Utstein recommendation for emergency stroke care.

BACKGROUND: Recent advances in treatment for stroke give new possibilities for optimizing outcomes. To deliver these prehospital care needs to become more efficient. AIM: To develop a framework to support improved delivery of prehospital care. The recommendations are aimed at clinicians involved in prehospital and emergency health systems who will often not be stroke specialists but need clear guidance as to how to develop and deliver safe and effective care for acute stroke patients. METHODS: Building on the successful implementation program from the Global Resuscitation Alliance and the Resuscitation Academy, the Utstein methodology was used to define a generic chain of survival for Emergency Stroke Care by assembling international expertise in Stroke and Emergency Medical Services (EMS). Ten programs were identified for Acute Stroke Care to improve survival and outcomes, with recommendations for implementation of best practice. CONCLUSIONS: Efficient prehospital systems for acute stroke will be improved through public awareness, optimized prehospital triage and timely diagnostics, and quick and equitable access to acute treatments. Documentation, use of metrics and transparency will help to build a culture of excellence and accountability.

Part 3: adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the "what" in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

National EMS Research Agenda.

Now, more than ever before, the spirit of the emergency services professional is recognized by people everywhere. Individuals from every walk of life comprehend the reality of the job these professionals do each day. Placing the safety of others above their own is their acknowledged responsibility. Rescue and treatment of ill and injured patients are their purpose as well as their gratification. The men and women who provide prehospital care are well aware of the unpredictable nature of emergency medical services (EMS). Prehospital care is given when and where it is needed: in urban settings with vertical challenges and gridlock; in rural settings with limited access; in confined spaces; within entrapments; or simply in the street, exposed to the elements. Despite the challenges, EMS professionals rise to the occasion to do their best with the resources available. Despite more than 30 years of dedicated service by thousands of EMS professionals, academic researchers, and public policy makers, the nation's EMS system is treating victims of illness and injury with little or no evidence that the care they provide is optimal. A national investment in the EMS research infrastructure is necessary to overcome obstacles currently impeding the accumulation of essential evidence of the effectiveness of EMS practice. Funding is required to train new researchers and to help them establish their careers. Financial backing is needed to support the development of effective prehospital treatments for the diseases that drive the design of the EMS system, including injury and sudden cardiac arrest. Innovative strategies to make EMS research easier to accomplish in emergency situations must be implemented. Researchers must have access to patient outcome information in order to evaluate and improve prehospital care. New biomedical and technical advances must be evaluated using scientific methodology. Research is the key to maintaining focus on improving the overall health of the community in a competitive and cost-conscious health care market. Most importantly, research is essential to ensure that the best possible patient care is provided in the prehospital setting. The bravery and dedication of EMS professionals cannot be underestimated. Images of firefighters, EMS personnel, and others going into danger while others are evacuating will remain burned in our collective consciousness. These professionals deserve the benefit of research to assist them in providing the best possible care in the challenging circumstances they encounter. With this document, we are seeking support for elevating the science of EMS and prehospital care to the next level. It is essential that we examine innovative ways to deliver prehospital care. Strategies to protect the safety of both the patient and the public safety worker must be devised and tested. There are many questions that remain to be asked, many practices to be evaluated, and many procedures to be improved. Research is the key to obtaining the answers.

Prehospital use of continuous positive airway pressure (CPAP) for presumed pulmonary edema: a preliminary case series.

OBJECTIVE: To describe the prehospital use of a continuous positive airway pressure (CPAP) system for the treatment of acute respiratory failure presumed to be due to cardiogenic pulmonary edema. METHODS: Prospective case-series analysis. Paramedics administered CPAP via face mask at 10 cm H2O to patients believed to be in cardiogenic pulmonary edema and in imminent need of endotracheal intubation (ETI). Data from run sheets and hospital records were analyzed for treatment intervals, vital signs, complications, admitting diagnoses, need for ETI, and mortality. RESULTS: Nineteen patients received prehospital CPAP therapy. Mean duration of therapy was 15.5 minutes. Pre- and post-therapy pulse oximetry was available for 15 patients and demonstrated an increase from a mean of 83.3% to a mean of 95.4%. None of the patients were intubated in the field. Two patients who did not tolerate the CPAP mask required ETI upon arrival in the emergency department (ED); an additional five patients required ETI within 24 hours. There was one death in the series and two additional adverse events (one aspiration pneumonia, one pneumothorax); none of these were attributable to the use of CPAP. The diagnosis of cardiogenic pulmonary edema was corroborated by the ED or in-hospital physician in 13 patients (68%). Paramedics reported no technical difficulties with the CPAP system. CONCLUSION: For patients with acute respiratory failure and presumed pulmonary edema, the prehospital use of CPAP is feasible and may avert the need for ETI. Future controlled studies are needed to assess the utility and cost-effectiveness of prehospital CPAP systems.

