George Ralls

A comparison of tele-education versus conventional lectures in wound care knowledge and skill acquisition.

We conducted a randomized controlled study to compare conventional lectures with tele-education for delivering wound care education. Education was delivered by the two methods simultaneously to two classes. Forty-eight paramedics received a live didactic presentation and 41 paramedics received the same lecture via videoconferencing. The participants were evaluated by a multiple-choice examination and a practical test of their wound closure skills. There were no significant differences in any category of the practical skills test, and no difference in the results of the written examination: the mean total score was was 109.0 (95% CI 105.7–112.4) in the conventional lecture group and 110.3 (95% CI 106.2–114.3) in the video group (P = 0.63). In a survey at the end of the study the live lecture group rated the overall effectiveness of teaching significantly higher than the video-based group: the median scores for effectiveness of teaching were 6.0 (IQR 5.5–6.0) in the live lecture group and 4.0 (IQR 3.0–5.0) in the video group (P < 0.001). Videoconferencing was at least as effective as live didactic presentation.

Endotracheal tube placement confirmation: 100% sensitivity and specificity with sustained four-phase capnographic waveforms in a cadaveric experimental model

BACKGROUND Waveform capnography is considered the gold standard for verification of proper endotracheal tube placement, but current guidelines caution that it is unreliable in low-perfusion states such as cardiac arrest. Recent case reports found that long-deceased cadavers can produce capnographic waveforms. The purpose of this study was to determine the predictive value of waveform capnography for endotracheal tube placement verification and detection of misplacement using a cadaveric experimental model. METHODS We conducted a controlled experiment with two intubated cadavers. Tubes were placed within the trachea, esophagus, and hypopharynx utilizing video laryngoscopy. We recorded observations of capnographic waveforms and quantitative end-tidal carbon dioxide (ETCO2) values during tracheal versus extratracheal (i.e., esophageal and hypopharyngeal) ventilations. RESULTS 106 and 89 tracheal ventilations delivered to cadavers one and two, respectively (n=195) all produced characteristic alveolar waveforms (positive) with ETCO2 values ranging 2-113mmHg. 42 esophageal ventilations (36 to cadaver one and 6 to cadaver two), and 6 hypopharyngeal ventilations (4 to cadaver one and 2 to cadaver two) all resulted in non-alveolar waveforms (negative) with ETCO2 values of 0mmHg. Esophageal and hypopharyngeal measurements were categorized as extratracheal (n=48). A binary classification test showed no false negatives or false positives, indicating 100% sensitivity (NPV 1.0, 95%CI 0.98-1.00) and 100% specificity (PPV 1.0, 95%CI 0.93-1.00). CONCLUSION Though current guidelines question the reliability of waveform capnography for verifying endotracheal tube location during low-perfusion states such as cardiac arrest, our findings suggest that it is highly sensitive and specific.

A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis

OBJECTIVE To determine the utility of a prehospital sepsis screening protocol utilizing systemic inflammatory response syndrome (SIRS) criteria and end-tidal carbon dioxide (ETCO2). METHODS We conducted a prospective cohort study among sepsis alerts activated by emergency medical services during a 12 month period after the initiation of a new sepsis screening protocol utilizing ≥2 SIRS criteria and ETCO2 levels of ≤25 mmHg in patients with suspected infection. The outcomes of those that met all criteria of the protocol were compared to those that did not. The main outcome was the diagnosis of sepsis and severe sepsis. Secondary outcomes included mortality and in-hospital lactate levels. RESULTS Of 330 sepsis alerts activated, 183 met all protocol criteria and 147 did not. Sepsis alerts that followed the protocol were more frequently diagnosed with sepsis (78% vs 43%, P < .001) and severe sepsis (47% vs 7%, P < .001), and had a higher mortality (11% vs 5%, P = .036). Low ETCO2 levels were the strongest predictor of sepsis (area under the ROC curve (AUC) of 0.99, 95% CI 0.99-1.00; P < .001), severe sepsis (AUC 0.80, 95% CI 0.73-0.86; P < .001), and mortality (AUC 0.70, 95% CI 0.57-0.83; P = .005) among all prehospital variables. Sepsis alerts that followed the protocol had a sensitivity of 90% (95% CI 81-95%), a specificity of 58% (95% CI 52-65%), and a negative predictive value of 93% (95% CI 87-97%) for severe sepsis. There were significant associations between prehospital ETCO2 and serum bicarbonate levels (r = 0.415, P < .001), anion gap (r = -0.322, P < .001), and lactate (r = -0.394, P < .001). CONCLUSION A prehospital screening protocol utilizing SIRS criteria and ETCO2 predicts sepsis and severe sepsis, which could potentially decrease time to therapeutic intervention.

