Jefferson G. Williams

A simulation trial of traditional dispatcher-assisted CPR versus compressions - Only dispatcher-assisted CPR

Objectives. Growing evidence indicates that it may not be essential to deliver ventilations in the first few minutes of CPR. We compared time to delivery of first compression in traditional CPR with ventilations andcompressions to compression-only CPR performed by untrained laypersons assisted by a mock 911 dispatcher. Methods. This randomized-controlled simulation study included a convenience sample of English-speaking emergency department visitors during a 6-month period. Exclusion criteria were prior CPR training or physical incapacity. A cardiac arrest scenario was presented to subjects who were then provided with one of two sets of telephone CPR instructions by a mock 911 dispatcher. One group received traditional CPR instructions (TCPR) andthe second group received compression only CPR instructions (COCPR). Subjects performed CPR on a Laerdal Resusci-Anne CPR manikin andrecording strips were analyzed for frequency andquality measures. Pre-and post-test questionnaires assessed subject fatigue andtelephone instruction understanding. The primary outcome was the time interval from 911 call to initiation of chest compressions. Analysis included Student t-test, Chi-square, andWilcoxon Rank Sum. Results. Of 377 potential subjects, 54 consented to randomization. The data from 50 subjects were analyzed. Compared to group TCPR, group COCPR initiated chest compressions faster (72 vs 117 sec, p < 0.0001), completed four cycles of CPR faster (168 vs. 250 sec, p < 0.0001), andpaused for a smaller percentage of the resuscitation (13% vs. 36%, p < 0.0001). Only 9% of ventilation opportunities in the TCPR group yielded ventilations of the correct volume. There were no differences between groups in perceived understanding of CPR instruction or fatigue. Conclusions. We have identified the potential timesavings that may occur during compressions-only CPR. Bystander resuscitation may be more efficient when ventilations are excluded from the CPR sequence.

Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases

Abstract Background. Ventricular fibrillation (VF) is considered the out-of-hospital cardiac arrest (OOHCA) rhythm with the highest likelihood of neurologically intact survival. Unfortunately, there are occasions when VF does not respond to standard defibrillatory shocks. Current American Heart Association (AHA) guidelines acknowledge that the data are insufficient in determining the optimal pad placement, waveform, or energy level that produce the best conversion rates from OOHCA with VF. Objective. To describe a technique of double sequential external defibrillation (DSED) for cases of refractory VF (RVF) during OOHCA resuscitation. Methods. A retrospective case series was performed in an urban/suburban emergency medical services (EMS) system with advanced life support care and a population of 900,000. Included were all adult OOHCAs having RVF during resuscitation efforts by EMS providers. RVF was defined as persistent VF following at least 5 unsuccessful single shocks, epinephrine administration, and a dose of antiarrhythmic medication. Once the patient was in RVF, EMS personnel applied a second set of pads and utilized a second defibrillator for single defibrillation with the new monitor/pad placement. If VF continued, EMS personnel then utilized the original and second monitor/defibrillator charged to maximum energy, and shocks were delivered from both machines simultaneously. Data were collected from electronic dispatch and patient care reports for descriptive analysis. Results. From 01/07/2008 to 12/31/2010, a total of 10 patients were treated with DSED. The median age was 76.5 (IQR: 65–82), with median resuscitation time of 51minutes (IQR: 45–62). The median number of single shocks was 6.5 (IQR: 6–11), with a median of 2 (IQR: 1–3) DSED shocks delivered. VF broke after DSED in 7 cases (70%). Only 3 patients (30%) had ROSC in the field, and none survived to discharge. Conclusion. This case series demonstrates that DSED may be a feasible technique as part of an aggressive treatment plan for RVF in the out-of-hospital setting. In this series, RVF was terminated 70% of the time, but no patient survived to discharge. Further research is needed to better understand the characteristics of and treatment strategies for RVF.

Sustained ventricular fibrillation in an alert patient: preserved hemodynamics with a left ventricular assist device.

