E. Brooke Lerner

Guidelines for prehospital management of traumatic brain injury 2nd edition

The information contained in these Guidelines, which reflects the current state of knowledge at the time of completion of the literature search (July 2006), is intended to provide accurate and authoritative information about the subject matter covered. Because there will be future developments in scientific information and technology, it is anticipated that there will be periodic review and updating of these Guidelines. These Guidelines are distributed with the understanding that the Brain Trauma Foundation, the National Highway Traffic Safety Administration, and the other organizations that have collaborated in the development of these Guidelines are not engaged in rendering professional medical services. If medical advice or assistance is required, the services of a competent physician should be sought. The recommendations contained in these Guidelines may not be appropriate for use in all circumstances. The decision to adopt a particular recommendation contained in these Guidelines must be based on the judgment of medical personnel, who take into consideration the facts and circumstances in each case, and on the available resources.

Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial

OBJECTIVE To compare integrated automated load distributing band CPR (iA-CPR) with high-quality manual CPR (M-CPR) to determine equivalence, superiority, or inferiority in survival to hospital discharge. METHODS Between March 5, 2009 and January 11, 2011 a randomized, unblinded, controlled group sequential trial of adult out-of-hospital cardiac arrests of presumed cardiac origin was conducted at three US and two European sites. After EMS providers initiated manual compressions patients were randomized to receive either iA-CPR or M-CPR. Patient follow-up was until all patients were discharged alive or died. The primary outcome, survival to hospital discharge, was analyzed adjusting for covariates, (age, witnessed arrest, initial cardiac rhythm, enrollment site) and interim analyses. CPR quality and protocol adherence were monitored (CPR fraction) electronically throughout the trial. RESULTS Of 4753 randomized patients, 522 (11.0%) met post enrollment exclusion criteria. Therefore, 2099 (49.6%) received iA-CPR and 2132 (50.4%) M-CPR. Sustained ROSC (emergency department admittance), 24h survival and hospital discharge (unknown for 12 cases) for iA-CPR compared to M-CPR were 600 (28.6%) vs. 689 (32.3%), 456 (21.8%) vs. 532 (25.0%), 196 (9.4%) vs. 233 (11.0%) patients, respectively. The adjusted odds ratio of survival to hospital discharge for iA-CPR compared to M-CPR, was 1.06 (95% CI 0.83-1.37), meeting the criteria for equivalence. The 20 min CPR fraction was 80.4% for iA-CPR and 80.2% for M-CPR. CONCLUSION Compared to high-quality M-CPR, iA-CPR resulted in statistically equivalent survival to hospital discharge.

Mass casualty triage: an evaluation of the data and development of a proposed national guideline.

Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States.

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.

Emergency Medical Service Dispatch Cardiopulmonary Resuscitation Prearrival Instructions to Improve Survival From Out-of-Hospital Cardiac Arrest A Scientific Statement From the American Heart Association

Each year, millions of people around the world experience out-of-hospital cardiac arrest (OHCA), a condition characterized by unexpected cardiovascular collapse.1,2 OHCA is a leading cause of death. The incidence of treated OHCA is ≈50 to 60 per 100 000 person-years and is comparable throughout many parts of the world. Resuscitation of these patients is challenging and requires a coordinated set of rescuer actions termed the “Chain of Survival.” The links in the Chain of Survival are immediate recognition of cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), rapid defibrillation, effective advanced life support, and integrated post–cardiac arrest care.3 These actions involve the participation of a spectrum of rescuers, including family members, bystanders, emergency medical service (EMS) dispatchers, pre–hospital care providers, and hospital-based personnel; each group of rescuers has specific motivations, responsibilities, and skills. Unfortunately, in most communities in the United States and Canada, only 5% to 10% of all OHCA patients in whom resuscitation is attempted survive to discharge from the hospital. In contrast, survival rates can approach 20% (50% for witnessed ventricular fibrillation) in communities where the Chain of Survival is strong.4 Efforts to improve survival from OHCA should be aimed at strengthening each link in the Chain of Survival. An important underpinning of successful resuscitation is the interdependence of each of these links. Specifically, the early links, those involving bystanders (immediate emergency activation and early bystander CPR), are essential for the effectiveness of subsequent links. Thus, efforts that can improve early recognition of OHCA and increase bystander CPR are likely to improve survival from OHCA. When a bystander calls the community emergency response number (eg, 911 in the United States) to request medical aid, the call creates an opportunity to improve both identification of OHCA and provision of …

