Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria.

INTRODUCTION: We aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis. METHODS: This study used a convenience sample of prehospital patients meeting established criteria for sepsis. Paramedics received education on systemic inflammatory response syndrome (SIRS) criteria, were trained in the use of TATs and hand-held lactate meters, and enrolled patients who had a recent history of infection, met ≥ 2 SIRS criteria, and were being transported to a participating hospital. Blood lactate was measured by paramedics in the prehospital setting and again in the emergency department (ED) via usual care. Paramedics entered data using an online database accessible at the point of care. RESULTS: Prehospital lactate values obtained by paramedics ranged from 0.8 to 9.8 mmol/L, and an elevated lactate (i.e. ≥ 4.0) was documented in 13 of 112 enrolled patients (12%). The unadjusted correlation of prehospital and ED lactate values was 0.57 (p< 0.001). The median interval between paramedic assessment of blood lactate and the electronic posting of the ED-measured lactate value in the hospital record was 111 minutes. Overall, 91 patients (81%) were hospitalized after ED evaluation, 27 (24%) were ultimately diagnosed with sepsis, and 3 (3%) died during hospitalization. Subjects with elevated prehospital lactate were somewhat more likely to have been admitted to the intensive care unit (23% vs 15%) and to have been diagnosed with sepsis (38% vs 22%) than those with normal lactate levels, but these differences were not statistically significant. CONCLUSION: In this pilot, EMS use of a combination of objective SIRS criteria, subjective assessment of infection, and blood lactate measurements did not achieve a level of diagnostic accuracy for sepsis that would warrant hospital prenotification and committed resources at a receiving hospital based on EMS assessment alone. Nevertheless, this work provides an early model for increasing EMS awareness and the implementation of novel devices that may enhance the prehospital assessment for sepsis. Additional translational research studies with larger numbers of patients and more robust methods are needed.

Chest Compression Injuries Detected via Routine Post-arrest Care in Patients Who Survive to Admission after Out-of-hospital Cardiac Arrest.

Abstract Objective. To examine injuries produced by chest compressions in out-of-hospital cardiac arrest (OHCA) patients who survive to hospital admission. Methods. A retrospective cohort study was conducted among 235 consecutive patients who were hospitalized after nontraumatic OHCA in Minnesota between January 2009 and May 2012 (117 survived to discharge; 118 died during hospitalization). Cases were eligible if the patient had received prehospital compressions from an emergency medical services (EMS) provider. One EMS provider in the area was using a mechanical compression device (LUCASTM) as standard equipment, so the association between injury and use of mechanical compression was also examined. Prehospital care information was abstracted from EMS run sheets, and hospital records were reviewed for injuries documented during the post-arrest hospitalization that likely resulted from compressions. Results. Injuries were identified in 31 patients (13%), the most common being rib fracture (9%) and intrathoracic hemorrhage (3%). Among those who survived to discharge, the mean length of stay was not statistically significantly different between those with injuries (13.5 days) and those without (10.8 days; p = 0.23). Crude injury prevalence was higher in those who died prior to discharge, had received compressions for >10 minutes (versus ≤10 minutes) and underwent computer tomography (CT) imaging, but did not differ by bystander compressions or use of mechanical compression. After multivariable adjustment, only compression time > 10 min and CT imaging during hospitalization were positively associated with detected injury (OR = 7.86 [95% CI = 1.7-35.9] and 6.30 [95% CI = 2.6-15.5], respectively). Conclusion. In patients who survived OHCA to admission, longer duration of compressions and use of CT during the post-arrest course were associated positively with documented compression injury. Compression-induced injuries detected via routine post-arrest care are likely to be largely insignificant in terms of length of recovery.

Advanced Clinical Interventions Performed by Emergency Medical Responder Firefighters prior to Ambulance Arrival.

Abstract Introduction. Data on the clinical interventions performed by emergency medical responder firefighters (EMRFs) are limited outside the context of cardiac arrest. We sought to understand the broader medical role of firefighters by examining fire-ambulance arrival order and documenting specific interventions provided by firefighters with advanced EMR training. Methods. A secondary analysis was conducted using electronic patient care records from a single ambulance service and two municipal fire departments that partner to provide emergency response in two suburbs of Minneapolis, Minnesota. Firefighters in both municipalities are dispatched to all medical calls, regardless of severity, and receive training in the following advanced EMR skills: intravenous line placement, administration of oral nitroglycerin and aspirin, placement of supraglottic airways, administration of albuterol via nebulizer, and injections of intramuscular glucagon and epinephrine. Time stamps for unit arrival on scene were used to determine arrival order and to quantify fire lead time (i.e., the interval EMRFs were on scene before paramedics). Results. Fire and ambulance records were linked for 10,403 patient encounters that occurred over 2.5 years. EMRFs arrived first in 9,001 calls (88%) with an average fire lead time of 4.5 minutes. In the two communities, firefighters performed at least one of the six advanced training interventions in 688 patient encounters (7.6%) when they reached the patient first, the most frequent being intravenous line placement (n = 340; 3.8%) and administration of oral nitroglycerin or aspirin (n = 303; 3.4%). EMRFs arrived first to 96 cases of cardiac arrest and performed chest compressions in 78%, automated external defibrillator use in 44%, supraglottic airway placement in 32%, and intravenous line starts in 18%. A modest positive association was observed between increasing fire lead time and use of cardiac arrest interventions by EMRFs. Conclusions. EMRFs performed advanced EMR training interventions in a small fraction of the patients they were able to reach before paramedics, and further study of the clinical significance of these interventions in the hands of this responder group is needed. EMRF training in these communities should continue to emphasize the fervent and consistent application of BLS resuscitation interventions in victims of cardiac arrest.