Abstract Emergency medical services (EMS) encountered an alert patient with sustained ventricular fibrillation with preserved hemodynamics via a left ventricular assist device (LVAD). Multiple firings of the patients implantable defibrillator were the only sign that this patient was experiencing the usually fatal ventricular arrhythmia. Initial attempts at rhythm conversion with amiodarone and 200-J biphasic shocks were unsuccessful. The patient was finally defibrillated to normal sinus rhythm after a 360-J biphasic shock. This case conference highlights the increasing prevalence of LVADs. These devices are used not only as a bridge to cardiac transplantation, but also as definitive therapy for patients in end-stage cardiac failure. Ventricular fibrillation has been shown to be well tolerated in patients with LVADs, and we discuss a standard of care for these patients. The occurrence of sustained ventricular fibrillation in patients with ventricular assist devices represents a challenging situation for EMS and emergency department providers and one that will be increasingly encountered in the future.

Retrospective validation of a protocol to limit unnecessary transport of assisted-living residents who fall

Abstract Objective. Emergency medical services (EMS) often transports patients who suffer simple falls in assisted-living facilities (ALFs). An EMS “falls protocol” could avoid unnecessary transport for many of these patients, while ensuring that patients with time-sensitive conditions are transported. Our objective was to retrospectively validate an EMS protocol to assist decision making regarding the transport of ALF patients with simple falls. Methods. We conducted a retrospective cohort study of patients transported to the emergency department from July 2010 to June 2011 for a chief complaint of “fall” within a subset of ALFs served by a specific primary care group in our urban EMS system (population 900,000). The primary outcome, “time-sensitive intervention” (TSI), was met by patients who had wound repair or fracture, admission to the ICU, OR, or cardiac cath lab, death during hospitalization, or readmission within 48 hours. EMS and primary care physicians developed an EMS protocol, a priori and by consensus, to require transport for patients needing TSI. The protocol utilizes screening criteria, including history and exam findings, to recommend transport versus nontransport with close primary care follow-up. The EMS protocol was retrospectively applied to determine which patients required transport. Protocol performance was estimated using sensitivity, specificity, and negative predictive value (NPV). Results. Of 653 patients transported across 30 facilities, 644 had sufficient data. Of these, 197 (31%) met the primary outcome. Most patients who required TSI had fracture (73) or wound repair (92). The EMS protocol identified 190 patients requiring TSI, for a sensitivity of 96% (95% CI: 93–98%), specificity of 54% (95% CI: 50–59%), and NPV of 97% (95% CI: 94–99%). Of 7 patients with false negatives, 3 were readmitted (and redischarged) after another fall, 3 sustained hip fractures that were surgically repaired, and 1 had a lumbar compression fracture and was discharged. Conclusions. In this cohort, two-thirds of patients with falls in ALFs did not require TSI. An EMS protocol may have sufficient sensitivity to safely allow for nontransport of these patients with falls in ALFs. Prospective validation of the protocol is necessary to test this hypothesis.

Critical Skills and Procedures in Emergency Medicine: Vascular Access Skills and Procedures

The venous and/or arterial vasculature may be accessed for fluid resuscitation, testing and monitoring, administration of blood product or medication, or procedural reasons, such as the implantation of cardiac pacemaker wires. Accessing the vascular system is a common and often critically important step in emergency patient care. This article reviews methods for peripheral, central venous, and arterial access and discusses adjunct skills for vascular access such as the use of ultrasound guidance, and other forms of vascular access such as intraosseus and umbilical cannulation, and peripheral venous cut-down. Mastery of these skills is critical for the emergency medicine provider.

Sudden Unexpected Death in North Carolina (SUDDEN): methodology review and screening results.

