Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation.

OBJECTIVE: To determine the short-term outcome of patients with a known seizure disorder who have a seizure, are evaluated by out-of-hospital care providers, and refuse transport. METHODS: This was a prospective study conducted over a 15-month period. Philadelphia Fire Department paramedics contacted a medical command physician whenever they encountered a patient with a known seizure disorder who had had another seizure and was refusing transport. After confirming that the patient had the mental capacity to refuse care and understood the associated risks, the physician recorded the patient's name, address, and telephone number. Beginning three days later, a registered nurse attempted to reach the patient by telephone and administer a brief questionnaire about his or her medical outcome. Patients not reached by telephone were sent a certified letter. The names of patients lost to follow-up were compared with medical examiner records to confirm that they had not died during the follow-up period. RESULTS: Of 63 patients enrolled in the study, 52 (82.5%) were reached in follow-up. Of these, three (5.8%) had another seizure within 72 hours and recontacted 911. One of these patients (1.9%) was hospitalized. Twenty (38.5%) patients contacted their primary care physicians. There were no deaths, including patients lost to follow-up. CONCLUSIONS: Most patients (94.2%) who were evaluated by out-of-hospital care providers for a seizure and refused transport had no further seizure activity in the subsequent 72 hours. However, because there is a risk of recurrence, out-of-hospital care providers and medical command physicians should ensure that patients understand the risks of refusal.

Managed care enrollee utilization of 911 medical services.

OBJECTIVE: To determine the mechanism by which managed care organization (MCO) enrollees enter the emergency medical services (EMS) system. METHODS: All enrollees belonging to the region's largest MCO and transported to emergency departments by a paramedic-level municipal EMS system were identified from billing records. Dispatch logs were examined to determine the time and origin of the call to the 911 communication center. Patient care records were used to obtain age, the level of care delivered (advanced or basic life support), and whether the patient received any medications while out of hospital. Hospital admission was also determined. RESULTS: Over a six-month period, 195 enrollees were transported. Three modes of 911 EMS system entry were identified: group I-enrollees who called 911 directly; group II-enrollees who called the MCO triage center, who then called 911 on behalf of the patient; and group III--enrollees who were sent to the MCO health center for evaluation, and subsequently the MCO called 911 to transfer the patient to the hospital. Of the 195 patients transported to the emergency department, the dispositions of 108 (55%) patients were obtained. Group I (n = 109) patients were more likely to be transported in the evening (3 PM to 11 PM), less likely to require advanced life support therapies, and less likely to be admitted to the hospital when compared with groups II (n = 32) and III (n = 54) patients. Group III patients were the most likely to receive advanced life support care and require admission to the hospital. CONCLUSION: The majority of MCO enrollees called 911 directly, and were most likely to do so during evening hours. Enrollees who called 911 directly (group I) had a trend toward lower acuity, based on the lowest ALS utilization of any group. Those enrollees who most frequently required advanced life support were those who received initial treatment at the MCO center prior to EMS transport. Though EMS system-specific, this type of descriptive analysis is helpful in assisting both EMS systems and MCOs to better assess utilization of 911 EMS resources by MCO enrollees. This study also challenges the prudent layperson paradigm.

The effectiveness of midazolam as a single pharmacologic agent to facilitate endotracheal intubation by paramedics.

OBJECTIVE: Endotracheal intubation (ETI) remains the "gold standard" for securing a patient's airway. In recent years, the use of pharmacologic agents to assist paramedics achieve successful intubation of problematic airways has become more common. This study was done to determine the efficacy of intravenous midazolam, a short-acting benzodiazepine, as a drug to facilitate intubation in patients resistant to conventional ETI. METHODS: This retrospective observational study reviewed the 22-month experience of a suburban municipal EMS system after midazolam was introduced as an agent to be used for systemic sedation to facilitate ETI. All calls where midazolam was used were reviewed on a monthly basis by investigators via retrospective review of the prehospital care reports. RESULTS: During the study period 13,212 emergency responses occurred, resulting in 154 ETIs by paramedics. Midazolam was used to facilitate 20 (13%) of these ETIs. "Clenched teeth" and failed conventional intubation were the most commonly cited indications for facilitated intubation. Eleven patients had medical complaints and nine were trauma patients. Successful ETI with midazolam was achieved in 17 of 20 (85%) cases. In 85% (15 of 17) of these cases, a single dose of midazolam was sufficient for ETI [mean dose 3.6 mg (SD 1.1 mg)]. The three patients with failed ETI received multiple doses of midazolam [mean dose 5.0 mg (SD 2.0 mg)]. CONCLUSION: The prehospital use of single-dose IV midazolam is generally effective in accomplishing facilitated ETI in patients resistant to conventional (nonpharmacologic) ETI.