The influence of demographic factors on seatbelt use by adults injured in motor vehicle crashes

This study determined demographic factors associated with reported seatbelt use among injured adults admitted to a trauma center. A retrospective chart review was conducted including all patients admitted to a trauma center for injuries from motor vehicle crashes (MVC). E-codes (i.e. ICD-9 external cause of injury codes) were used to identify all patients injured in a MVC between January 1995 and December 1997. Age, sex, race, residence zip code (i.e. a proxy for income based on geographic location of residence), position in the vehicle, and seatbelt use were obtained from the trauma registry. Forward logistic regression was used to identify significant predictors of seatbelt use. Complete data was available for 1366 (82%) patients. Seatbelt use was reported for 45% of patients under age of 25 years, 52% of those 25-60 years, and 68% of those over 60 years. Overall, seatbelt use was reported for 45% of men and 63% of women, as well as for 56% of Caucasians (i.e. Whites) and 34% of African Americans. In addition, seatbelt use was reported for 33% of those earning less than

Is Total Out-of-hospital Time a Significant Predictor of Trauma Patient Mortality?

20,000 per year and 55% of those earning over

Studies evaluating current field triage: 1966-2005.

20,000. Finally, seatbelt use was reported for 57% of drivers and 43% of passengers. Logistic regression revealed that age, female gender, Caucasian race, natural log of income, and driver were all significant predictors of reported seatbelt use. These results show that seatbelt use was more likely to be reported for older persons, women, Caucasians, individuals with greater incomes, and drivers. Seatbelt use should be encouraged for everyone; however, young people, men, African Americans, individuals with lower incomes, and passengers should be targeted specifically.

Part 3: Adult Basic Life Support and Automated External Defibrillation

OBJECTIVE To determine if there is an association between total out-of-hospital time and trauma patient mortality. METHODS A retrospective review was performed of a convenience sample of consecutive medical records for all admitted patients transported by helicopter or ambulance from the scene of injury to the regional trauma center. Descriptive and univariate analyses were conducted to determine which variables were associated with patient mortality and total out-of-hospital time. Multiple predictors logistic regression was used to determine if total out-of-hospital time was associated with trauma patient outcome, while controlling for the variables associated with trauma patient mortality. RESULTS Of the 2,925 patients who were transported from the scene, 1,877 met the inclusion criteria. Six percent (116) did not survive. The multiple predictors model included CUPS (critical, unstable, potentially unstable, stable) status, patient age, Injury Severity Score, Revised Trauma Score, and total out-of-hospital time as predictors of mortality. Total out-of-hospital time (odds ratio 0.987; p = 0.092) was the only variable not found to be a significant predictor of mortality. CONCLUSIONS Provider-assigned CUPS status, patient age, Injury Severity Score, and Revised Trauma Score all were significant predictors of trauma patient mortality. Total out-of-hospital time was not associated with mortality.

Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs.

The American College of Surgeons (ACS) field triage guidelines are used to determine which patients require prompt transport to a trauma center andwhich can be transported to a lower-level facility. The objective of this report was to conduct a literature review to determine the sensitivity andspecificity of the ACS field triage criteria andeach step of the criteria. The bibliographic database MEDLINE was used to conduct a literature search for relevant English-language articles published between 1966 and2005. The search was conducted by combining the Medical Subject Headings (MeSH) “emergency medical services,” “triage,” and“wounds andinjury.” To ensure that the search was comprehensive, the reference sections of all selected articles were searched for additional relevant references andsearches by other organizations were reviewed to identify additional relevant articles. The MEDLINE search identified 542 titles. The author reviewed the titles, and107 abstracts were selected for further review. Through the MEDLINE search, the reference section review, andthe review of other searches, 80 articles were identified as relevant. Of those, five studies evaluated the full ACS criteria. Two of these calculated the specificity (8%) and/or sensitivity (95%–97%) of the ACS criteria. The remaining studies looked at the percentage of patients transported or admitted to a trauma center. Three studies looked at the predictive value of the physiologic step, andone of these calculated the sensitivity (56%) andspecificity (86%). Two studies specifically analyzed the anatomic step. One of these calculated the sensitivity (45%). This search found that there is insufficient evidence to support the overall ACS field triage criteria. However, of the various steps, the physiologic andanatomic steps had the best evidence to support them.