Prehospital End-tidal Carbon Dioxide Predicts Mortality in Trauma Patients

Abstract Background: End-tidal carbon dioxide (EtCO2) measurement has been shown to have prognostic value in acute trauma. Objective: Evaluate the association of prehospital EtCO2 and in-hospital mortality in trauma patients and to assess its prognostic value when compared to traditional vital signs. Methods: Retrospective, cross-sectional study of patients transported by a single EMS agency to a level one trauma center. We evaluated initial out-of-hospital vital signs documented by EMS personnel including EtCO2, respiratory rate (RR), systolic BP (SBP), diastolic BP (DBP), pulse (P), and oxygen saturation (O2) and hospital data. The main outcome measure was mortality. Results: 135 trauma patients were included; 9 (7%) did not survive. The mean age of patients was 40 (SD17) [Range 16–89], 97 (72%) were male, 76 (56%) were admitted to the hospital and 15 (11%) went to the ICU. The mean EtCO2 level was 18 mmHg (95%CI 9–28) [Range 5–41] in non-survivors compared to 34 mmHg (95%CI 32–35) [Range 11–51] in survivors. The area under the ROC curve (AUC) for EtCO2 in predicting mortality was 0.84 (0.67–1.00) (p = 0.001), RR was 0.82 (0.63–1.00), SBP was 0.72 (0.49–0.96), DBP was 0.72 (0.47–0.97), pulse was 0.51 (0.26–0.76), and O2 was 0.64 (0.37–0.91). Cut-off values at 30 mmHg yielded sensitivity = 89% (51–99), specificity = 68% (59–76), PPV = 13% (6–24) and NPV = 99% (93–100) for predicting mortality. There was no correlation between RR and EtCO2 (correlation 0.16; p = 0.06). Conclusion: We found an inverse association between prehospital EtCO2 and mortality. This has implications for improving triage and assisting EMS in directing patients to an appropriate trauma center.

Comparison of START and SALT triage methodologies to reference standard definitions and to a field mass casualty simulation

OBJECTIVES We compared Sort, Assess, Lifesaving Intervention, Treatment/Transport (SALT) and Simple Triage and Rapid Treatment (START) triage methodologies to a published reference standard, and evaluated the accuracy of the START method applied by emergency medical services (EMS) personnel in a field simulation. DESIGN Simulated mass casualty incident (MCI). Paramedics trained in START triage assigned each victim to green (minimal), yellow (delayed), red (immediate), or black (dead) categories. These victim classifications were recorded by investigators and compared to reference standard definitions of each triage category. The victim scenarios were also compared to the a priori classifications as developed by the investigators. SETTING MCI field simulation. MAIN OUTCOME MEASURE Comparison of the correlation of START and SALT triage methodologies to reference standard definitions. Another outcome measure was the accuracy of the application of START triage by EMS personnel in the field exercise. RESULTS The strongest correlation to the reference standard was SALT with an r = 0.860 (p < 0.001) and κ = 0.632 (p < 0.001). START and SALT triage systems agreed 100 percent on both black and green classifications. There were significant correlations between the field triage and both START and SALT methods (p < 0.001, respectfully). SALT had a significantly lower undertriage rate (9 percent [95%CI 2-15]) than both START (20 percent [95%CI 11-28]) and field triage (37 percent [95%CI 24-52]). There were no significant differences in overtriage rates. CONCLUSIONS In our study, the SALT triage system was overall more accurate triage method than START at classi-fying patients, specifically in the delayed and immediate categories. In our field exercise, paramedic use of the START methodology yielded a higher rate of undertriage compared to the SALT classification.