Objectives This paper describes the methodology for a prospective, community-based study of sudden unexpected death in Wake County, North Carolina. Methods From 1 March to 29 June 2013, data of presumed cardiac arrest cases were captured from Wake County Emergency Medical Services. Participants were screened into the presumed sudden unexpected death group based on specific and sequential screening criteria, and medical and public records were collected for each participant in this group. A committee of independent cardiologists reviewed all data to determine final inclusion/exclusion of each participant into registry. Results We received 398 presumed cardiac arrest referrals. Of these, 105 participants, age 18–65 years old, were identified as presumed sudden unexpected deaths. The primary reason for exclusion was survival to hospital (38%). Ninety-five per cent of participants in the presumed sudden unexpected death group experienced an unwitnessed death. Hypertension was present in almost 50%, while dyslipidaemia and diabetes mellitus were present in almost 25% of the same group. In addition, the presumed sudden unexpected death group includes 67.6% males (95% CI 58 to 76) whereas the control group only included 58.9% (95% CI 46 to 55) males. Conclusions Participant identification and data collection processes identify presumed sudden unexpected death cases and secure medical and public data for screening and final adjudication. The study infrastructure developed in Wake County will allow its expansion to other counties in North Carolina. Preliminary data indicate the study presently focuses on a population demographically representative of North Carolina.

Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid Overdoses in a Large U.S. EMS System

Abstract Objective: The United States is currently experiencing a public health crisis of opioid overdoses. To determine where resources may be most needed, many public health officials utilize naloxone administration by EMS as an easily-measured surrogate marker for opioid overdoses in a community. Our objective was to evaluate whether naloxone administration by EMS accurately represents EMS calls for opioid overdose. We hypothesize that naloxone administration underestimates opioid overdose. Methods: We conducted a chart review of suspected overdose patients and any patients administered naloxone in Wake County, North Carolina, from January 2013 to December 2015. Patient care report narratives and other relevant data were extracted from electronic patient care records and the resultant database was analyzed by two EMS physicians. Cases were divided into categories including “known opioid use,” “presumed opioid use,” “no known opioid,” “altered mental status,” “cardiac arrest with known opioid use,” “cardiac arrest with no known opioid use,” or “suspected alcohol intoxication,” and then further separated based on whether naloxone was administered. Patient categories were compared by patient demographics and incident year. Using the chart review classification as the gold standard, we calculated the sensitivity and positive predictive value (PPV) of naloxone administration for opioid overdose. Results: A total of 4,758 overdose cases from years 2013–15 were identified. During the same period, 1,351 patients were administered naloxone. Of the 1,431 patients with known or presumed opioid use, 57% (810 patients) received naloxone and 43% (621 patients) did not. The sensitivity of naloxone administration for the identification of patients with known or presumed opioid use was 57% (95% CI: 54%–59%) and the PPV was 60% (95% CI: 57%–63%). Conclusion: Among patients receiving care in this large urban EMS system in the United States, the overall sensitivity and positive predictive value for naloxone administration for identifying opioid overdoses was low. Better methods of identifying opioid overdose trends are needed to accurately characterize the burden of opioid overdose within and among communities.

