Heather A. Lindstrom

Sufficient Catheter Length for Pneumothorax Needle Decompression: A Meta-Analysis

INTRODUCTION Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis. METHODS A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness. RESULTS The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm. DISCUSSION A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence.

Prehospital Naloxone Administration as a Public Health Surveillance Tool: A Retrospective Validation Study

BACKGROUND Abuse or unintended overdose (OD) of opiates and heroin may result in prehospital and emergency department (ED) care. Prehospital naloxone use has been suggested as a surrogate marker of community opiate ODs. The study objective was to verify externally whether prehospital naloxone use is a surrogate marker of community opiate ODs by comparing Emergency Medical Services (EMS) naloxone administration records to an independent database of ED visits for opiate and heroin ODs in the same community. METHODS A retrospective chart review of prehospital and ED data from July 2009 through June 2013 was conducted. Prehospital naloxone administration data obtained from the electronic medical records (EMRs) of a large private EMS provider serving a metropolitan area were considered a surrogate marker for suspected opiate OD. Comparison data were obtained from the regional trauma/psychiatric ED that receives the majority of the OD patients. The ED maintains a de-identified database of narcotic-related visits for surveillance of narcotic use in the metropolitan area. The ED database was queried for ODs associated with opiates or heroin. Cross-correlation analysis was used to test if prehospital naloxone administration was independent of ED visits for opiate/heroin ODs. RESULTS Naloxone was administered during 1,812 prehospital patient encounters, and 1,294 ED visits for opiate/heroin ODs were identified. The distribution of patients in the prehospital and ED datasets did not differ by gender, but it did differ by race and age. The frequency of naloxone administration by prehospital providers varied directly with the frequency of ED visits for opiate/heroin ODs. A monthly increase of two ED visits for opiate-related ODs was associated with an increase in one prehospital naloxone administration (cross-correlation coefficient [CCF]=0.44; P=.0021). A monthly increase of 100 ED visits for heroin-related ODs was associated with an increase in 94 prehospital naloxone administrations (CCF=0.46; P=.0012). CONCLUSIONS Frequency of naloxone administration by EMS providers in the prehospital setting varied directly with frequency of opiate/heroin OD-related ED visits. The data correlated both for short-term frequency and longer term trends of use. However, there was a marked difference in demographic data suggesting neither data source alone should be relied upon to determine which populations are at risk within the community.

Patients Immobilized with a Long Spine Board Rarely Have Unstable Thoracolumbar Injuries

Abstract Most Emergency Medical Services (EMS) protocols require spine immobilization with both a cervical collar and long spine board for patients with suspected spine injuries. The goal of this research was to determine the prevalence of unstable thoracolumbar spine injuries among patients receiving prehospital spine immobilization: a 4-year retrospective review of adult subjects who received prehospital spine immobilization and were transported to a trauma center. Prehospital and hospital records were linked. Data was reviewed to determine if spine imaging was ordered, whether acute thoracolumbar fractures, dislocations, or subluxations were present. Thoracolumbar injuries were classified as unstable if operative repair was performed. Prehospital spine immobilization was documented on 5,593 unique adult subjects transported to the study hospital. A total of 5,423 (97.0%) prehospital records were successfully linked to hospital records. The subjects were 60.2% male, with a mean age of 40.6 (SD = 17.5) years old. An total of 5,286 (97.4%) subjects had sustained blunt trauma. Hospital providers ordered imaging to rule out spine injury in 2,782 (51.3%) cases. An acute thoracolumbar fracture, dislocation, or subluxation was present in 233 (4.3%) cases. An unstable injury was present in 29 (0.5%) cases. No unstable injuries were found among the 951 subjects who were immobilized following ground level falls. Hospital providers ordered at least one spine x-ray or CT in most patients, and a thoracolumbar imaging in half of all patients immobilized. Only 0.5% of patients who received prehospital spine immobilization had an unstable thoracolumbar spine injury.

Prehospital Providers’ Perceptions of Emergency Calls Near Life’s End

The nature of emergency end-of-life calls is changing as people live longer and die from chronic illnesses. This study explored prehospital providers’ perceptions of (1) end-of-life 911 calls, (2) the signs and symptoms of dying, and (3) medical orders for life sustaining treatment (MOLST). The exploratory–descriptive pilot study was survey based and cross-sectional. Calls to nursing homes occur most often, (47.8% every shift). The MOLST was seen infrequently (57.9% rarely never). The most frequent signs and symptoms of dying were diagnosis (76%), hospice involvement (82%), apnea (75%), mottling (55%), and shortness of breath (48%). The MOLST identifies wishes about intubation (74%), resuscitation (74%), life-sustaining treatment (72%), and cardiopulmonary resuscitation (70%). Synergy exists between the fields of prehospital, hospice, and palliative medicine which offers potential for improved education and care.