Cervical spine fractures in elderly patients with hip fracture after low-level fall: an opportunity to refine prehospital spinal immobilization guidelines?

BACKGROUND: Conventional prehospital spine-assessment approaches based on low index of suspicion and mechanism of injury (MOI) result in the liberal application of spinal immobilization in trauma patients. A painful distracting injury (DI), such as a suspected hip fracture, historically has been a sufficient condition for immobilization, even in an elderly patient who suffers a simple fall from standing and exhibits no other risk factors for spinal injury. Because the elderly are at increased risk of hip fracture from low-level falls, and are also particularly susceptible to the discomfort and morbidity associated with immobilization, the prevalence of cervical spine (c-spine) fracture in this patient population was examined. METHODS: Hospital billing records were used to identify all cases of traumatic femur fracture in Minnesota (USA) in 2010-2011. Concurrent diagnosis and external cause codes were used to estimate the prevalence of c-spine fracture by age and MOI. RESULTS: Among 1,394 patients with femur fracture, 23 (1.7%) had a c-spine fracture. When the MOI was a fall from standing or sitting height and the patient age was ≥ 65, the prevalence dropped to 0.4% (2/565). The prevalence was similar when the definition of hip fracture additionally included pelvis fractures (0.5%; 11/2,441). Eight of the 11 patients with c-spine fracture had diagnosis codes indicative of criteria other than the DI that likely would have resulted in immobilization (eg, head injury and compromised mental status). CONCLUSIONS: C-spine fracture is extremely rare in elderly patients who sustain hip fracture as a result of a low-level fall, and appears to be accompanied frequently by other known predictors of spinal injury besides DI. More research is needed to determine whether conservative use of spinal immobilization may be warranted in elderly patients with hip fracture after low-level falls when the only criteria for immobilization is the distracting hip injury.

Implementation of a mechanical chest compression device as standard equipment in a large metropolitan ambulance service.

BACKGROUND: We will describe the implementation of the LUCAS™1 chest compression device as standard equipment in the treatment of cardiac arrest across a large ambulance service and provide descriptive data on device-treated arrests and provider experience during the initial 2 years of use. METHODS: Provider training and deployment of 38 devices occurred in our 70-vehicle, 400-provider ambulance service within 3 months. A retrospective case series of device-eligible out-of-hospital cardiac arrests occurring between May 2008 and June 2010 was analyzed. Clinical data were extracted from an electronic prehospital patient care record and information on provider experience with the device was collected via online survey. RESULTS: LUCAS™1 was used in 79% of resuscitation attempts (498 of 631). Primary reasons for nonuse were resuscitation of limited duration and extreme body size. Return of spontaneous circulation (ROSC) was documented in 35% and 41% of device- and non-device-treated arrests, respectively (p = 0.31), but among arrests where time from arrival at patient to discontinuation of cardiopulmonary resuscitation was >5 min, the rates were 26% and 24%, respectively (p = 0.78). CONCLUSIONS: A large ambulance service in the United States initiated standard use of a mechanical compression device within 3 months. In an applied setting, the LUCAS™1 device fits most patients and was well received by prehospital providers. Resuscitation of limited duration due to early death or early ROSC frequently precludes device use, and this has important implications for evaluating the association between device use and ROSC in observational settings.

Therapeutic hypothermia after out-of-hospital cardiac arrest: evaluation of a regional system to increase access to cooling.

BACKGROUND: Therapeutic hypothermia (TH) improves survival and confers neuroprotection in out-of-hospital cardiac arrest (OHCA), but TH is underutilized, and regional systems of care for OHCA that include TH are needed. METHODS AND RESULTS: The Cool It protocol has established TH as the standard of care for OHCA across a regional network of hospitals transferring patients to a central TH-capable hospital. Between February 2006 and August 2009, 140 OHCA patients who remained unresponsive after return of spontaneous circulation were cooled and rewarmed with the use of an automated, noninvasive cooling device. Three quarters of the patients (n=107) were transferred to the TH-capable hospital from referring network hospitals. Positive neurological outcome was defined as Cerebral Performance Category 1 or 2 at discharge. Patients with non-ventricular fibrillation arrest or cardiogenic shock were included, and patients with concurrent ST-segment elevation myocardial infarction (n=68) received cardiac intervention and cooling simultaneously. Overall survival to hospital discharge was 56%, and 92% of survivors were discharged with a positive neurological outcome. Survival was similar in transferred and nontransferred patients. Non-ventricular fibrillation arrest and presence of cardiogenic shock were associated strongly with mortality, but survivors with these event characteristics had high rates of positive neurological recovery (100% and 89%, respectively). A 20% increase in the risk of death (95% confidence interval, 4% to 39%) was observed for every hour of delay to initiation of cooling. CONCLUSIONS: A comprehensive TH protocol can be integrated into a regional ST-segment elevation myocardial infarction network and achieves broad dispersion of this essential therapy for OHCA.

Nursing use between 2 methods of procedural sedation: midazolam versus propofol.

We compared propofol (P) and midazolam (M) use in sedation using nurses' (RN's) monitoring times, costs, and visual analog scale (VAS) satisfaction scores. We randomized 40 patients to either P or M groups. The P group received 0.5 mg/kg IV followed by titration to a Ramsay Sedation Scale of 3 or 4. The M group received 1 mg IV every 2 minutes to a Ramsay Sedation Scale of 3 or 4. Time for sedation, procedure, and recovery were compared. VAS scores were measured for the patient, RN, and physician. Thirty-two patients completed the study. Median RN monitoring time was 52 minutes for the M group and 36 minutes for the P group. VAS score differences were significant only in the physician group. We concluded that compared with midazolam, propofol required less RN monitoring and had lower costs. Physician satisfaction was higher with propofol sedation than with midazolam and required less time.