Evaluation of an Integrated Rescue Task Force Model for Active Threat Response

Abstract Objective: An integrated response to active threat events is essential to saving lives. Coordination of law enforcement officer (LEO) and emergency medical services (EMS) roles requires joint training, as maximizing survival is a shared responsibility. We sought to evaluate the performance of an integrated LEO-EMS Rescue Task Force (RTF) response to a simulated active shooter incident utilizing objective performance measures. Methods: Following prior didactic training, we conducted a series of evaluation scenarios for EMS providers and patrol officers in our urban/suburban advanced life support EMS system (pop. 1,000,000). The scenario-tested command staff, LEOs tasked with neutralizing an active shooter threat, and two RTFs of LEOs and EMS providers each tasked with triage and treatment of 11 simulated casualties scattered over 2 office building floors totaling 13,000 square feet. Trained evaluators recorded performance on 30 objective data elements related to LEO-EMS operations/communication, time intervals, and trauma care. Data were analyzed using descriptive statistics and t-tests for between group comparisons. Results: Over 18 days, 69 scenario events evaluated 388 EMS providers and 468 LEOs. Overall median (90th percentile) times in minutes from dispatch were: unified command established 4.1 (5.5), RTF assembled 9.4 (13.5), first victim contact 11.9 (16.5), first victim to internal casualty collection point (CCP) 16.6 (20.8), all victims ready for evacuation 21.6 (26.0). Life-saving interventions included tourniquet placed: 96% (95% CI 92–99) and LEO placed tourniquet: 88% (79–94). Clinical delays included inappropriate chest decompression: 4% (2–9) and unnecessary initial treatment: 17% (12–25). Correct operational actions included communication with LEO to ensure EMS was safe to treat: 70% (61-77) and appropriate CCP selection: 84% (74–91). Incorrect operational actions included failure to maintain protective LEO-EMS formation: 49% (45–62) and inappropriate single patient evacuation: 20% (14–28). Limitations included the lack of a pre-training control group for this novel program. Conclusions: We described the performance of an integrated LEO-EMS Rescue Task Force response to a simulated active shooter event in a large city. In general, clinical care was appropriate while operational targets can be improved. Objective measurement of response goals may be used for benchmarking and performance improvement for active threat events.

Acute Crisis Care for Patients with Mental Health Crises: Initial Assessment of an Innovative Prehospital Alternative Destination Program in North Carolina

ABSTRACT Objective: Emergency Departments (ED) are overburdened with patients experiencing acute mental health crises. Pre-hospital transport by Emergency Medical Services (EMS) to community mental health and substance abuse treatment facilities could reduce ED utilization and costs. Our objective was to describe characteristics, treatment, and outcomes of acute mental health crises patients who were transported by EMS to an acute crisis unit at WakeBrook, a North Carolina community mental health center. Methods: We performed a retrospective cohort study of patients diverted to WakeBrook by EMS from August 2013–July 2014. We abstracted data from WakeBrook medical records and used descriptive statistics to quantify patient characteristics, diagnoses, length of stay (LOS), and 30-day recidivism. Results: A total of 226 EMS patients were triaged at WakeBrook. The median age was 38 years, 55% were male, 58% were white, and 38% were uninsured. The most common chief complaints were suicidal ideation or self-harm (46%) and substance abuse (19%). The most common diagnoses were substance-related and addictive disorders (42%), depressive disorders (32%), and schizophrenia spectrum and other psychotic disorders (22%). Following initial evaluation, 28% of patients were admitted to facilities within WakeBrook, 40% were admitted to external psychiatric facilities, 18% were stabilized and discharged home, 5% were transferred to an ED within 4 hours for further medical evaluation, and 5% refused services. The median LOS at WakeBrook prior to disposition was 12.0 hours (IQR 5.4-21.6). Over a 30-day follow-up period, 60 patients (27%) had a return visit to the ED or WakeBrook for a mental health issue. Conclusions: A dedicated community mental health center is able to treat patients experiencing acute mental health crises. LOS times were significantly shorter compared to regional EDs. Successful broader programmatic implementation could improve care quality and significantly reduce the volume of patients treated in the ED for acute mental health disorders.

Therapeutic systemic hypothermia for a pediatric patient with an isolated cervical spinal cord injury

Context: While uncommon, spinal cord injuries most frequently occur in adolescent and young adult males. Established treatment options are limited and focused on supportive care. Therapeutic systemic hypothermia is an emerging experimental treatment currently undergoing clinical trials in adults. Findings: Here we report a case of a 13-year-old male with an American Spinal Injury Association Impairment Scale grade C traumatic cervical spinal cord injury treated with 48 hours of therapeutic systemic hypothermia who made a complete neurological recovery. To our knowledge, this is the youngest such case report. Clinical relevance: This case suggests that consideration should be given to including pediatric patients in future clinical trials of therapeutic hypothermia for spinal cord injury.