A randomized trial of the effects of early cardiac serum marker availability on reperfusion therapy in patients with acute myocardial infarction: the serial markers, acute myocardial infarction and rapid treatment trial (SMARTT).

OBJECTIVES: The purpose of this study was to assess whether the immediate availability of serum markers would increase the appropriate use of thrombolytic therapy. BACKGROUND: Serum markers such as myoglobin and creatine kinase, MB fraction (CK-MB) are effective in detecting acute myocardial infarction (AMI) in the emergency setting. Appropriate candidates for thrombolytic therapy are not always identified in the emergency department (ED), as 20% to 30% of eligible patients go untreated, representing 10% to 15% of all patients with AMI. Patients presenting with chest pain consistent with acute coronary syndrome were evaluated in the EDs of 12 hospitals throughout North America. METHODS: In this randomized, controlled clinical trial, physicians received either the immediate myoglobin/CK-MB results at 0 and 1 h after enrollment (stat) or conventional reporting of myoglobin/CK-MB 3 h or more after hospital admission (control). The primary end point was the comparison of the proportion of patients within the stat group versus control group who received appropriate thrombolytic therapy. Secondary end points included the emergent use of any reperfusion treatment in both groups, initial hospital disposition of patients (coronary care unit, monitor or nonmonitor beds) and the proportion of patients appropriately discharged from the ED. RESULTS: Of 6,352 patients enrolled, 814 (12.8%) were diagnosed as having AMI. For patients having AMI, there were no statistically significant differences in the proportion of patients treated with thrombolytic therapy between the stat and control groups (15.1% vs. 17.1%, p = 0.45). When only patients with ST segment elevation on their initial electrocardiogram were compared, there were still no significant differences between the groups. Also, there was no difference in the hospital placement of patients in critical care and non- critical care beds. The availability of early markers was associated with more hospital admissions as compared to the control group, as the number of patients discharged from the ED was decreased in the stat versus control groups (28.4% vs. 31.5%, p = 0.023). CONCLUSIONS: The availability of 0- and 1-h myoglobin and CK-MB results after ED evaluation had no effect on the use of thrombolytic therapy for patients presenting with AMI, and it slightly increased the number of patients admitted to the hospital who had no evidence of acute myocardial necrosis.

Facilitated percutaneous coronary intervention for acute myocardial infarction.

Facilitated percutaneous coronary intervention is a treatment strategy for acute myocardial infarction in which patients are given medications in the emergency department that open or partially open infarct-related coronary arteries. The patients are then taken to the cardiac catheterization laboratory for early angiography and angioplasty or placement of a coronary artery stent. Preliminary evidence suggests that this treatment strategy may offer outcomes similar to or better than primary angioplasty and superior to solitary fibrinolytic therapy. In addition, the treatment can be started even in hospitals that do not have primary intervention capability. Currently, large-scale clinical trials are assessing the impact of the facilitated percutaneous coronary intervention treatment strategy on the clinical outcomes of patients with acute myocardial infarction.

Automated external defibrillators in long-term care facilities are cost-effective.

