, age decade (P = 0.0001), associated with the time to initial analgesia. Association between age and time to initial analgesia persisted in multivariable analysis adjusting for initial pain score, facility type, and time of presentation; for each decade increase the time to initial analgesia was linearly prolonged by 6.9 min (95% CI, 1.9-11.9; P = 0.007). In univariable assessment, time to initial analgesia was not associated with either detailed ethnicity (14 categories, P = 0.109) or four-category ethnicity (P = 0.138); in multivariable analysis ethnicity remained non-significant as either 14-category (all ethnicities' P ≥ 0.085) or four-category (all P ≥ 0.138). No demographic or operational variables were associated with the secondary endpoint; opioid initial choice was associated only with pain score (P= 0.003). CONCLUSION: In a consecutive series of patients with abdominal pain, advancing age was the only demographic variable associated with prolonged time to initial analgesia. Older patients were found to have a linearly increasing, age-dependent risk for prolonged wait for pain care.

Applications of Artificial Intelligence in Helicopter Emergency Medical Services: A Scoping Review.

OBJECTIVE: Recent systematic reviews of acute care medicine applications of artificial intelligence (AI) have focused on hospital and general prehospital uses. The purpose of this scoping review was to identify and describe the literature on AI use with a focus on applications in helicopter emergency medical services (HEMS). METHODS: A literature search was performed with specific inclusion and exclusion criteria. Articles were grouped by characteristics such as publication year and general subject matter with categoric and temporal trend analyses. RESULTS: We identified 21 records focused on the use of AI in HEMS. These applications included both clinical and triage uses and nonclinical uses. The earliest study appeared in 2006, but over one third of the identified studies have been published in 2021 or later. The passage of time has seen an increased likelihood of HEMS AI studies focusing on nonclinical issues; for each year, the likelihood of a nonclinical focus had an odds ratio of 1.3. CONCLUSION: This scoping review provides overview and hypothesis-generating information regarding AI applications specific to HEMS. HEMS AI may be ultimately deployed in nonclinical arenas as much as or more than for clinical decision support. Future studies will inform future decisions as to how AI may improve HEMS systems design, asset deployment, and clinical care.

Helicopter Emergency Medical Services Outcomes Research 1983 to 2022: Evidence Overview and Longitudinal Trends.

OBJECTIVE: Helicopter emergency medical services (HEMS) literature has been assessed in reviews focusing on various diagnoses, but there are few, if any, summaries of the entire body of HEMS outcomes evidence. Our goal was to summarize the existing research addressing patient-centered outcomes potentially accrued with HEMS. METHODS: As part of the Critical Care Transport Collaborative Outcomes Research Effort, we generated the HEMS Outcomes Assessment Research Database and executed descriptive analyses of longitudinal trends from 1983 to 2022. Both indexed and gray literature sources were incorporated in the HEMS Outcomes Assessment Research Database. Studies were reviewed by at least 2 authors to select those that addressed a patient-centered outcome. Studies addressing solely HEMS logistics were excluded. Categoric analyses were executed with the Fisher exact test, and continuous variables were evaluated for normality with normal quantile plotting and a comparison of medians and 95% confidence intervals. RESULTS: We found that HEMS outcomes study sample sizes increased steadily from 1983 to 2012, with the most recent decade demonstrating a marked increase in the rate of publication of HEMS outcomes studies. Most research (70.6%) addressed trauma patient outcomes, but recent decades have seen a significant increase in non-trauma studies. Recent decades have also been characterized by an increase in the production of HEMS outcomes research outside of North America and Europe. CONCLUSION: This study summarizes the current state of the HEMS outcome literature. We highlight increasing contributions from worldwide researchers and increasing focus on HEMS benefits in non-trauma cases, particularly time-critical cases such as cardiac or stroke diagnoses. This provides a basis for further investigations into patient-oriented benefits potentially accrued with HEMS.