Comparing Quick Sequential Organ Failure Assessment Scores to End-tidal Carbon Dioxide as Mortality Predictors in Prehospital Patients with Suspected Sepsis

Introduction Early identification of sepsis significantly improves outcomes, suggesting a role for prehospital screening. An end-tidal carbon dioxide (ETCO2) value ≤ 25 mmHg predicts mortality and severe sepsis when used as part of a prehospital screening tool. Recently, the Quick Sequential Organ Failure Assessment (qSOFA) score was also derived as a tool for predicting poor outcomes in potentially septic patients. Methods We conducted a retrospective cohort study among patients transported by emergency medical services to compare the use of ETCO2 ≤ 25 mmHg with qSOFA score of ≥ 2 as a predictor of mortality or diagnosis of severe sepsis in prehospital patients with suspected sepsis. Results By comparison of receiver operator characteristic curves, ETCO2 had a higher discriminatory power to predict mortality, sepsis, and severe sepsis than qSOFA. Conclusion Both non-invasive measures were easily obtainable by prehospital personnel, with ETCO2 performing slightly better as an outcome predictor.

Prehospital end-tidal carbon dioxide differentiates between cardiac and obstructive causes of dyspnoea

Background Differentiating between cardiac and obstructive causes for dyspnoea is essential for proper management, but is difficult in the prehospital setting. Objective To assess if prehospital levels of end-tidal carbon dioxide (ETCO2) differed in obstructive compared to cardiac causes of dyspnoea, and could suggest one diagnosis over the other. Methods We conducted a retrospective cohort study among patients transported by emergency medical services during a 29-month period who were diagnosed with either obstructive pulmonary disease or congestive heart failure (CHF) by ICD-9 codes. Initial prehospital vital signs, including ETCO2, were recorded. Records were linked by manual archiving of emergency medical services and hospital data. Results There were 106 patients with a diagnosis of obstructive or cardiac causes of dyspnoea that had prehospital ETCO2 levels measured during the study period. ETCO2 was significantly lower in patients diagnosed with CHF (31 mm Hg 95% CI 27 to 35) versus obstructive pulmonary disease (39 mm Hg 95% CI 35 to 42; p<0.001). Lower ETCO2 levels predicted CHF, with an area under the Receiver Operating Characteristics Curve of 0.70 (95% CI 0.60 to 0.81). Using ETCO2 <40 mm Hg as a cut-off, the sensitivity for predicting heart failure was 93% (95% CI 88% to 98%), the specificity was 43% (95% CI 33% to 52%), the positive predictive value was 38% (95% CI 29% to 48%), and the negative predictive value was 94% (95% CI 89% to 99%). Conclusions Lower levels of ETCO2 were associated with CHF, and may serve as an objective diagnostic adjunct to predict this cause of dyspnoea in the prehospital setting.

An Emergency Department Paramedic Staffing Model Significantly ImprovesEMS Transport Unit Offload Time â A Novel Approach to an ED CrowdingChallenge