Delayed cardiovascular sequelae from Kawasaki syndrome.

The cardiovascular complications of Kawasaki syndrome (KS) are potentially life-threatening. Such complications are usually associated with early stages of the disease and involve symptoms related to myocarditis myocardial ischemia. This report describes an unusual case of a 12-year-old girl with a remote history of KS who presented with supraventricular tachycardia (SVT). The potential relationship between KS and SVT based on results of previous clinicopathologic studies of the conduction system of patients with KS is discussed; this discussion also addresses the importance of early identification, appropriate treatment, and prompt referral once the diagnosis of KS has been made.

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study.

A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.

The impact of prehospital physicians on out-of-hospital nonasystolic cardiac arrest.

OBJECTIVE: To determine whether the presence of an on-scene medical control physician (OSMCP) alters the management and outcome of out-of-hospital nontraumatic, nonasystolic cardiac arrest (CA) patients. METHODS: This was a retrospective case series of CA patients who were cared for in an all advanced life support, third-service, municipal emergency medical services (EMS) system over a one-year period. Excluded from the study were all traumatic CA patients and solely asystolic patients. The remaining CA patients were divided into the two study groups according to the presence of an OSMCP or whether they were cared for by paramedics only (PO). For each group patient age, EMS response time, the number of personnel on the scene, the presence of bystander CPR, the initial cardiac rhythm, and scene time were determined. In addition, time to first defibrillation for patients in ventricular fibrillation, the rate of drug administrations per minute, the return of spontaneous circulation (ROSC) on emergency department (ED) arrival, and survival to hospital discharge were collected for each group. RESULTS: Eighty CA runs were reviewed, with 49 meeting entry criteria; nine in the OSMCP group and 40 in the PO group. There was no difference between the groups with regard to patient age, response time, scene time, or number of personnel on the scene. The two groups were similarly matched with regard to initial cardiac rhythm, the presence of bystander or first-responder CPR, and time to first defibrillation. The number of drug dosages administered per minute was higher in the OSMCP group (0.62 doses per minute) as compared with the PO group (0.34 doses per minute)[p < 0.03]. ROSC and survival to hospital discharge revealed a nonsignificant tendency toward more frequent ROSC in the OSMCP group [p < 0.07], and a significantly higher incidence of survival to discharge in the OSMCP group [p < 0.009]. CONCLUSIONS: Out-of-hospital CA patients treated in the OSMCP group had a trend toward more frequent ROSC upon ED arrival and a higher rate of survival to hospital discharge. The OSMCP group patients received medications at nearly twice the rate of the PO group patients. Although a larger trial is needed, more frequent dosing of drugs during CA may have contributed to increased survival in the OSMCP group.

The impact of prehospital instant photography of motor vehicle crashes on receiving physician perception.

OBJECTIVES: The study was conducted to determine whether the use of prehospital instant photography of motor vehicle crashes (MVCs) by paramedics altered receiving physician (RP) perception of the magnitude of crash severity, as compared with verbal reports of vehicle damage. In addition, the study sought to determine whether altered RP perception resulted in any subsequent changes in emergency department (ED) management. METHODS: A prospective questionnaire and retrospective chart review were used at a Level I suburban trauma center receiving MVC patients from a single municipal paramedic agency. Patients injured in MVCs who required advanced life support (ALS) interventions and were subsequently evaluated by either surgical residents, emergency medicine residents, or attending emergency physicians in the ED were eligible for study enrollment. Instant photographs of interior and exterior vehicle damage were obtained by paramedics who then provided a verbal report of vehicle damage to the RP. Initially blinded from the photographs, the RP was then asked to rate the severity of the crash based on the verbal report and list planned interventions (laboratory tests, blood products, radiographs, and probable patient disposition). The RP was then shown the crash photographs and once again asked to rate the crash severity based on the addition of the photos and list changes in patient management based on any alterations in his or her perception. Hospital records were then examined to determine costs billed to patients and the length of hospital stay for those patients who were admitted. RESULTS: Instant photographs resulted in changes in physician perception in 47% (27 of 58) of the cases. Eighty-five percent of these physicians rated the MVC as more severe than the verbal report had indicated (p < 0.05 by multiple and logistic regression). The RPs who did alter their perceptions based upon the addition of MVC photos then changed their ED management in 59% (16 of 27) of the cases. Patients whose crash photographs altered RP perception of crash severity and who were subsequently released from the ED had average ED costs of $686, as compared with average ED charges of $595 for released patients whose crash photos did not alter physician perception of crash severity (p > 0.05 by Student's t-test). Inpatient charges and lengths of stay were also similar between the two groups for admitted patients: $21,363/14 days for the perception-change group and $24,726/8 days for the no-change-in-perception group (p > 0.05 for all comparisons). CONCLUSION: The augmentation of verbal paramedic reports with prehospital instant photographs frequently altered both physician perception of MVC severity and subsequent ED management of these trauma patients. However, cost to the patient and length of hospital stay were not significantly altered as a result of the change in physician perception.

