Joshua G. Salzman

Consecutive Field Trials Using Two Different Intraosseous Devices

Objective. Establishing traditional intravenous (IV) access in adult trauma andmedical patients can be difficult. We evaluated provider performance for obtaining intraosseous access with two FDA-approved intraosseous devices (F.A.S.T. 1TM andEZ-IO®) in two sequential field trials. Methods. One hundred twenty-four providers consented to participate in the first field trial evaluating the use of the F.A.S.T. 1TM system. Three hundred eighty-nine providers consented to participate in the second field trial, evaluating the use of the EZ-IO. Following each insertion attempt, a telephone data collection process with a member of the research team was completed. Insertion success rate andmeasures of provider comfort andsatisfaction with each device were collected andanalyzed. Results. One hundred seventy-eight insertions (89 F.A.S.T. 1TM; 89 EZ-IO®) were completed between February 2000 andDecember 2005. Sixty-four of the 89 insertions of the F.A.S.T. 1TM were successful, and78 of the 89 insertions of the EZ-IO® were successful (72% vs. 87%; χ2 = 6.8; p = 0.009). Providers using the F.A.S.T.1TM attempted more IV insertions prior to using the IO device than the providers using the EZ-IO (2.6 vs. 2.0, p = 0.005). There were no differences in provider comfort or provider assessed device performance between the two devices (p = 0.52; p = 0.13, respectively). Conclusion. In our comparison of two field trials of prehospital provider use of the F.A.S.T.1TM andEZ-IO® systems, more successful insertions with the EZ-IO® were achieved than with the F.A.S.T.1TM device. Limitations of our comparison include nonrandomization, the sequential field trial design, the potential for a learning effect, andself-reporting of data points by providers. A prospective, randomized evaluation of these devices is warranted to draw definitive conclusions about provider insertion success rate with these devices.

Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway

OBJECTIVE To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management. METHODS Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO(2) reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared. RESULTS A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic=1; range=1-7). The overall placement success rate was virtually equal across the two groups (ETI=80.2%, King LTS-D=80.5%; p=0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI=19.5s vs. King LTS-D=20.0s; z=-0.25; p=0.80). CONCLUSION In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device

BACKGROUND A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. METHODS This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3). RESULTS Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p=0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p=0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. CONCLUSIONS Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.

The emergency department experience with prehospital ketamine: a case series of 13 patients.

Abstract Background. There are no published reports examining the effects that ketamine administered prior to hospital arrival has on patients after their transfer to the emergency department (ED). Objective. In order to better understand the risk–benefit ratio for the prehospital use of ketamine, we examined the ED courses of 13 patients to whom emergency medical services (EMS) had administered ketamine for chemical restraint. Methods. This project was undertaken as part of our EMS systems continuous quality improvement (CQI) process. Data were collected retrospectively. All patients who were given ketamine by EMS providers under our medical direction were identified by prehospital care report queries. The treating paramedic and emergency physician were provided a CQI form after disposition of the patient from their care. The data were tabulated and descriptive statistics were calculated. Results. Thirteen patients were given ketamine by EMS providers, with 13 of 13 having EMS records and 12 of 13 having ED records available for review. Time from ketamine administration to peak sedation was <5 minutes in 11 patients and 20 minutes for two patients. On emergency physician examination, five of 12 patients had Richmond Agitation Sedation Scale (RASS) scores of –5 (unarousable), one of 12 had a RASS score of –4 (deep sedation), four of 12 had RASS scores of –3 (moderate sedation), and two of 12 had RASS scores of –2 (light sedation). Three patients developed hypoxia, two in the ED and one prior to hospital arrival. Two of these patients required intubation and one was treated with jaw thrust. Indications for intubation were recurrent laryngospasm and intracranial bleeding. One additional patient experienced a single episode of hypersalivation, which was successfully treated with suctioning of the oropharynx. Of the nonintubated patients, three of 10 were diagnosed with an emergence reaction and five of 10 required additional sedation. The primary diagnosis on ED disposition was drug/ethanol intoxication (3), psychosis (4), intracranial bleeding (1), seizure (1), suicidal ideation (1), agitation (1), and altered mental status (1). Five patients were discharged from the ED, seven were admitted (two to the intensive care unit, four to medicine, and one to psychiatry), and one patients disposition was unknown. Conclusions. In this series of 13 patients, ketamine administered by EMS produced moderate or deeper sedation. Respiratory complications included hypoxia, laryngospasm, and hypersalivation. Emergence reactions occurred in 30% of nonintubated patients, but they were successfully treated with small doses of benzodiazepines. Key words: ketamine; sedation; emergency department; chemical restraint; risk–benefit