Objective: We assessed the impact of emergency department (ED) paramedic staffing on emergency medical services (EMS) unit offload time, an intervention designed to assist with EMS unit patient offload when the ED is at full bed capacity. Methods: This prospective pre/post intervention study assessed patients offloaded via the regional EMS system at an urban tertiary care teaching hospital. Three groups were compared: 1) a pre-paramedic group with data obtained prior to any paramedics staffing the ED; 2) a transition (control) group with data obtained during paramedic orientation; and 3) a post-paramedic group with data measured after paramedics were staffing the ED. Research assistants stationed in the ambulance bay of the ED enrolled a convenience sample of patients for seven consecutive days and recorded offload time as patients were brought in by EMS. The primary outcome measure was offload time (the interval between patient arrival via EMS and transfer of patient care to an ED stretcher). Results: A total of 519 offloaded patients were assessed: 207 in the pre-paramedic period, 93 in the transition (control) period and 219 in the post-paramedic period. Overall median offload times (in minutes) in the preparamedic and post-paramedic groups were 10 [IQR 4-32] versus 4 [IQR 1-16] respectively (p<0.001). In those who were triaged directly to an ED bed the median offload times were 14 [IQR 3-40] and 4 [IQR 1-16] respectively (p<0.001). The proportion of patients offloaded within 5 minutes went from 29% before the paramedic intervention to 53% after (p<0.001). The proportion of patients offloaded within 30 minutes went from 66% before paramedics to 83% (p<0.001) after and those offloaded within 60 minutes went from 87% to almost 100% (p<0.001). Conclusion: An ED paramedic-staffing model focused on receiving EMS-arrived patients at times when the ED is at full bed capacity significantly reduced the offload time for EMS units.

CORRELATION OFMONITOR–DEFIBRILLATORTIMES WITHCOMPUTERAIDEDDISPATCHCENTERTIMES WITHIN ANEMS SYSTEM

uncomplicated heat-related illness. Paramedics were instructed to assess vital signs, allergies, contraindications to treatment, and signs or symptoms of serious underlying illness. After treatment, patients could be released or transferred to a site medical facility for additional care. These directives were implemented at a large single-day outdoor rock concert in July 2003. Ambulance and first aid post records were collected and patient demographics, chief complaint, time of incident, treatment, and disposition were obtained. Results: Over 450,000 people attended the concert, with 1,870 presenting for medical attention. A significant proportion required water, sunscreen, or bandages and records were not taken of these encounters. Records were obtained for 1,205 patients, of whom 407 received medications under the directives. The disposition was not recorded in 13 cases. 299 patients were treated with acetaminophen, of whom 269 (90.0%) were released and 23 (7.7%) required additional care. 62 patients were treated with dimenhydrinate, of which 44 (71%) were released and 14 (23%) required transport. 36 patients received diphenhydramine, of whom 34 (94%) were released. Ten patients received Polysporin for minor wounds. 71 patients received intravenous fluids under medical direction, of whom 12 (17%) were released. The average volume infused was 950 6 430 mL. Conclusions: A treat and release medical directive for paramedics providing care at mass gatherings allows the release of selected patients and may divert patients from requiring care at a medical facility. Intravenous fluid therapy was usually indicative of the need for a higher level of care. 74 IMPACT OF REASSIGNING DISPATCHED AMBULANCES FROM LOWERTO HIGHER-PRIORITY CALLS Jonnathan M. Busko, Thomas Blackwell, Carolinas Medical Center

SUBJECTIVEEVALUATION OFPREHOSPITALLMA USE BYEMERGENCYMEDICALTECHNICIANS ANDPARAMEDICS

improvement as assessed by paramedics, and admission rates. Results: A total of 371 patients were included (n = 192 albuterol alone, n = 179 ipratropium/albuterol). There were no statistically significant differences between groups with regard to the change in HR, respiratory rate, or SaO2. In addition, there were no differences in the proportion of patients with clinical improvement or deterioration as assessed by paramedics. There were no statistically significant differences in the admission rate from the ED except in the subgroup of patients using an MDI at the time of illness. Of note, more than one-third (133/371) of patients were ultimately determined to have a diagnosis other than RAD, the majority of whom were diagnosed with cardiac disease. Conclusions: The addition of ipratropium bromide to albuterol for the prehospital treatment of reactive airways disease does not appear to result in clinical outcome improvements. A substantial number of patients enrolled in the study were diagnosed with cardiac disease.