OBJECTIVE: To assess the cost per life saved of equipping long-term care facilities (LTCFs) with automated external defibrillators (AEDs). METHODS: Outcomes for cardiac arrests within LTCFs were retrieved for 1994 to 1997 from a comprehensive out-of-hospital cardiac arrest registry in a mid-sized U.S. city. The total expense for all LTCFs to obtain and maintain AEDs and to educate and maintain staff skill was estimated for a theoretical four-year period. The cost per life saved to the time of hospital discharge was calculated based on an estimated survival rate of 25% of patients found in ventricular fibrillation (VF) with placement of AEDs in LTCFs. A sensitivity analysis that varied survival rates and costs was conducted. RESULTS: Over four years, there were 160 actual arrests in 43 LTCFs, with a hospital discharge survival rate of 2/160. Twenty of 160 presented to emergency medical services in VF. Training costs for four years were $1,225 per AED. Purchase and maintenance expenses for one AED over four years were $3,941. Placing AEDs in LTCFs would cost $87,837 per life saved if 25% of patients found in VF survived to hospital discharge. Sensitivity analysis using survival rates of 5%, 15%, and 35% established the cost per life saved at $439,184, $146,395, and $62,741, respectively. When costs were calculated at one-half and twice the estimated expense, the cost per life saved was $43,918 and $175,674, respectively. CONCLUSION: Placing AEDs in LTCFs is cost-effective at $87,837 per life saved, if a hospital discharge survival rate of 25% of patients in VF can be achieved.

Identification of patients at risk by graded exercise testing in an emergency department chest pain center.

The study applied a retrospective follow-up design to determine the prognostic effect of graded exercise testing (GXT) in patients with low- to moderate-risk chest pain evaluated in an emergency department 9-hour protocol chest pain center (CPC) from January 1, 1993 to August 1, 1996. The cohort of 1,209 patients were followed to the date of death or first adverse cardiac event up to 1 year after CPC admission. Cardiac events were defined as coronary artery bypass graft, percutaneous transluminal coronary angioplasty, cardiogenic shock, cardiac-related death, congestive heart failure admission, ventricular tachycardia/ventricular fibrillation arrest, and myocardial infarction. Patients with acute ST-segment elevation or depression of >1 mm, positive enzyme (creatine kinase myocardial band) testing, or unstable angina during their CPC evaluation were admitted without GXT testing. Statistical analysis included chi-square test for complication rates and Cox proportional-hazards modeling. Nine hundred fifty-eight of 1,209 patients underwent GXT testing. Patients with positive, inconclusive, and normal GXTs had complication rates of 36.8% (7 of 19), 3.4% (9 of 267), and 1.1% (5 of 456), respectively. After adjusting for age, sex, and race, the relative risk of complication was 38.9 (95% confidence interval 11.7 to 129.6) with a positive GXT, and 3.6 (95% confidence interval 1.2 to 10.7) with an inconclusive GXT compared with a normal GXT. The GXT is a good prognostic indicator of adverse cardiac events in low- to moderate-risk chest pain in patients evaluated in an emergency department CPC.

Emergency medical care: types, trends, and factors related to nonurgent visits.

OBJECTIVES: To describe and compare national trends in ED use by statistical analyses on data from the 1992 to 1996 National Hospital Ambulatory Medical Care Survey (NHAMCS) with a special interest in factors related to nonurgent visits. METHODS: The NHAMCS collects data for ED visits using a four-stage national probability sample. Data from 135,723 ED visits in 1992-1996 were analyzed using the chi-square test for proportions with logistic regression modeling for multivariate analysis. RESULTS: More than half of the ED visits were considered nonurgent. There was a decreasing trend for nonurgent ED visits over the first three years of the sample (54.0% to 52.1%, p < 0.05). The proportion of ED visits for nonurgent care bounced back in 1995 (54.7%) and 1996 (54.1%). Significant variation existed in the proportion of nonurgent care visit based on disease category, age, race, and insurance coverage status. Marked variation in nonurgent visits also existed among geographic regions and types of hospital ownership. CONCLUSIONS: Analyses of data from the NHAMCS identify trends in ED use. The study of nonurgent ED visits with this database has inherent methodologic problems such as retrospective coding and geographic coding inconsistency. Since the nonurgent visit is clearly linked to certain social-demographic factors, addressing these underlying issues by establishing a comprehensive health care system is a priority.

Confirmation of airway placement.

Proper airway management in the prehospital setting is essential. Recent data from Orange County, Florida, suggest that the problem of misplaced endotracheal tubes may be greater than previous studies have indicated. Strong medical direction, strict protocols, and active continuous quality improvement programs are needed to ensure that paramedics learn the correct techniques of endotracheal intubation, and that they verify tube placement with an end-tidal carbon dioxide monitor, and maintain ongoing monitoring of tube placement during transport.

A nationwide prehospital stroke survey.