Potential negative effects of epinephrine on carotid blood flow and ETCO2 during active compression-decompression CPR utilizing an impedance threshold device.

OBJECTIVES This study examines the effects of IV epinephrine administration on carotid blood flow (CBF) and end tidal CO(2) (ETCO(2)) production in a swine model of active compression-decompression CPR with an impedance threshold device (ACD-CPR+ITD). METHODS Six female swine (32 ± 1 kg) were anesthetized, intubated and ventilated. Intracranial, thoracic aorta and right atrial pressures were measured via indwelling catheters. CBF was recorded. ETCO(2), SpO(2) and EKG were monitored. V-fib was induced and went untreated for 6 min. Three minutes each of standard CPR (STD), STD-CPR+impedance threshold device (ITD) and active compression-decompression (ACD)-CPR+ITD were performed. At minute 9 of the resuscitation, 40 μg/kg of IV Epinephrine was administered and ACD-CPR+ITD was continued for 1 min. Statistical analysis was performed with a paired t-test. p values of <0.05 were considered statistically significant and all values are reported in mmHg unless otherwise noted. RESULTS Aortic pressure, cerebral and coronary perfusion pressures increased from STD<STD+ITD<ACD-CPR+ITD (p<0.001). Epinephrine administered during ACD-CPR+ITD signficantly increased mean aortic pressure (29 ± 5 vs 42 ± 12, p = 0.01), cerebral perfusion pressure (12 ± 5 vs 22 ± 10, p = 0.01), and coronary perfusion pressure (8 ± 7 vs 17 ± 4, p = 0.02); however, mean CBF and ETCO(2) decreased (respectively 29 ± 15 vs 14 ± 7.0 ml/min, p = 0.03; 20 ± 7 vs 18 ± 6, p = 0.04). CONCLUSIONS In this model, administration of epinephrine during ACD-CPR+ITD significantly increased markers of macrocirculation, while significantly decreasing carotid blood flow and ETCO(2). This calls into question the ability of calculated perfusion pressures to accurately reflect oxygen delivery to end organs. The administration of epinephrine during ACD-CPR+ITD does not improve cerebral tissue perfusion.

Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial.

Abstract Objectives. The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. Methods. This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC™ video laryngoscopes and six King Vision™ (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience. Results. Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices. Conclusion. The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.

Use of the King LTS-D During Medication-Assisted Airway Management

Objective. This case series evaluated provider use of the King LTS-D as a primary airway in patients requiring rapid-sequence intubation (RSI). Methods. Twenty-seven paramedics completed a one-hour training session on the use of the device. All patients meeting the services standard criteria for medication-assisted airway management were included in the study. Following each insertion, paramedics contacted a research hotline to complete data collection. The primary endpoint was successful insertion, with secondary endpoints including time from succinylcholine administration to successful ventilation, pre- and post-insertion vital signs (oxygen saturation [SaO2], pulse rate, and systolic and diastolic blood pressure), and end-tidal carbon dioxide [ETCO2] value 2 minutes after insertion. Analysis between pre- and postinsertion variables was completed using the Wilcoxon signed-rank test. Results. A total of 11 patients met the enrollment criteria and were treated with the device by nine of the 27 paramedics enrolled in the study. All 11 insertions (100%) were successful, with 10 of the 11 (91%) successes achieved on the first insertion attempt. No significant difference existed between pre- and post-insertion pulse rate or blood pressure measures. A significant difference in SaO2 values was present (p = 0.007). Median ETCO2 for the study sample was 40 mmHg (interquartile range [IQR] = 33–46 mmHg). Seventy-three percent (8/11) of patients had a time interval of succinylcholine administration to first ventilation of 1 minute or less (range = 1–3 minutes). One case of aspiration was noted on hospital chart review. Conclusion. In this case series, paramedics were able to successfully place and use the King LTS-D in patients meeting our emergency medical services (EMS) system indications for RSI.