Paramedic Intubation: Patient Position Might Matter

Abstract Objective. Paramedics often intubate in challenging environments. We evaluated whether patient position might affect prehospital intubation success rates utilizing a cadaver model. Methods. The study was conducted in two phases: a cross-sectional survey and an experimental model in which paramedics were asked to demonstrate intubation skills on cadavers in three positions. New York State certified paid and volunteer paramedics and critical care emergency medical technicians were recruited from multiple agencies. To assess past experience, participants self-reported the number of patients they attempted to intubate in the previous 12 months and the patient positions in which they attempted those intubations. Participants attempted to intubate nonembalmed cadavers in a controlled environment in three positions: on the floor, on a low stretcher to simulate the patient care compartment of an ambulance, and on an elevated stretcher. Paramedics were allowed a maximum of three intubation attempts of one minute each per cadaver. Endotracheal tube placement was verified by a single attending emergency physician using direct visualization. Results. Self-reports of intubation attempts in the previous 12 months indicated that participants had attempted to intubate a mean of 6.4 patients per paramedic. Self-reported positions of patient intubations were 57% on the floor, 33% in the ambulance, 7% on a stretcher of unspecified height, and 3% in some other position. During the study, 84 paramedics performed 251 intubations on 42 cadavers. First-attempt and cumulative first- and second-attempt success rates were 77.4 and 89.3% for the floor position, 74.7 and 94.0% for the low stretcher (ambulance) position, and 86.9 and 96.4% for the elevated stretcher position, respectively. First attempt success was higher in the elevated stretcher position compared to the low stretcher position (OR = 2.25, 95% CI 1.01–5.00). No other position contributed to greater odds of ETI success either on the first or second attempt. Conclusions. Endotracheal intubation success was higher with the cadaver positioned on an elevated stretcher compared to a low stretcher. Paramedics must be aware of patient position when performing prehospital intubation.

Prehospital high-dose sublingual nitroglycerin rarely causes hypotension.

INTRODUCTION High-dose intravenous nitroglycerin is a common in-hospital treatment for respiratory distress due to congestive heart failure (CHF) with hypertension. Intravenous (IV) nitroglycerin administration is impractical in the prehospital setting. In 2011, a new regional Emergency Medical Services (EMS) protocol was introduced allowing advanced providers to treat CHF with high-dose oral nitroglycerin. The protocol calls for patients to be treated with two sublingual tabs (0.8 mg) when systolic blood pressure (SBP) was >160 mm Hg, or three sublingual tabs (1.2 mg) when SBP was >200 mm Hg, every five minutes as needed. Hypothesis/Problem To assess the protocols safety, the incidence of hypotension following prehospital administration of multiple simultaneous nitroglycerin (MSN) tabs by EMS providers was studied. METHODS This study was a retrospective cohort study of patients from a single commercial EMS agency over a 6-month period. Records from patients with at least one administration of MSN were reviewed. For each administration, the first documented vital signs pre- and post-administration were compared. Administrations were excluded if pre- or post-administration vital signs were missing. RESULTS One hundred case-patients had at least one MSN administration by an advanced provider during the study period. Twenty-five case-patients were excluded due to incomplete vital signs. Seventy-five case-patients with 95 individual MSN administrations were included for analysis. There were 65 administrations of two tabs, 29 administrations of three tabs, and one administration of four tabs. The mean change in SBP following MSN was -14.7 mm Hg (SD = 30.7; range, +59 to -132). Three administrations had documented systolic hypotension in the post-administration vital signs (97/71, 78/50 and 66/47). All three patients were over 65 years old, were administered two tabs, had documented improved respiratory status, and had repeat SBP of at least 100. The incidence of hypotension following MSN administration was 3.2%. Discussion High-dose oral nitroglycerin administration is a practical alternative to IV nitroglycerin in the prehospital setting when administered by advanced providers. The prehospital protocol for high dose oral nitroglycerin was demonstrated to be safe in the cohort of patients studied. Limitations of the study include the relatively small sample size and the inability to identify hypotension that may have occurred following the cessation of data collection in the field. CONCLUSION Hypotension was rare and self-limited in prehospital patients receiving MSN.

Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest

Introduction: Guidelines endorse intravenous (IV) and intraosseous (IO) medication administration for cardiac arrest treatment. Limited clinical evidence supports this recommendation. A multiagency, retrospective study was performed to determine the association between parenteral access type and return of spontaneous circulation (ROSC) in out of hospital cardiac arrest. Methods: This was a structured, retrospective chart review of emergency medical services (EMS) records from three agencies. Data was analyzed from adults who suffered OHCA and received epinephrine through EMS established IV or IO access during the 18‐month study period. Per regional EMS protocols, choice of parenteral access type was at the providers discretion. Non‐inferiority analysis was performed comparing the association between first access type attempted and ROSC at time of emergency department arrival. Results: 1310 subjects met inclusion criteria and were included in the analysis. Providers first attempted parenteral access via IV route in 788 (60.15%) subjects. Providers first attempted parenteral access via IO route in 552 (39.85%) subjects. Rates of ROSC at time of ED arrival were 19.67% when IV access was attempted first and 19.92% when IO access was attempted first. An IO first approach was non‐inferior to an IV first approach based on the primary end point ROSC at time of emergency department arrival (p = 0.01). Conclusion: An IO first approach was non‐inferior to an IV first approach based on the end point ROSC at time of emergency department arrival.

The Realities of Operationalizing MOLST Forms in Emergency Situations

that the MOLST is an advance directive, which it is not. The role of trained and qualified clinical professionals in the MOLST process cannot be understated; all of the professionals participating in the MOLST process must do so within scope of practice. Furthermore, too often MOLST forms are completed as a checklist document without following the nationally referenced 8-Step MOLST Protocol (see Figure 1), which was publicly posted for the first time in 2005, nationally referenced since 2006, and revised in 2011 to comply with Family Health Care Decisions Act.5e7 The authors should be emphasizing the correct process for MOLST completion and addressing the current gaps in practice as part of their recommendations. The authors also use MOLST and POLST almost interchangeably throughout the article. While New York’s MOLST is an endorsed POLST Paradigm Program, it is important to note that the NYMOLST form is not the same as many POLST forms around the country, and therefore some of the research about POLST forms cited by the authors is likely to not be applicable to New York’s MOLST Program, which the authors do not acknowledge.2,8,9 This is particularly relevant given that New York’s MOLST form has muchmore explicit and distinct clinical choices than many states’ POLST forms.2,8

Women in Emergency Medicine Residency Programs: An Analysis of Data From Accreditation Council for Graduate Medical Education–approved Residency Programs

Understanding the factors associated with attracting women to a residency program would help residency program leadership build programs that are appealing to women candidates. The objective of this study was to identify factors associated with the percentage of women residents in emergency medicine (EM) residency programs.

Parenteral midazolam is superior to diazepam for treatment of prehospital seizures.

Abstract Introduction. Diazepam and midazolam are commonly used by paramedics to treat seizures. A period of drug scarcity was used as an opportunity to compare their effectiveness in treating prehospital seizures. Methods. A retrospective chart review of a single, large, commercial agency during a 29-month period was performed. The period included alternating shortages of both medications. Ambulances were stocked with either diazepam or midazolam based on availability of the drugs. Adult patients who received at least 1 parenteral dose of diazepam or midazolam for treatment of seizures were included. The regional prehospital protocol recommended 5 mg intravenous (IV) diazepam, 5 mg intramuscular (IM) diazepam, 5 mg IM midazolam, or 2.5 mg IV midazolam. Medication effectiveness was compared with respect to the primary end point: cessation of seizure without repeat seizure during the prehospital encounter. Results. A total of 440 study subjects received 577 administrations of diazepam or midazolam and met the study criteria. The subjects were 52% male, with a mean age of 48 (range 18–94) years. A total of 237 subjects received 329 doses of diazepam, 64 (27%) were treated with first-dose IM. A total of 203 subjects received 248 doses of midazolam; 71 (35%) were treated with first-dose IM. Seizure stopped and did not recur in 49% of subjects after parenteral diazepam and 65% of subjects after parenteral midazolam (p = 0.002). Diazepam and midazolam exhibited similar first dose success for IV administration (58 vs. 62%; p = 0.294). Age, gender, seizure history, hypoglycemia, the presence of trauma, time to first administration, prehospital contact time, and frequency of IM administration were similar between groups. Conclusion. For parenteral administration, midazolam demonstrated superior first-dose seizure suppression. This study demonstrates how periods of drug scarcity can be utilized to study prehospital medication effectiveness.