OBJECTIVES: To identify deficiencies in stroke knowledge among prehospital providers. METHODS: A nationwide multiple-choice survey was sent to 689 paramedics (EMT-Ps) and 294 advanced EMTs (EMT-Is) from a random selection of the National Registry of Emergency Medical Technicians database. Of the 23 questions, five addressed demographic information, four quantity of training, five general knowledge, 6 and seven management, and two open-ended questions addressed the signs, symptoms, and risk factors of stroke. The EMT-P and EMT-I answers were compared using chi-square analysis or Fisher's exact test. RESULTS: Of the 355 (36%) respondents, 256 (72%) were EMT-Ps and 99 (28%) were EMT-Is. Virtually all the EMT-Ps (99%) and EMT-Is (98%) knew that a stroke injures the brain, but only 199 (78%) of the EMT-Ps and 47 (47%) of the EMT-Is correctly defined a transient ischemic attack (TIA) (p < 0.001). Slurred speech, weakness/ paralysis, and altered mental status were the three most commonly cited symptoms of stroke by both groups. The EMT-Ps were more likely to recognize that dextrose is potentially harmful to stroke patients [EMT-P = 216 (85%), EMT-I = 71 (72%), p = 0.005]; 169 (66%) of the EMT-Ps and 75 (76%) of the EMT-Is felt that elevated blood pressures should be lowered in the prehospital setting. Only 93 (36%) of the EMT-Ps and 22 (22%) of the EMT-Is knew that tissue plasminogen activator (tPA) must be given within three hours of symptom onset (p = 0.01). CONCLUSION: Most EMS providers are knowledgeable about the symptoms of stroke but are unaware of the therapeutic window for thrombolysis and the recommended avoidance of prehospital blood pressure reduction. In addition, further education is needed regarding TIAs.

Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial.

BACKGROUND: Approximately 6 million U.S. patients present to emergency departments annually with symptoms suggesting acute cardiac ischemia. Triage decisions for these patients are important but remain difficult. OBJECTIVE: To test whether computerized prediction of the probability of acute ischemia, used with electrocardiography, improves the accuracy of triage decisions. DESIGN: Controlled clinical trial. SETTING: 10 hospital emergency departments in the midwestern, southeastern, and northeastern United States. PATIENTS: 10689 patients with chest pain or other symptoms suggestive of acute cardiac ischemia. INTERVENTION: The probability of acute ischemia predicted by the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI), either automatically printed or not printed on patients' electrocardiograms. MEASUREMENTS: Emergency department triage to a coronary care unit (CCU), telemetry unit, ward, or home. Other measurements were the bed capacity of the CCU relative to that of the telemetry unit; training or supervision status of the triaging physician; and patient diagnoses and outcomes based on clinical, electrocardiographic, and creatine kinase data. RESULTS: For patients without cardiac ischemia, in hospitals with high-capacity CCUs and relatively low-capacity cardiac telemetry units, use of ACI-TIPI was associated with a reduction in CCU admissions from 15% to 12%, a change of -16% (95% CI, -30% to 0%), and an increase in emergency department discharges to home from 49% to 52%, a change of 6% (CI, 0% to 14%; overall P=0.09). Across all hospitals, for patients evaluated by unsupervised residents, use of ACI-TIPI was associated with a reduction in CCU admissions from 14% to 10%, a change of -32% (CI, -55% to 3%); a reduction in telemetry unit admissions from 39% to 31%, a change of -20% (CI, -34% to -2%); and an increase in discharges to home from 45% to 56%, a change of 25% (CI, 8% to 45%; overall P=0.008). Among patients with stable angina, in hospitals with high-capacity CCUs, use of ACI-TIPI was associated with a reduction in CCU admissions from 26% to 13%, a change of -50% (CI, -70% to -17%), and an increase in discharges to home from 20% to 22%, a change of 10% (CI, -29% to 71%; overall P=0.02). At hospitals with high-capacity telemetry units, use of ACI-TIPI was associated with a reduction in telemetry unit admissions from 68% to 59%, a change of -14% (CI, -27% to 1%), and an increase in emergency department discharges to home from 10% to 21%, a change of 100% (CI, 22% to 230%; overall P=0.02). Among patients with acute myocardial infarction or unstable angina, use of ACI-TIPI did not change appropriate admission (96%) to the CCU or telemetry unit at hospitals with high-capacity CCUs or telemetry units. CONCLUSIONS: Use of ACI-TIPI was associated with reduced hospitalization among emergency department patients without acute cardiac ischemia. This result varied as expected according to the CCU and cardiac telemetry unit capacities and physician supervision at individual hospitals. Appropriate admission for unstable angina or acute infarction was not affected. If ACI-TIPI is used widely in the United States, its potential incremental impact may be more than 200000 fewer unnecessary hospitalizations and more than 100000 fewer unnecessary CCU admissions.