Spontaneous cervicothoracic epidural hematoma following prolonged valsalva secondary to trumpet playing.

Spontaneous spinal epidural hematoma is an uncommon clinical entity. Patients with this disease may present with devastating neurological deficits that can mimic other diseases. Emergency physicians should be familiar with this condition to assure appropriate therapy in a timely manner. A typical case of spontaneous spinal epidural hematoma is presented with review of appropriate differential diagnosis and management.

Geriatric use of emergency medical services.

STUDY OBJECTIVE: To quantify use by geriatric patients of emergency medical services (EMS) compared with that by young adult patients. METHODS: We conducted a retrospective, consecutive case series over a 6-month period in a suburban, all-paramedic municipal EMS system serving 76,500 residents, of whom approximately 15% are 65 years of age or older and 33% are between 25 and 45 years old. Patient age, the sole entry criterion, was used to distinguish two groups: the young adult group, defined as patients 25 to 45 years old; and the geriatric group, defined as patients 65 years or older. RESULTS: Of the 2,712 patients whose cases were reviewed during the study period, 1,734 (65%) met the entry criterion. The geriatric group (n=1,043) accounted for 39% of the total call volume, compared with the young adult group (n=690), which accounted for 25% of total call volume. Patients in the young adult group were 7.3 times more likely to have been in a motor vehicle accident, whereas the GP group was 2.6 times more likely to have cardiorespiratory complaints, 1.8 times more likely to have fallen, and 1.7 times more likely to have minor medical problems requiring transportation and more frequently required advanced life support (ALS) care (54% versus 33%) (P<.001 for all comparisons). Scene times for geriatric patients were found to be longer than those for young adults (ALS, P<.001; basic life support [BLS], P<.05). However, costs billed to the patient were greater for young adults for all care rendered (BLS, P<.001; ALS, P<.05). CONCLUSION: Use by geriatric patients of EMS differed significantly from that by young adults. Geriatric patients used EMS more frequently and required more ALS care than did young adults. Although geriatric patients required longer scene times for EMS care, young adults incurred greater charges for service. These findings, although perhaps system specific, speak to the need for ongoing analysis of EMS health care delivery to better serve a population increasing in age.

Acute sensorineural hearing loss following intravenous ketoralac administration.

Ketoralac is an injectable nonsteroidal antiinflammatory drug (NSAID) widely used in both out-patient and in-patient settings. Side effects such as acute renal failure, hyperkalemia, gastritis, gastrointestinal bleeding, and asthmatic exacerbation, although rare, have been previously reported. We report the case of a 20-year-old female with polyarteritis nodosa (PAN) who developed bilateral sensorineural hearing loss 25 minutes after receiving 30 mg of intravenous ketoralac. The patient denied any previous medication sensitivities, and was taking oral methotrexate and prednisone at the time of emergency department admission. Both PAN and methotrexate have been independently demonstrated to cause sensorineural hearing loss. We postulate that the patient's hearing loss was the result of ketoralac's direct and indirect ototoxic effects that were potentiated as a result of her underlying illness and medications. We recommend the cautious use of ketorolac in patients with underlying illnesses where NSAID-induced ototoxicity could result in adverse otologic consequences.

The prehospital use of nebulized albuterol on patients with wheezing whose chief complaint is shortness of breath.

The use of prehospital nebulized beta-agonists has become widespread, and their safety and efficacy has been documented. Our purpose was to study their broadened use and determine their effectiveness in specific sub-sets of wheezing patients. We conducted a six and one-half month prospective study to determine the benefit of nebulized albuterol treatments on a variety of wheezing patients whose chief complaint to paramedics was shortness of breath. Sixty-two patients were enrolled in the study and were subdivided into four groups based on patient history; asthma, COPD, asthma & COPD (A/C), and non-Asthma/non-COPD (NANC). The effectiveness of the treatment was evaluated objectively by peak expiratory flow rates (PEFR) obtained before and immediately after treatment and subjectively by the patients' evaluation of their own dyspnea. Changes in PEFR were subjected to analysis by a paired T-test. Albuterol was effective in increasing the PEFR in patients with asthma, COPD and NANC. Patients with both asthma and COPD did not demonstrate increased PEFR after treatment. The majority of all patients were subjectively improved after nebulized albuterol treatments. We conclude that aerosolized albuterol is safe and effective in the prehospital treatment of patients complaining of dyspnea who are wheezing.