Survival Benefit of Helicopter Scene Response for Patients with an Injury Severity Score of at Least Nine: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIM: Helicopter EMS (HEMS) is a well-established mode of rapid transportation for patients with need for time-sensitive interventions, especially in patients with significant traumatic injuries. Traditionally in the setting of trauma, HEMS is often considered appropriate when used for patients with "severe" injury as defined by Injury Severity Score (ISS) >15. This may be overly conservative, and patients with a lower ISS may benefit from HEMS-associated speed or care quality. Our objective was to perform a meta-analysis of trauma HEMS transports to evaluate for possible mortality benefit in injured cases defined by an ISS score >8, lower than the customary ISS cutoff of >15. METHODS: A broad search of the literature was performed including PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials, and Google Scholar from the years 1970 to 2022. The gray literature and reference lists of included publications were also examined. We included studies with the outcome of mortality in HEMS vs control in trauma transports from scene of injury for patients (adult or pediatric) with ISS > 8. RESULTS: Nine eligible studies were used in the final analysis: six in the primary analysis and three in sensitivity analysis due to patient overlap. All studies reported statistically significant survival benefit in HEMS compared to control group. The minimum survival odds ratio (OR) benefit observed was OR 1.15 (95% CI 1.06-1.25) and maximum was OR 2.04 (95% CI 1.18-3.57). Risk of bias tool (ROBINS-I) application yielded moderate to low risk of bias, mainly due to the observational nature of the studies included. CONCLUSIONS: There was a statistically significant survival benefit in patients with ISS > 8 when HEMS was used over traditional ground ambulance transportation, although novel and more inclusive trauma triage criteria may be more appropriate in the future to guide HEMS utilization decision-making. Restricting HEMS to trauma patients with ISS >15 likely misses survival benefit that could be afforded to the subset of trauma patients with serious injury.

State-by-state estimates of avoidable trauma mortality with early and liberal versus delayed or restricted administration of tranexamic acid.

OBJECTIVE: Early administration of tranexamic acid (TXA) has been shown to save lives in trauma patients, and some U.S. emergency medical systems (EMS) have begun providing this therapy prehospital. Treatment protocols vary from state to state: Some offer TXA broadly to major trauma patients, others reserve it for patients meeting vital sign criteria, and still others defer TXA entirely pending a hospital evaluation. The purpose of this study is to compare the avoidable mortality achievable under each of these strategies, and to report on the various approaches used by EMS. METHODS: We used the National Center for Health Statistics Underlying Cause of Death data to identify a TXA-naïve population of trauma patients who died from 2007 to 2012 due to hemorrhage. We estimated the proportion of deaths where the patient was hypotensive or tachycardic using the National Trauma Data Bank. We used avoidable mortality risk ratios from the landmark CRASH 2 study to calculate lives saved had TXA been given within one hour of injury based on a clinician's gestalt the patient was at risk for significant hemorrhage; had it been reserved only for hypotensive or tachycardic patients; or had it been given between hours one to three of injury, considered here as a surrogate for deferring the question to the receiving hospital. RESULTS: Had TXA been given within 1 hour of injury, an average of 3409 deaths per year could have been averted nationally. Had TXA been given between one and three hours after injury, 2236 deaths per year could have been averted. Had TXA only been given to either tachycardic or hypotensive trauma patients, 1371 deaths per year could have been averted. Had TXA only been given to hypotensive trauma patients, 616 deaths per year could have been averted. Similar trends are seen at the individual state level. A review of EMS practices found 15 statewide protocols that allow EMS providers to administer TXA for trauma. CONCLUSION: Providing early TXA to persons at risk of significant hemorrhage has the potential to prevent many deaths from trauma, yet most states do not offer it in statewide prehospital treatment protocols.

Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document.

Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.

Improvement in motor and exploratory behavior in Rett syndrome mice with restricted ketogenic and standard diets.

Rett syndrome (RTT) is a rare X-linked autistic-spectrum neurological disorder associated with impaired energy metabolism, seizure susceptibility, progressive social behavioral regression, and motor impairment primarily in young girls. The objective of this study was to examine the influence of restricted diets, including a ketogenic diet (KD) and a standard rodent chow diet (SD), on behavior in male Mecp2(308/y) mice, a model of RTT. The KD is a high-fat, low-carbohydrate diet that has anticonvulsant efficacy in children with intractable epilepsy and may be therapeutic in children with RTT. Following an 11-day pretrial period, adult wild-type and mutant Rett mice were separated into groups that were fed either an SD in unrestricted or restricted amounts or a ketogenic diet (KetoCal) in restricted amounts for a total of 30 days. The restricted diets were administered to reduce mouse body weight by 20-23% compared to the body weight of each mouse before the initiation of the diet. All mice were subjected to a battery of behavioral tests to determine the influence of the diet on the RTT phenotype. We found that performance in tests of motor behavior and anxiety was significantly worse in male RTT mice compared to wild-type mice and that restriction of either the KD or the SD improved motor behavior and reduced anxiety. We conclude that although both restricted diets increased the tendency of Rett mice to explore a novel environment, the beneficial effects of the KD were due more to calorie restriction than to the composition of the diet. Our findings suggest that calorically restricted diets could be effective in reducing the anxiety and in improving motor behavior in girls with RTT.