Ensuring the chain of recovery for stroke in your community. Chain of Recovery Writing Group.

Until recently, the prehospital and emergency department management of nonhemorrhagic stroke was largely supportive care. Studies now have demonstrated the potential of certain therapeutic interventions to reverse the debilitating consequences of such strokes. But despite the potential benefit, there exists a clear time dependency for such interventions, not only to ensure therapeutic efficacy, but also to diminish the likelihood of significant therapeutic complications. In turn, to optimize the chances of a better outcome for the patient with stroke, each community must establish and continue to refine a chain of recovery for stroke patients. The chain of recovery is a metaphor that describes a series of sequential actions that must take place in a timely fashion to optimize the chances of recovery from stroke. Each of these sequential actions forms an individual link in the chain, and each link must be intact. The links include: identification of the onset of stroke symptoms by the patient or bystanders; dispatch life support services, which preferably include enhanced 9-1-1 and medically supervised and trained dispatchers who can rapidly deploy the closest responders and transport units; emergency medical services (EMS) personnel who can rapidly assess and transport the stroke patient to the closest appropriate center capable of providing advanced stroke diagnostics and interventions; en route notification of the receiving facility so that appropriate personnel can be readied for rapid diagnosis and intervention; and receiving facilities capable of providing rapid diagnosis and advanced treatment of stroke, including the availability of specialists who can evaluate underlying etiologies as well as plan future therapies and rehabilitation. To ensure that the chain of recovery is in place, aggressive public education campaigns should be implemented to increase the probability that stroke symptoms and signs will be recognized as soon as possible by patients and bystanders. In addition, because most of the current training programs for EMS dispatchers and prehospital care personnel are lacking with regard to stroke, it is recommended that such personnel and their EMS system managers be updated on current management and treatment strategies for stroke.

Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain.

STUDY OBJECTIVES: To determine the test performance characteristics of serum cardiac troponin T (cTnT) measurement for diagnosis of acute myocardial infarction (AMI), and to determine the ability of cTnT to stratify emergency department patients with chest pain into high- and low-risk groups for cardiac complications. METHODS: We conducted a prospective observational cohort study with convenience sampling in a tertiary care, urban ED. The study sample comprised 667 patients presenting to the ED with a complaint of chest pain or other symptoms suggesting acute ischemic coronary syndrome (AICS). Patients were assigned to different blood sampling protocols for cTnT therapy on the basis of their ECG at presentation: nondiagnostic for AMI at 0, 3, 6, 9, 12, and 24 hours after ED presentation; or ECG diagnostic for AMI at 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 18, and 24 hours after ED presentation. RESULTS: Of 667 patients, 34 had AMI diagnosed within 24 hours of ED arrival. Using a .2 microgram/L discrimination level for cTnT, sensitivity for AMI within 24 hours of ED arrival was 97% (95% confidence interval, 91.4% to 99.9%), and specificity was 92% (89.8%-94.1%). When the effects of age, race, sex, and creatine kinase-MB isoenzyme subunit test results were controlled, a patient with cTnT of .2 microgram/L or greater was 3.5 (1.4 to 9.1) times more likely to have a cardiac complication within 60 days of ED arrival than a patient with a cTnT value below .2 microgram/L. CONCLUSION: Measurement of cTnT will accurately identify myocardial necrosis in patients presenting to the ED with possible AICS. Elevated cTnT values identify patients at increased risk of cardiac complications.

Ensuring the chain of recovery for stroke in your community.