Paramedic Student Adherence to the National Standard Curriculum Recommendations

Objectives The National Standard Curriculum–Paramedic (NSC-P) is the accepted curriculum for paramedic programs across the country. The purpose of this study was to examine the completion of the NSC-P clinical internship recommendations by paramedic students. Methods. Paramedic student internship experience data from 2001 to 2005 was retrospectively reviewed from FISDAP™. Student records that met the following inclusion criteria were analyzed: 1) student provided consent for research, 2) data verified by a preceptor, and3) student successfully graduated from their paramedic program. The data were descriptively evaluated to determine the number of students who completed 100% of the NSC-P recommendations, to determine what percentage of students were completing each category, andto determine the average number of tasks completed by students for each recommendation. Results. Of the 1,817 student records that met the inclusion criteria, 140 (7.7%) completed 100% of the NSC-P recommended goals in each category. Students met or exceeded the recommended number of tasks most often for 15 medication administrations (92%), 25 successful IV accesses (88%), 30 geriatric assessments (63.7%), 5 live endotracheal intubations (63.5%), and50 adult assessments (63.2%). A majority of PS are completing less than 50% of the NCS-P recommendations for 20 ventilations on an un-intubated patient, 20 psychiatric patient assessments, 8 pediatric respiratory distress assessments, and10 obstetric patient assessments. Conclusion. A vast majority of paramedic students are not completing all of the NSC-P recommendations. The reasons for this shortcoming are likely multifaceted andrequire further research.

Magnetic resonance imaging and computed tomography utilization trends in an academic ED

OBJECTIVE The objective of this study is to examine the annual utilization trends of emergency department (ED)-ordered magnetic resonance imaging (MRI) and computed tomography (CT) at an urban academic hospital from 2007 to 2011. We hypothesized that MRI and CT use would increase annually over the study period. METHODS This was a retrospective observational study of ED encounters between January 1, 2007, and December 31, 2011. All patients seen by a provider were identified, and demographics were abstracted. Type of CT and/or MRI examination, clinical indication, and final disposition were collected. Records of patients with an ED-ordered MRI were also examined for presence of a CT within ±3 days of their encounter date. Unadjusted linear regression was used to assess for differences among years for both CT and MRI. Secondary outcomes were descriptively summarized. RESULTS A total of 7089 MRI (20 per 1000) and 85,673 CT (243 per 1000) examinations were ordered over a 60-month period. Computed tomography use decreased significantly (P=.021). Magnetic resonance imaging use significantly increased (2.2 per 1000 ED visits each year, P=.005). Magnetic resonance imaging of the head was ordered most frequently (10.7 per 1000). The overwhelming majority of MRI images were completed for acute neurologic/behavioral problem. Of patients with an MRI completed, 89.4% had a CT completed within 3 calendar days with most of the CT examinations (81%) completed during the encounter. CONCLUSION There was a steady increase in MRI testing in our academic ED, with most MRIs ordered for acute neurologic or behavioral changes. There was a corresponding decreasing trend for CT scans.

Supraglottic Airway Device Use as a Primary Airway During Rapid Sequence Intubation

INTRODUCTION This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls. SETTING Rotor-wing division of a single critical care transportation company METHODS 53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO2, ETCO2 at 2 minutes after placement, and complications were also analyzed. RESULTS 38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR = 0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12-46). Pre- and post-insertion SaO(1)2 values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO2 at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patients airway was the most frequently reported complication (46%). CONCLUSION Success rates with the King LTS-D were not significantly different from historical control ETI data. Time to placement was comparable to previous reports.