Until recently, the prehospital and ED management of nonhemorrhagic stroke was largely supportive care. Studies have now demonstrated the potential of certain therapeutic interventions to reverse the debilitating consequences of such strokes. The clinical benefit for such interventions and the risk of significant therapeutic complications are highly time-dependent. To optimize the chances of a better outcome for the patient with stroke, each community must establish and continue to refine a chain of recovery for stroke patients. The chain of recovery is a metaphor that describes a series of sequential actions that must take place in a timely fashion to optimize the chances of recovery from stroke. Each of these sequential actions forms an individual link in the chain, and each link must be intact. The links include: identification of the onset of stroke symptoms by the patient or bystanders; dispatch life support services, which preferably include enhanced 9-1-1 and medically supervised and trained dispatchers who can rapidly deploy the closest responders and transport units; emergency medical services (EMS) personnel who can rapidly assess and transport the stroke patient to the closest appropriate center capable of providing advanced stroke diagnostics and interventions; en route notification of the receiving facility so that appropriate personnel can be readied for rapid diagnosis and intervention; and receiving facilities capable of providing rapid diagnosis and advanced treatment of stroke, including the availability of specialists who can evaluate underlying etiologies as well as plan future therapies and rehabilitation. To ensure that the chain of recovery is in place, aggressive public education campaigns should be implemented to increase the probability that stroke symptoms and signs will be recognized as soon as possible by patients and bystanders. In addition, because most of the current training programs for EMS dispatchers and EMS personnel are lacking with regard to stroke, it is recommended that such personnel and their EMS system managers be updated on current management and treatment strategies for stroke.

Field trial of endotracheal intubation by basic EMTs.

STUDY OBJECTIVE: The 1994 basic-EMT (EMT-B) curriculum recommended teaching EMT-Bs the skill of endotracheal intubation. In this study we assessed the success and complication rates of endotracheal intubations in the field by EMT-Bs. METHODS: We conducted a prospective clinical trial over a period of 28 months in an urban out-of-hospital EMS system. Four first-responder EMT-B engine companies with paramedic backup received 10 hours; intubation training in three sessions spread over at least 2 weeks. The training module was similar to that of the 1994 EMT-B curriculum and included at least 10 intubations on manikins. The EMTs used manikins with closed chest cavities to learn assessment of endotracheal-tube placement. Patients were eligible for intubation by the EMTs if they were apneic and older than 15 years. We calculated 95% confidence interval (CIs) for intubation success rates. RESULTS: Sixty-six EMT-Bs passed the training examinations and were authorized to perform intubation in the field. Endotracheal intubation was attempted by EMTs in 103 patients; the attempt was successful in 53 (95% CI, 42% to 61%). All patients who were not intubated by EMT-Bs were intubated by paramedics, with the exception of six cases. One attempt at intubation was made in 52 patients, two attempts in 44, and three in 7. Three unrecognized esophageal intubations occurred. CONCLUSION: EMT-Bs trained in a short course successfully intubated about half the patients they encountered in this study. This low intubation success rate calls into question the validity of the endotracheal-intubation training module in the 1994 EMT-B national curriculum.

Out-of-hospital administration of mannitol to head-injured patients does not change systolic blood pressure.

OBJECTIVE: To determine the effect of out-of-hospital mannitol administration on systolic blood pressure (BP) in the head-injured multiple-trauma patient. METHODS: This was a prospective, randomized, double-blind, placebo-controlled clinical trial involving a university-based helicopter air medical service and level-1 trauma center hospital. Endotracheally intubated head-trauma victims with Glasgow Coma Scale (GCS) scores < 12 were enrolled from November 22, 1991, to November 20, 1992, if evaluated by the participating aeromedical transport team within 6 hours of injury. Patients were excluded if they were < 18 years old, had already received mannitol or another diuretic, were potentially pregnant, or were receiving CPR. All patients were intubated prior to study drug (mannitol [1 g/kg] or normal saline) use. Pulse and BP were measured every 15 minutes for 2 hours following study drug administration. RESULTS: A total of 44 patients were enrolled. After exclusion of 3 patients who did not meet all inclusion criteria, there were 20 patients in the mannitol group and 21 patients in the placebo group. The groups were similar at baseline in age, pulse, systolic BP (baseline mannitol: 124 +/- 47 mm Hg; placebo: 128 +/- 32 mm Hg), GCS score, and Injury Severity Scale score. Systolic BP did not change significantly throughout the observation period in either group. This study had 83% power to detect a mean systolic BP drop to < 90 mm Hg. CONCLUSION: Out-of-hospital administration of mannitol did not significantly change systolic BP in this group of head-injured multiple-trauma patients.